Presented by:

Astuti Mappuji

Advisor:
dr.Satria
dr.Edwin

Supervisor :
Dr. dr. Karya Triko B, Sp.OT (K) Spine
 Patients Identity

Name : Mr. A
Age : 23 Years old
Med Record : 692411
Gender : Male
 History Taking
Chief Complain : Back pain

Suffered since 4 months before admitted to wahidin sudirohusodo

hospital. The patient feels pain in his back, the pain worse at the morning
when he wake up. Pain is not spread. No traumatic history. There was
long time cought history. Bleeding cought history is denied. History of
fluctuate fever and sweat in the night. History of body weight loss until 6
kg with before body weight was 51 kg, there is no chest pain. Defecation
and urination are in control. History of consumed antituberculosis drug
since 2 years ago but not done yet. History of contact with tuberculosis
sufferer is denied. Patient usually smoke 2 pack of cigarrete every day.
Physical Examination
General status :
well-nourished/ conscious
Weight : 45 kg
Tall : 151 cm
Body Mass Index : 19,7 kg/m2

Vital sign :
BP : 120/80 mmHg
HR : 82x /mnt
RR : 20x /mnt
BT : 36.7C
VAS : 8/10
Local Status
Vertebra Region:
Look : Deformity (+), Swelling (-), Gibbus (+)
Feel : tenderness (+) as high as L3-L4
MOTORIC FUNCTION
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2 Any anal sensation
2 2 2 2 N
2 2 2 2
2 2 2 2 0 Absent
2 2 2 2 1 Impaired
2 2 2 2 2 Normal
NT Not testable
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
 Reflex

Physiologic Reflex Pathologic Reflex

R L
Biceps (N) (N) R L
Triceps (N) (N) Babinski (-) (-)
Achilles ( N ) (N) Chadock (-) (-)
Patellar ( N) (N) Openheim (-) (-)
Hoffman (-) (-)
Tromner (-) (-)
Clinical Picture
Laboratory Study
CBC Value
WBC 9,9 x 103/mm3

RBC 4,76 x 106/mm3

HGB 12,9 g/dl

HCT 38,4%

PLT 332 x 103/mm3

Thoracal X Ray
THORACOLUMBAL AND LUMBOSACRAL XRAY
AP/LATERAL
MRI COLUMNA VERTEBRALIS
Resume
A male, 23 years old enter to the hospital with back pain. Suffered since 4 months
before admitted to wahidin sudirohusodo hospital. The patient feels pain in his
back, the pain worse at the morning when he wake up. Pain is not spread.There was
long time cought history, History of fluctuate fever and sweat in the night. History
of body weight loss until 6 kg. Defecation and urination are in control. History of
consumed antituberculosis drug since 2 years ago but not done yet. History of
contact with tuberculosis sufferer is denied. Patient usually smoke 2 pack of
cigarrete every day.

In physical examination obtained deformity, there is gibbus. Tendernerness at the

level L3-L4. Right and left motoric function 5/5, not neurologic deficit, physiologis
and patologic reflex normal.

On Radiologic examination, there are spondylitis TB at the level T7-T9 with abscess

.
 Diagnosis
Low Back Pain e.c Tuberculous Spondylitis
Paravertebral abscess
 Treatment
Non-operative:
Antituberculosis drug therapy
Bed Rest
Planning for decompression, posterior
stabilisation, and abscess drainage.
Vertebra column
Relation of spinal nerve to vertebrae
Tuberculous Spondylitis
The spine is the most common site of skeletal
tuberculosis (TB), and accounts for 50 % of all
musculoskeletal TB.
It is thought that there are approximately 2 million
people with spinal tuberculosis worldwide
Pathology (Kumar):
1. Implantation Stage
2. Early Destruction Stage
3. Late Destruction Stage
4. Neurologic Deficits Stage
5. Residual Deformity Stage
 Clinical Symptoms
Fatigue
Weakness
Weight loss
Anorexia
Low grade fever
Night sweats
Productive cough
Hemoptysis
 Clinical
Presentation depends on the following:
Stage of disease
Site
Presence of complications such as neurologic
deficits, abscesses, or sinus tracts
The reported average duration of symptoms
at the time of diagnosis is 3-4 months.
 Back pain is the earliest and most common
symptom.
Patients have usually had back pain for weeks prior to
presentation.
Pain can be spinal or radicular.
Constitutional symptoms include fever and weight
loss.
Neurologic abnormalities occur in 50% of cases
and can include spinal cord compression with
paraplegia, paresis, impaired sensation, nerve root
pain, or cauda equina syndrome
 Physical
Examination should include the
following:
Careful assessment of spinal alignment
Inspection of skin, with attention to
detection of sinuses
Abdominal evaluation for subcutaneous
flank mass
Meticulous neurologic examination
 Thoracic spine is frequently reported as the
most common site of involvement
comprise 80-90%
Spine deformity (kyphosis) of some degree
occurs in almost every patient.
There may be large cold abscesses of
paraspinal tissues or psoas muscle that
protrude under the inguinal ligament. They
may erode into the perineum or gluteal area.
 Neurologic deficits may occur early in the course
of disease. Signs depend on the level of spinal cord
or nerve root compression.
Disease involving the upper cervical spine can
cause rapidly progressive symptoms.
Retropharyngeal abscesses occur in almost all
cases.
Neurologic manifestations occur early and range
from a single nerve palsy to hemiparesis or
quadriplegia.
Gibbious Deformity
Anterior wedging leads to focal kyphosis this is the
angular gibbious deformity.
 Tuberculous Spondylitis
Radiological Findings

Griffith, J. Imaging of Musculoskeletal Tuberculosis: A new look at an old disease. 2002. Clinical orthopedics and related
research.
Spine Tuberculosis-x-rays. (a) Early disease with loss of the disc spase.
(b) Severe collapse, have any sign of paraplegia. (c) Psoas abscess often calcify
during the healing satge. (d) A para vertebral abscess is a fairly constant finding
with thoracic disease
Treatment
The objectives are to:
(1) eradicate or at least arrest the disease
(2) prevent or correct deformity;
(3) prevent or treat the major complication-
paraplegia.
Antibiotics
- Four-drug therapy (isoniazid, rifampisin,
pyrazinamide & ethambutol)
- At least six months of therapy
- Usually responds well (even in severe
cases)
Operative treatment
May play role in spinal stabilization or abcess
drainage/debridement
More role if advanced neurologic deficits,
worsening deficits on medical therapy or severe
kyphosis
Usually two-procedure process - first anterior
decompression and reconstruction then
posterior fusion
 Indications
Neurologic deficit (acute neurologic
deterioration, paraparesis, paraplegia)
Spinal deformity with instability
No response to medical therapy
Nondiagnostic percutaneous needle
biopsy sample
Complication
Abscess
Spine deformities
Neurologic deficits and paraplegi
Prognosis
Current treatment modalities are highly effective if not
complicated by severe deformity or established
neurologic deficit.
Therapy compliance and drug resistance are
additional factors that significantly affect individual
outcomes.
Paraplegia resulting from the active disease causing
cord compression usually responds well to
chemotherapy.
If medical therapy does not result in rapid
improvement, operative decompression will greatly
increase the recovery rate.
Paraplegia can manifest or persist during healing
because of permanent spinal cord damage.