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ott's D|sease

5yoooyms lotts syoJtome lotts cotles lotts cotvotote ooqolot kypbosls kypbosls secooJoty
to tobetcolosls tobetcolosls of tbe sploe tobetcoloos spooJylltls ooJ uovlJs Jlseose
n|story
O Cne of oldesL dlseases of whlch we have evldence
4 8C LgypLlan mummles noLed wlLh Lyplcal feaLures
4 - from verLebral leslon ln 12yearold from 1 ldenLlfled M
Luberculosls

O Classlc descrlpLlon flrsL ln 1779 by erclval oLL an Lngllsh surgeon CLher noLable
achlevemenLs
4 lrsL Lo llnk cancer Lo envlronmenLal carclnogens (scroLal cancer ln chlmney
sweeps)
4 oLLs fracLure blmalleolar ankle fracLure
4 oLLs puffy Lumor subperlosLeal abcess and osLeomyellLls of Lhe fronLal bone
serous compllcaLlon of slnuslLls

O @he usual slLes Lo be lnvolved are Lhe lower Lhoraclc and upper lumbar verLebrae
O @he source of lnfecLlon ls usually ouLslde Lhe splne lL ls mosL ofLen spread from Lhe
lungs vla Lhe blood
O @here ls a comblnaLlon of osteomye||t|s and lnfecLlve arLhrlLls
O Dsually more Lhan one verLebra ls lnvolved @he area mosL affecLed ls Lhe anLerlor parL
of Lhe verLebral body ad[acenL Lo Lhe subchondral plaLe @uberculosls may spread from
LhaL area Lo ad[acenL lnLerverLebral dlscs
O ln adulLs dlsc dlsease ls secondary Lo Lhe spread of lnfecLlon from Lhe verLebral body buL
ln chlldren lL can be a prlmary slLe as Lhe dlsc ls vascular ln chlldren
O lL ls Lhe commonesL place for Luberculosls Lo affecL Lhe skeleLal sysLem alLhough lL can
affecL Lhe hlps and knees Loo
O @he lnfecLlon spreads from Lwo ad[acenL verLebrae lnLo Lhe ad[olnlng dlsc space
O lf only one verLebra ls affecLed Lhe dlsc ls normal buL lf Lwo are lnvolved Lhe dlsc
beLween Lhem collapses as lL ls avascular and cannoL recelve nuLrlenLs
O CaseaLlon occurs wlLh verLebral narrowlng and evenLually ertebra| co||apse and splnal
damage dry sofL Llssue mass ofLen forms and superlnfecLlon ls rare


Lp|dem|o|ogy

O oLLs dlsease ls rare ln Lhe D buL ln developlng counLrles lL represenLs abouL 2 of
cases of Luberculosls and Lo 3 of musculoskeleLal Luberculosls
O @uberculosls worldwlde accounLs for 17 bllllon lnfecLlons and 2 mllllon deaLhs per year
O Cver 9 of Luberculosls occurs ln poorer counLrles buL a global resurgence ls affecLlng
rlcher ones
O lndla Chlna lndonesla aklsLan and 8angladesh have Lhe largesL number of cases buL
Lhere has been a marked lncrease ln Lhe number of cases ln Lhe former SovleL Dnlon and
ln subSaharan frlca ln parallel wlLh Lhe spread of Plv
O bouL Lwo Lhlrds of affecLed paLlenLs ln developed counLrles are lmmlgranLs as shown
from boLh London and arls and splnal Luberculosls may be qulLe a common
presenLaLlon
O @he dlsease affecLs males more Lhan females ln a raLlo of beLween 13 and 21 ln Lhe
DS lL affecLs mosLly adulLs buL ln Lhe counLrles where lL ls commonesL lL affecLs mosLly
chlldren

|sk factors

O Lndem|c tubercu|os|s
O oor socloeconomlc condlLlons
O nIV |nfect|on

L1ICLCG of 1ubercu|os|s of Sp|ne
- CausaLlve organlsm MycobacLerlum Luberculosls
- Spread PaemaLogenous (by blood)
- Commonly assoclaLed wlLh eblllLaLlng dlseases lS rug addlcLlon lcohollsm

Symptoms of 1ubercu|os|s of Sp|ne
Symptoms
@he onseL ls gradual
- 8ack paln ls locallsed
- 8esLrlcLed splnal movemenLs
- ever
- -lghL sweaLs
- norexla
- WelghL loss
S|gns
- @here may be kyphosls (splnal curvaLure)
- Muscle wasLlng
- paraverLebral swelllng may be seen
- @hey Lend Lo assume a proLecLlve uprlghL sLlff poslLlon
- lf Lhere ls neural lnvolvemenL Lhere wlll be neurologlcal slgns
- psoas abscess (may presenL as a lump ln Lhe groln and resemble a hernla)

resentat|on

O @he onseL ls gradual
O ack pa|n ls locallsed
O ever n|ght sweats anorexla and we|ght |oss
O Slgns may lnclude kyphosls (common) and/or a paraverLebral swelllng
O ffecLed paLlenLs Lend Lo assume a proLecLlve uprlghL sLlff poslLlon
O lf Lhere ls neural lnvolvemenL Lhere wlll be neurologlcal slgns
O psoas abscess may presenL as a lump ln Lhe groln and resemble a hernla
4 psoas abscess mosL ofLen orlglnaLes from a Luberculous abscess of Lhe lumbar
verLebra LhaL Lracks from Lhe splne lnslde Lhe sheaLh of Lhe psoas muscle
4 CLher causes lnclude exLenslon of renal sepsls and posLerlor perforat|on of the
bowe|
4 @here ls a Lender swelllng below Lhe lngulnal llgamenL and Lhey are usually
apyrexlal
4 @he condlLlon may be confused wlLh a femora| hern|a or enlarged lngulnal lymph
nodes


D|fferent|a| d|agnos|s

O yogenlc osLelLls of Lhe splne
O Sp|na| tumours

Inest|gat|ons

O LlevaLed LS8
O SLrongly poslLlve ManLoux skln LesL
O Splnal xray may be normal ln early dlsease as 3 of Lhe bone mass musL be losL for
changes Lo be vlslble on xray laln xray can show verLebral desLrucLlon and narrowed
dlsc space
O M8l scannlng may demonsLraLe Lhe exLenL of splnal compresslon and can show changes
aL an early sLage 8one elemenLs vlslble wlLhln Lhe swelllng or abscesses are sLrongly
suggesLlve of oLLs dlsease raLher Lhan mallgnancy C@ scans and nuclear bone scans can
also be used buL M8l ls besL Lo assess rlsk Lo Lhe splnal cord
O needle blopsy of bone or synovlal Llssue ls usual lf lL shows Lubercle bacllll Lhls ls
dlagnosLlc buL usually culLure ls requlred CulLure should lnclude mycology

INVLS1IGA1ICN for 1ubercu|os|s of Sp|ne
|ood
- @LC LeucocyLosls
- LS8 ralsed durlng acuLe sLage
1ubercu||n sk|n test
- SLrongly poslLlve
- -egaLlve LesL does noL exclude dlagnosls
Asp|rate from [o|nt space abscess
- @ransparency Lurbld
- Colour creamy
- ConslsLency cheesy
- lbrln cloL large
- Mucln cloL poor
- W8C 23/ccmm
n|sto|ogy
- Shows granulomaLous Lubercle
kay sp|ne
Larly
- -arrowed [olnL space
- lffuse verLebral osLeoporosls ad[acenL Lo [olnL
- Lroslon of bone
- uslform parasplnal shadow of abscess ln sofL Llssue
LaLe
- esLrucLlon of bone
- Wedgeshaped deformlLy (collapse of verLebrae anLerlorly)
- 8ony ankylosls

Assoc|ated d|seases

O @uberculosls colnfecLlon wlLh Plv has become common lL ls up Lo 11 ln some areas of
Lhe D and over 6 ln counLrles such as Zambla Zlmbabwe and SouLh frlca
O ln Lhe developed world Lhe dlsease ls more common ln cerLaln secLlons of socleLy such
asa|coho||cs Lhe undernour|shed eLhnlc mlnorlLy communlLles and Lhe elderly
O @he dlsease ls also more common ln paLlenLs afLer gasLrecLomy for pepLlc ulcer

D|str|but|on

O @he commonesL area affecLed ls @1 Lo L1
O @he lower Lhoraclc reglon ls Lhe mosL common area of lnvolvemenL aL Lo 3 wlLh
Lhe lumbar splne ln a close second place aL 33 Lo 3
O @he cervlcal splne accounLs for abouL 1

Management

O lmmoblllsaLlon of Lhe splne ls usually for 2 or 3 monLhs
O rug LreaLmenL Lhls ls covered ln Lhe arLlcle on Lhe Management of 1ubercu|os|s
@herapy may need Lo exceed 6 monLhs
O nLlbloLlcs
O ourdrug Lherapy (lsonlazld rlfampln pyrazlnamlde
O eLhambuLol)
O May be more compllcaLed lf concerns of mulLldrug
O reslsLanL @8 or lf assoclaLed wlLh sepLlcemla
O L leasL slx monLhs of Lherapy
O Dsually responds well (even ln severe cases)

GLNLAL MANAGLMLN1 for otts D|sease
- 8ed resL
- lmmoblllsaLlon of affecLed [olnL by spllnLage
- -uLrlLlous hlgh proLeln dleL
- ralnage of abscess
- Surglcal decompresslon
- hysloLherapy
Surg|ca|
O May play role ln splnal sLablllzaLlon or abcess dralnage/debrldemenL
O More role lf advnced neurologlc deflclLs worsenlng deflclLs on medlcal Lherapy or
severe kyphosls
O Dsually Lwoprocedure process flrsL anLerlor decompresslon and reconsLrucLlon Lhen
posLerlor fuslon

O Surgery plays an lmporLanL parL ln Lhe managemenL lL conflrms Lhe dlagnosls relleves
compresslon lf lL occurs permlLs evacuaLlon of pus and reduces Lhe degree of
deformaLlon and Lhe duraLlon of LreaLmenL
O Powever a Cochrane revlew found LhaL rouLlne surgery ln addlLlon Lo chemoLherapy
had noL been shown Lo lmprove ouLcome buL Lhe problem was LhaL Lhe evldence was
poor
O sLudy from lndla suggesLed LhaL surgery ls noL mandaLory

Comp||cat|ons

O rogresslve bone desLrucLlon leads Lo verLebral collapse and kyphosls
4 @he splnal canal can be narrowed by abscesses granulaLlon Llssue or dlrecL dural
lnvaslon @hls leads Lo sp|na| cord compress|on and neurologlcal slgns (oLLs
paralysls)
4 yphosls occurs because of collapse ln Lhe anLerlor splne and can be severe
4 Leslons ln Lhe Lhoraclc splne have a greaLer rlsk of kyphosls Lhan Lhose ln Lhe
lumbar splne
4 -eurologlcal problems can be prevenLed by early dlagnosls and prompL
LreaLmenL lL can reverse paralysls and mlnlmlse dlsablllLy
4 comblnaLlon of conservaLlve managemenL and surglcal decompresslon glves
success ln mosL paLlenLs
4 LaLe onseL paraplegla ls besL avolded by prevenLlon of Lhe developmenL of severe
kyphosls
4 aLlenLs wlLh Luberculosls of Lhe splne who are llkely Lo have severe kyphosls
should have surgery ln Lhe acLlve sLage of dlsease
4 @he degree of kyphosls Lhe area of affecLed verLebrae and Lhe lack of sphlncLer
conLrol all correlaLe wlLh Lhe chance of recovery from paraplegla
O cold abscess can occur lf Lhe lnfecLlon exLends Lo ad[acenL llgamenLs and sofL Llssues
bscesses ln Lhe lumbar reglon may descend down Lhe sheaLh of Lhe psoas Lo Lhe
femoral Lrlgone reglon and evenLually erode lnLo Lhe skln and form slnuses

rognos|s

O @he progress ls slow and lasLs for monLhs or even years
O rognosls ls beLLer lf caughL early and modern reglmes of chemoLherapy are more
effecLlve
O sLudy from London showed LhaL dlagnosls can be dlfflculL and ls ofLen laLe

reent|on

O s for all Luberculosls CG acc|nat|on
O lmprovemenL of socloeconomlc condlLlons
O revenLlon of nIV and AIDS