CHRONIC SPECIFIC BONE INFECTION DR.MARWAN ZAMZAMI,ABOS

CHRONIC SPECIFIC BONE INFECTION TUBERCULOSIS TUBERCULOSIS BRUCELLOSIS BRUCELLOSIS FUNGAL FUNGAL SYPHILIS SYPHILIS

TUBERCULOSIS THE BASIC MICROSCOPIC LESION; THE TUBERCLE THE BASIC MICROSCOPIC LESION; THE TUBERCLE FIRST DISCOVERED BY THE FRENCH PHYSICIAN LAENNEC ( ) WHO DIED AT THE AGE OF 45 BY TB FIRST DISCOVERED BY THE FRENCH PHYSICIAN LAENNEC ( ) WHO DIED AT THE AGE OF 45 BY TB

TUBERCULOSIS ESTIMATED 30 MILLION TB PATIENTS WORLD WIDE. ESTIMATED 30 MILLION TB PATIENTS WORLD WIDE % ( – ) HAVE SKELETAL INVOLVEMENT

TUBERCULOSIS OF BONES AND JOINTS TB Bacilli lived in symbiosis with mankind since time immemorial. Recorded in ancient Egyptian mummies TB Bacilli lived in symbiosis with mankind since time immemorial. Recorded in ancient Egyptian mummies Still common in developing countries Still common in developing countries

REDUCED INCIDENCE OF TB DUE TO: IMPROVED LIVING STANDARDS; SANITATION, HYGIENE, NUTRITION IMPROVED LIVING STANDARDS; SANITATION, HYGIENE, NUTRITION B.C.G. VACCINE (80% PROTECTION) B.C.G. VACCINE (80% PROTECTION)

TUBERCULOSIS BACILLI MYCOBACTERIUM TUBERCULOSIS BOVINE UNPASTEURISED MILK HUMAN MORE COMMON OTHERS LESS COMMON

TUBERCULOSIS YOUNGER AGEOLDER AGE

TUBERCULOSIS FACTORS FAVORING LOCALISATION BLOOD SUPPLY AND STAGNATION BLOOD SUPPLY AND STAGNATION LOCAL TRAUMA; HAEMATOMA? LOCAL TRAUMA; HAEMATOMA? LOCAL STEROIDS ? LOCAL STEROIDS ?

TB PATHOLOGY Secondary to other primary TB lesions (Pulm., GL, Renal, LN) Secondary to other primary TB lesions (Pulm., GL, Renal, LN) Route of spread: Route of spread: HAEMATOGENOUS **** DIRECT (much less) * bone to joint * soft tissue to bone THE PRIMARY LESION THE PRIMARY LESIONQUIESCENT ACTIVE: (Apparent, Latent)

TB PATHOLOGY INFLAMMATION HYPEREMIA - OSTEOPENIA INFLAMMATION HYPEREMIA - OSTEOPENIA TB FOLLICLES (TUBERCLE): TB FOLLICLES (TUBERCLE): LYPHOCYTE – MONOCYTES ENDOTHELIAL CELLS LANGHANS GIANT CELLS COALESCE COALESCE CASEATION LATER CASEATION LATER GRANULATION TISSUE GRANULATION TISSUE BONE DISTRUCTION BONE DISTRUCTION SINUSES SINUSES

TB Follicle

TB PATHOLOGY (JOINTS) SYNOVIAL SWELLING SYNOVIAL SWELLING GRANULATION TISSUE PERIPHERAL ARTICULAR DESTRUCTION PERIPHERAL ARTICULAR DESTRUCTION NO PROTEOLYTIC ENZYMES CENTRAL ARTICULAR WEIGHT- BEARING AREA PRESERVED RICE BODIES RICE BODIES FIBRIN & ARTICULAR CARTILAGE INCREASED BLOOD SUPPLY INCREASED BLOOD SUPPLYOSTEOPENIA

CLINICAL PICTURE AGE AGE INSIDIOUS ONSET INSIDIOUS ONSET MONO ARTICULAR MONO ARTICULAR OTHER LESIONS OTHER LESIONS FAMILY HISTORY – CONTACT FAMILY HISTORY – CONTACT GROUPS AT RISK GROUPS AT RISK

SYMPTOMS & SIGNS CONSTITUTIONAL LOW GRADE FEVER LOW GRADE FEVER ANOREXIA ANOREXIA WEIGHT LOSS WEIGHT LOSS NIGHT SWEATING NIGHT SWEATING TACHYCARDIA TACHYCARDIA ANEMIA ANEMIA

SYMPTOMS & SIGNS LOCAL Symptoms : PAIN PAIN NIGHT CRIES NIGHT CRIES SWELLING SWELLING STIFFNESS STIFFNESS ULTERED FUNCTION ULTERED FUNCTION Signs : WASTING WASTING SYNOVIAL SWELLING SYNOVIAL SWELLING TENDERNESS TENDERNESS WARM WARM STIFFNESS STIFFNESS LIMPING LIMPING

INVESTIGATIONS LEUCOPENIA – LYMPHOCYTOSIS LEUCOPENIA – LYMPHOCYTOSIS ANEMIA ANEMIA RAISED ESR RAISED ESR MANTOUX POSITIVE MANTOUX POSITIVE NOT IN: MILIARY TB / RECENTLY VACCINATED/ ON STEROIDS / REDUCED IMMUNITY / FEVER ON STEROIDS / REDUCED IMMUNITY / FEVER

RADIOLOGY CHEST X-RAY : ALL PATIENTS CHEST X-RAY : ALL PATIENTS JOINTS: PHEMISTER’S TRIAD: JOINTS: PHEMISTER’S TRIAD: 1. PERIARTIC. OSTEOPENIA 2. REDUCED JOINT SPACE 3. PERIPH. OSSEOUS EROSIONS BONES: 1. DESTRUCTION 2. SEQUESTRATION 3. ABSCESS FORMATION

RADIOLOGY BONE SCAN: MONO – ARTICULAR BONE SCAN: MONO – ARTICULAR CF: RHEUMATOID ARTHRITIS CALLIUM SCAN INFECTION CALLIUM SCAN INFECTION CT SCAN MORPHOLOGY CT SCAN MORPHOLOGY MRI MORPHOLOGY MRI MORPHOLOGY

DIAGNOSTIC ASPIRATION: ASPIRATION: AFB POSITIVE HISTOLOGICAL HISTOLOGICAL CULTURE CULTURE

TB SPINE (POTT’S DISEASE) PERCIVAL POTT 1779 SECONDARY TO OTHER PRIMARY SECONDARY TO OTHER PRIMARY HEMATOLOGICAL HEMATOLOGICAL 20% OTHER VISCERA 12% OTHER BONES/JOINTS TWO ADJACENT VERTEBRAE SOMETIMES MORE THAN ONE TWO ADJACENT VERTEBRAE SOMETIMES MORE THAN ONE SKIP LESIONS IN 7% SKIP LESIONS IN 7%

TB SPINE SURGICAL PATHOLOGY FIRST THREE DECADES FIRST THREE DECADES THORACO-LUMBAR THORACO-LUMBAR CENTRAL SPINE CENTRAL SPINE SPARKS POSTERIOR ELEMENTS SPREADEDS UP/DOWN ANT./POST. LONG. LIGS. LESIONS COALESCE – COLLAPSE LESIONS COALESCE – COLLAPSE KYPHUS FORMATION KYPHUS FORMATION

TB SPINE SURGICAL PATHOLOGY PARA VERTEBRAL ABSCESS PARA VERTEBRAL ABSCESS CERVICAL: RETROPHARALYGEAL THORACIC: P.V. & ALONG RIBS LUMBAR: PSOAS ABSCESS POSTERIOR:LUMBAR TRIANGLE ANTERIOR: ILIAC FOSSA BELOW ING. LIG. BELOW ING. LIG. NEUROLOGICAL COMPLICATION NEUROLOGICAL COMPLICATION MORE IN THORACIC (NARROWEST CANAL) MORE IN THORACIC (NARROWEST CANAL)

TB SPINE CLINICAL FEATURES GENERAL: INSIDIOUS ONSET GENERAL: INSIDIOUS ONSETCONSTITUTIONAL LOCAL:PAIN – FIRST INDICATION LOCAL:PAIN – FIRST INDICATION LOCAL – REFERRED LOCAL – REFERRED STIFFNESS – SPASM WEAKNESS – NEUROLOGICAL

SIGNS OF TB SPINE MUSCLE SPASM MUSCLE SPASM KHPHUS – GIBBOUS KHPHUS – GIBBOUS TENDERNESS TENDERNESS STIFFNESS STIFFNESS PARA VERTEBRAL ABSCESS PARA VERTEBRAL ABSCESS NEUROLOGICAL – WEAKNESS NEUROLOGICAL – WEAKNESS PARAPLEGIA PARAPLEGIA

TB SPINE RADIOLOGICAL FEATURES DISC NOT INVOLVED PRIMARILY DISC NOT INVOLVED PRIMARILY NARROWING OF DISC SPACE NARROWING OF DISC SPACE BONE DESTRUCTION BONE DESTRUCTION USUALLY TWO ADJACENT VERTEBRAE MAY SHOW SKIP LESIONS MAY SHOW SKIP LESIONS PARA VERTEBRAL ABSCESS PARA VERTEBRAL ABSCESS KHYPUS KHYPUS CT/MYELOGRAM/MRI IN PARAPLEGIA CT/MYELOGRAM/MRI IN PARAPLEGIA

PARAPLEGIA IN TB SPINE IN 10-30% OF TB SPINE IN 10-30% OF TB SPINE MORE IN THORACIC REGION MORE IN THORACIC REGION PRESSURE ON CORD ANTERO LATERAL PRESSURE ON CORD ANTERO LATERAL MOTOR EARLIER THAN SENSORY SIGNS: UPPER MOTOR NEURON SIGNS: UPPER MOTOR NEURON MAY START BY CORD SHOCK REMARKABLE ABILITY TO RECOVER REMARKABLE ABILITY TO RECOVER

PARAPLEGIA IN TB SPINE CAUSED BY EXTRADURAL PRESSURE GRANULATION TISSUE GRANULATION TISSUE PRESSURE OF ABSCESS & CASEATON PRESSURE OF ABSCESS & CASEATON SEQUESTRUM SEQUESTRUM PATHOLOGICAL FRACTURE/DISLOC. PATHOLOGICAL FRACTURE/DISLOC. SEVERE KYPHUS SEVERE KYPHUS INFLAMMATION: TOXIC EDEMA INFLAMMATION: TOXIC EDEMA VASCULAR VASCULAR

MANAGEMENT OF TB SPINE USUALLY CONSERVATIVE USUALLY CONSERVATIVE GENERAL GENERAL SPECIFIC SPECIFICRESTIMMOBILISECHEMOTHERAPY SURGICAL SURGICAL DIAGNOSE DIAGNOSEASPIRATION DRAIN ABSCESS DRAIN ABSCESS DEBRIDE DEBRIDE DECOMPRESS DECOMPRESSANTERIORANTERO-LATERAL STABILISE FUSION STABILISE FUSION

MOST CASES OF TB SPINE RESPOND VERY WELL TO CONSERVATIVE TREATMENT INCLUDING THOSE WITH PARAPLEGIA THE NEED FOR SURGICAL DECOMPRESSION OF THE CORD IS LIMITED

BRUCELLOSIS MILK AND MILK PRODUCTS MILK AND MILK PRODUCTS BACK PAIN AND STIFFNESS BACK PAIN AND STIFFNESS MUSCLE SPASM FEVER – MILD SACRO-ILIAC JOINT SACRO-ILIAC JOINT LESS DESTRUCTIVE OF TB LESS DESTRUCTIVE OF TB BRUCELLA TITRE BRUCELLA TITRE ANTIBIOTICS ANTIBIOTICS e.g. SEPTRIN - OXYTETRACYCLINE

SYPHILIS SPIROCHETE SPIROCHETE TREPONEMA PALLIDUM CONGENITAL SYPHILIS – COMMONEST CONGENITAL SYPHILIS – COMMONEST CHRONIC OSTEOCHONDRITIS CHRONIC OSTEOCHONDRITISPERIOSTEITISOSTEITIS TIBIA LESABRE TIBIA TIBIA LESABRE TIBIA

FUNGAL INFECTION CHRONIC – VERY LOW GRADE CHRONIC – VERY LOW GRADE FEET – FARMERS – THORNS Madura Foot FEET – FARMERS – THORNS Madura Foot SLOW DESTRUCTION SLOW DESTRUCTION SINUSES – GRANULES SINUSES – GRANULES SECONDARY BACTERIAL INFECTION SECONDARY BACTERIAL INFECTION RESISTANT TO CHEMOTHERAPY RESISTANT TO CHEMOTHERAPY NEEDS SURGICAL DEBRIDEMENT NEEDS SURGICAL DEBRIDEMENT IF ADVANCED MAY NEED AMPUTATION IF ADVANCED MAY NEED AMPUTATION