CARIES SPINE AND SPINAL STENOSIS DR. NADIR MEHMOOD ASSOCIATE PROFESSOR SURGERY IIMC-T, RLY HOSP

CLINICAL ASPECTS OF TUBERCULOSIS Pathogenesis of tuberculosis Infection versus disease Host factors Pathogen factors

PATHOGENESIS Host factors include Social e.g. Age e.g. Immunity e.g. Poverty alcoholism Age e.g. Newborn Teenage girl Old age Immunity e.g. HIV Gamma interferon

PATHOGENESIS Organism factors e.g. Virulence factors [Drug resistance]

PATHOGENESIS Tuberculous disease is a consequence of: Primary infection e.g. In a baby Reactivation ‘natural’ Associated with immunosupression Re infection

PULMONARY TB TYPICALLY AFFECTS THE UPPER ZONES OF THE LUNG

CLINICAL FEATURES Clinical illness Pulmonary Extrapulmonary

CLINICAL ILLNESS TB may affect any tissue of the body including: Skin and soft tissue Lymph nodes Bones and joints Intra abdominal structures including peritoneum Kidneys Adrenal glands Central nervous system Tuberculoma meningitis

Clinical clues for TB Clinical symptoms – usually ‘chronic’ rather than acute Fever Sweats Weight loss Focal symptoms Epidemiology History of TB, HIV Country of origin, recent travel/work Contact with TB Investigations- CP ESR,URINE R/E, CXR, X-RAYS, C/S, SKIN TESTS,ELISA, CRP, PCR, CT, MRI

TB – guidelines for the clinician Great mimicker Low index of suspicion Pulmonary TB usually easy to consider Non pulmonary often requires ‘lateral thinking’

What will happen if diagnosis or treatment for TB spinal osteomyelitis is delayed?

MENINGES OF THE SPINAL CORD

What will happen if treatment delayed What will happen if treatment delayed? – gibbus formation (acute angulation of spine with or without neurological damage)

The physical appearance – Potts disease of spine - gibbus

Progress Increasing back pain and neurological symptoms – mild leg weakness Treatment Continue therapy consider surgical decompression

Other considerations - clinical Further progress Weakness of legs Neurosurgery and internal splinting Other considerations - clinical Has the patient got HIV? Is vitamin D level normal? Other considerations - epidemiological From where has the pt got infection? To whom might the pt have given it?

TREATMENT OF TB BTS guidelines – 1999 Thorax 2000: 55; 210-218 NICE guidelines – 2006 Sensitive TB – 4 drugs for 2 months 2 drugs for 4 months Resistant TB - 6 drugs for 24 months (second line drugs are not so effective) [Eng, Wales & NI 2004, 6.8% Isoniazid resistant, 1% MDR TB (R to Isoniazid and rifampicin)]

Problems of TB therapy Toxicity e.g. liver Multiple therapy Prolonged treatment Drug interactions

Compliance Treatment will not work if not taken DOTS (Directly Observed Therapy) if: Likely poor compliance MDRTB

Public health - avoiding transmission TB is statutorily notifiable disease Multidisciplinary approach – medical, TB nurses, CCDC etc. Identify and manage possible sources of infection and contacts Considerations treat as OP where possible multi occupancy housing, social deprivation negative pressure rooms in hospitals (limited facility) beware transmission in OP setting e.g. waiting area

WHY FAILURE? Patient non compliance Deliberate Failure to understand e.g. language, culture Social e.g. alcohol Patient movement e.g. ‘lost to follow up’ Lack of medical/nursing support others

Summary TB is a challenging disease for the clinician Must have microbiology before starting treatment – more rapid lab tests? Need to encourage compliance Need for multidisciplinary approach to diagnosis and management and control Need shorter, better, cheap anti TB regimes

SAMPLE MSQs The starting pathogenesis in TB is; Secondary TB Miliary TB Ghon focus CNS involvment GIT involvment The advanced stage in Potts disease is Paresis Lost urinary control Gibbus formation Paraplegia Death Poor compliance to treatment, TB of any site becomes Resistant to treat MDRTB XDRTB MILIARY TB TB ABSCESS

Thank You.