Infection, Chapter 12 Flashcards
(99 cards)
1
Q
What is the most responsible organism cause all bone and joint infection in normal host ?
A
Staphylococcus aureus
2
Q
What are the responsible organisms cause bone & joint infection in immunocompromised host ?
A
S. aureus, other organism are ..
- H. influenzae
- Diplococcus pneumoniae
- Mycobacterium
- Pseudomonas
- Fungi
- Gram-negative organism
3
Q
When the humerus was involved in infant patient, the responsible organism is …
A
Streptococcus group B
4
Q
1) How much percentage do pre-existing organ infection occur in bone and joint infection ?
2) And what are the most commonly involved organ ?
A
50% of cases.
Most commonly involved pre-existing organ are..
- Skin
- Respiratory tract
- Genitourinary tract
5
Q
Concerning about suppurative osteomyelitis most often occur between age ? and is there gender predilection ? and which gender ?
A
Between 2 and 12 years with male : female about 3 : 1 ประมาณว่าเด็กชายซนกว่า exposed trauma มากกว่า ไรงิ
6
Q
Which bones are most commonly involved in suppurative osteomyelitis ?
A
Large tubular bones of extremities.. - Femur, the most common - Tibia, humerus and radius, favored sites - Rare calvicle as pelvis (but pelvis not rel. trauma)
7
Q
” Bone infection at pelvis occurs with rarely associate with trauma. “
Does the above statement is true ?
A
Yeah
chu!
- )3(/// x ////
8
Q
What is the major predisposing factor to development suppurative osteomyelitis ?
A
IVDU,
in this pt. group the unusal sites predilection are "S" joints: >> Spine >> SI >> Symphysis pubis >> Sternoclavicular joint
9
Q
Please described the difference vascular anatomy between
- Infantile pattern
- Childhood pattern
- Adult pattern
that contribute to difference infection pattern of bone and joint …
A
- Infantile pattern
> เป็นลักษณะ เลือดที่มาเลี้ยงตอนยังเป็น fetus ซึ่งจะยังคงอยู่ ใน tubular bone จนอายุ 1 ปี โดยการที่มีลักษณะดังกล่าวอาจทำให้ยังมี metaphyseal and diaphyseal vessels ทะลุ physis (epiphyseal plate)
> Trueta พบว่า vascular barrier ที่ epiphyseal plate สามารถพบได้ ตั้งแต่อายุ 8 เดือน และโตเต็มที่ตอนอายุ 18 เดือน
> Co’z infantile pattern epiphyseal involvement - Childhood pattern
> เกิดขึ้นช่วง ระหว่าง 1 ขวบ จน epiphyseal ปิด
> เป็นช่วงที่ blood flow บริเวณ metaphysis เป็น turbulence flow และ ช้า ทำให้เกิดสภาวะที่เหมาะสมต่อการเจริญของ microbe
> Co’z infection โดน metaphysis โดยที่ spare joint และ epiphysis - Adult pattern
> ในช่วงที่เป็น adult metaphyseal vessels จะค่อยๆ penetrate ผ่าน ส่วนที่เคยเป็น physis
–> re-establishing communication ระหว่าง metaphysis และ subarticular end of bone (epiphysis)
> Co’z increased incidence of septic arthritis secondary to OM in adult
10
Q
Does the process of osteolytic lesion in infection and bone metastasis involved osteoclast activity both ?
If not which one involve ?
A
No, in bone infection, the hyperemia at marginal area promote the osteoclast activity.
In bone metastasis, pressure effect cause bone resorption, not involved osteoclastic activity.
11
Q
When infection through bone marrow and cortec and at last involved subperiosteal space, why this process in subperiosteal space is readily (เร็ว) ในเด็กทารก
A
เนื่องจากในเด็ก มี Sharpey’s fibers น้อยกว่าในผู้ใหญ่ จึงทำให้ perisoteal easily detach from bone
12
Q
What are the “ Sequestrum “ , “ Involucrum “ , “ Cloaca “ and “ Empyema nessitatis “ meanings ?
A
Sequestrum
» Mean the dead bone,
» In small size may removed by osteoclast
In larger size mat need surgical removal
Involucrum
» Latin “ to wrap or cover “
» As the pus lifts the periosteal, causes new bone formation and pain.
–> The periosteal new bone is the body’s to attempt to well off infectious process
» เห็นเป็น thick bony sleeve หุ้ม shaft of bone ส่วนที่ infected (cortical collar of new bone)
Cloaca
» a defect in involucrum (draining sinus)
» functioning to decompressed or discharge inflammatory product from bone
» Also referred as “ empyema nessitatis “
13
Q
When developed malignant transformation from the cloaca in chronic osteomyelitis, we called ?
A
Marjolin’s ulcer
14
Q
How long is the latent period of Marjolin Ulcer from onset of OM to CA ?
A
Latent period is about 20 - 30 year
15
Q
What is the most reliable treatment of Marjolin’s ulcer ?
คำถามไม่ค่อยดีนะ
A
Amputation
16
Q
Where is the most common sites in developed Marjolin’s ulcer in osteomyelitis?
A
Tibia and fibula
17
Q
From the knowledge of development of Marjolin’s ulcer, when encounter the case of chronic OM what should be performed in all case of chronic ulcer ?
A
Biopsy งัย ถ้าเป็น CA ก้อตัดเลย
18
Q
1) How long is the Radiographic latent period in detection of OM ?
2) How long is the Radiographic latent period in detection of OM in spine* ?
[เน้น spine]
A
1) about 10 days
2) About 3 weeks
19
Q
Please described early signs and late signs of Osteomyelitis on Radiographs..
[ From Yochum P 1378 ]
A
Early signs [Latent period 10 d, spine 21 d]
» Soft tissue
- Elevation and displacement of fat plane
- Obliteration of fat plane
- Increased density of soft tissue
» Bone
- Moth-eaten or Permeative bony destruction of medullary and cortical bone
- Periosteal new bone
(Solid, Laminated, Codman’s triangle)
Late signs
>> Soft tissue
- Draining sinus tract (secondary sinus tract carcinoma)
- Debris
>> Bone
- Destruction the adjacent cortex
- Involucrum
- Cloaca
- Sequestrum
- Sclerosis and moth-eaten sclerosis
>> Joints
- Loss of joint space
- Ankylosis
20
Q
What is the most early detecting image modality in detection bone destruction ?
A
Bone scan, Positive in a few hour after onset of symptoms
21
Q
What most common used radiopharmaceutical in detection bone infection ?
A
Tc 99m MDP
Gallium-67 citrate
–||–||–||–||–||–||–||–||–||–||–||–||–||–
In dynamic (triple phase scan) shows increased uptake all in three phase
(จำไม่ค่อยได้แล้ว)
- Vascular (uptake จาก hyperemia)
- Parenchyma
- Late (uptake ใน bone, ไม่เกิดใน cellulitis)
22
Q
Please described the change of bone infection in MRI, T1W and T2W signal ?
A
T1 ดำ
T2 ขาว
อักเสบเลยมีน้ำ
23
Q
When the T1 low and high T2 involving the “__________” aspect of bone in children, diagnostic of bone infection could be made.
A
juxta-physeal medullary
24
Q
When the radiographic sign of bone infection in soft tissue developed ?
Early or later than Bone change ?
A
3 days,
often early than bone change
(10d, 21d in spine)
25
When soft tissue change in bone infection occured, the obliteration of myofascial marginal plane will occured in deep myofascial structures first and then affected more superficial levels.
Does the above statement is true ?
Yes ตรงไปตรงมานะ
26
In obliteration of soft tissue plane between infectious process and neoplastic process, what is the difference ?
In neoplasm usually displaces and deform soft tissue margin w/o obliterating them.
In infect / inflammation usually obliterated soft tissue margin.
27
When does the bone sequestrum formation occured after initial onset of symptoms ?
About 3 -6 weeks after initial onset of symptoms
28
How much percentage of spine involvement in OM occured ?
In which patient group does the spinal OM occured ?
In which part of spines is the most common site of spinal OM ?
2-4%
(ต้องจำ จารย์ชอบถาม หนังสือ ชอบเขียนว่า well known)
Debilitated patient in 5th to 6th decade
Male > Female
Lumbar spine followed by thoracic spine
29
For spinal OM the most common organism is ?
Staphylococcus aureus
30
1) Other than S.aureus what are the organism cause spinal OM ?
2) Between Gram positve and negative which one are more common organism in general cases and IVDU ?
1)
Gram positive :
- Streptococcus
- Pneumococcus
Gram negative :
- E. coli
- Pseudomonas
- Salmonella
- Klebsiella
- Corynebacterium
2) Gram positive is more common in general cases but Gran negative is more common in IVDU
-----------------------------------------
NOTE
* Brucellosis
(Brucella abortis, B. melitensis, B. suis)
>> common causes of joint infection (30%)
>> Spine involvement (25-50%)
>> SI joint (40-70%)
31
1. What is the most common complaint symptom in spinal OM ?
2. Does the following statement in true ?
a. " In symptom of pain from spinal OM, pt. may presented with radicular pain and aggravated by motion "
b. " Almost all case do have fever in spinal OM "
c. " often WBC is normal in spinal OM but more common to elevated in appendicular OM "
d. " in IVDU patient, increased incidence of cervical spine OM "
1. Back pain
2.
a. True, infective symptom may mimic degenerative change
b. False, fever is infrequent in adult and in children only 1/3 developed fever
c. True, แปลกแต่เจง Yochum เขียนไว้
d. True
32
Concerning about spinal OM,
>> In children age < 20 years, what is the cause of disc involvement before vertebral body.
>> In adult, what is the initial focus of infection in spinal OM ?
>> ในเด็กอายุ < 20 ปี,
- Disc vessels still exist, infection can occured before vertebral body
- Initial findings is narrowing disc height with paraspinal edema (abscess)
- Follow by desturction of vertebral end plate then verteebral body
>> ในผู้ใหญ่
- ตำแหน่งแรกของการติดเชื้อ คือ
Anterior vertebral endplate ซึ่ง containing vascular arcade และเป็นที่ให้ nutrition กับ intervertebral disc ร่วมกับเป็นบริเวณที่มี low flow
- จึงทำให้ organism มักมา lodge อยู่บริเวณ subchondral plate ก่อน involve disc
- Later developed vertebral collapse and paraspinal swelling
33
Does intradisc gas common in spinal infection ?
If intradisc gas occured from infection, what are the responsible organism ?
No
Clostridia, Brucellosis, TB and streptococcus
34
How can we observed soft tissue swelling in spine infection in plain radiograph in each part (cervical, thoracic and lumbar spines) ?
For cervical spine
>> Widening prevertebral soft tissue (retropharyngeal, or retrotracheal space)
For Thoracic spine
>> Displacement of paraspinal line
For Lumbar spine
>> paravertebral or psoas abscess
35
Brucella spondylitis exhibits diminish disc height, loss of vertebral end plate and 15% developed paraspinal abscess.
What are the other manifestation of Brucella spondylitis ?
What is most common site of Brucella spondylitis ?
1. Anterior discovertebral erosion simulating Schmorl's node with normal disc
2. Ivory vertebra
3. Peripheral vacumm phenomenon
4. Frequently anterior osteophytes
The most common site is Lower Lumbar spine.
36
1) What are naming species of Brucellosis that is pathogen in spondylitis ?
2) What are the common DDx of Brucella spondylitis and why ?
1) Brucella abortis, B. melitensis, B. suis
2) Psoriatic arthritis and Reiter's syndrome
From จาก pattern involvement
>> common causes of joint infection (30%)
>> Spine involvement (25-50%)
>> SI joint (40-70%)
37
Concerning about Brodie's abscess
- What is the classical presentation ?
- And from the clinical presentation what is the DDx of the Brodie's abscess ?
- From radiographic findings of Brodie's abscess what are the DDx ?
- What is the usual precede history ?
- What patient group is common to developed ?
- Which site of bone is most common involved and what bone commonly affected, please described in decreased order ขอห้าลำดับ (เอง) ?
- Classic presentation: Nocturnal pain, relieve with aspirin
- Clinically Mimic the osteoid osteoma
- a) Osteoid osteoma ถ้าไม่พูดถึงขนาดแยกกันไม่ได้
b) Eosinophilic granuloma มีหลากหลาย radiographic findings ที่ overlap กะ abscess
- Recent distant infection or dental Sx
- Common in male children
- Location: Metaphysis of long bone
1st Distal tibia
2nd Proximal tibia
3rd Distal femur
4th & 5th Proximal & distal fibula
6th Distal radius
++ Less frequent effect diaphysis of tubular and flat bone
38
Concerning about Brodie's abscess
- อะไร คือ Brodie's abscess
- Wall of Brodie's abscess consist of ?
- What are the content of Brodies's abscess ?
- Are the Brodie's abscess is common to be sterile or no organism found ?
- In which condition of Brodie's abscess has negative bacterial cultures ?
- What is the most responsible organism ?
- เป็น localized or aborted form of suppurative OM (ประมาณว่า localized form ของ OM)
- Inflammatory granulation tissue and sclerotic change of surrounding spongy. bone.
- Necrotic debris, purulent or mucoid fluid
- Often sterile or C/S Negative
- When internal content is mucoid fluid.
- S. aureus
39
Please described radiographic appearance of Brodie's abscess ..
Abscess...
- Oval, Elliptical or serpiginous radiolucency with no visible matrix
- Surrounded by a halo or doughnut rim of heavy reactive sclerosis
- Radiolucency usually >/= 1 cm with no associated with bony enlargement or cortical break through.
[ **** เป็นจุดที่ใช้แยกกับ Osteoid osteoma มักจะมีขนาด < 1 cm และอาจมี targaet center calcification + Nidus of osteoid osteoma ประกอบด้วย vascular stroma ซึ่งจะแสดง "vascular blush" ใน arteriogram >> confirm Dx ได้]
40
What is the characteristic MRI sign/findings of subacute osteomyelitis ?
Penumbra sign !!!
High SI T1 (abscess) surrounded by a relatively less hyperintense rim
เป็น sign ที่ suggestive Infection > Neoplasm
41
1) What is Garre's sclerosing osteomyelitis ?
- =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
2) Which patient group and what symptom developed Garre's sclerosing osteomyelitis ?
- =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
3) Where are the common site in developing Garre's sclerosing osteomyelitis ?
- =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
4) What is the radiographic appearance of Garre's sclerosing osteomyelitis ?
1) Garre's sclerosing osteomyelitis.. is
- A peculiar (= ประหลาดล้ำ) form of chronic, low grade, diffuse, non-purulent OM
- Characterized by striking absence of pathogens on attempted C/S
- ถ้าจับเชื้อได้จะเป็น S. aureus
- Extremely rare condition
-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
2) Pt. group and symptoms
- Only in children and young adult
- Symptom are moderate nocturnal pain (เอ่อ Yochum รู้ว่า moderate เท่าไหร่ด้วย ?) with palapable bone mass on PE
-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
3) Common sites
Long tubular bone
[Resnick ว่า mandible]
-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-
4) Radiographic findings
- Exuberant (= มากมาย) degree of fusiform thickening of bone.
- Often cortical with significant ossifying periostitis and reactive new bone formation
- No bone destruction or sequestrum.
42
What is the most common organism in chronic OM ?
S. aureus
43
What are the complication of chronic osteomyelitis ?
What is SAPHO syndrome ?
Complication of chronic OM
> Marjolin's Ulcer
> SAPHO syndrome
```
SAPHO syndrome comprised of
> Synovitis
> Acne
> Pustulosis
> Hyperostosis
> Osteitis syndrome
```
44
Please described the radiographic findings and the single most common site of chronic Osteomyelitis ?
```
Radiographic findings of chronic OM:
> Increased density of affected bone
- Sclerosis
- Periosteal new bone
(Solid or Laminated)
- Cortical thickening
- Area of bone destruction
- Dense Sequestra
> !! Soft tissue mass is Rare in chronic OM when presented can mimic neoplasm
```
Tibia is the single most common site of chronic Osteomyelitis.
กระดูกอื่นก็โดนได้นะ
45
1. In differential and diagnosis post-op scar from reactive infection after operation 1 year, what is the better tools ?
A) MRI
B) Bone Scan
C) CT
2. In absence of history of surgery, what is the best image modality in diagnosis low grade bone infection ?
A) MRI
B) Bone Scan
C) CT
3. What is the best tool to visualized sequestra, cortical erosion, and bony fragmentation ?
1. B
>> within the 1st year MR cannot be differentiated these 2 condition
>> CT Yochum ไม่ได้พูด
2. A
>> MRI sensitive > bone scan
>> In absence of MR findings, the acute activity of chronic OM can be excluded
3. CT
>> Yochum เขียนไว้อ่ะ
46
What is the cause of prolonged ATB usage in chronic osteomyelitis and surgical debridement is also need ?
- Frequent fragment of bone
| - Organism is isolated from blood supply and primary site of infection (ประมาณเลือดเข้าไปเลี้ยงไม่ดี)
47
Please give the synonym of childhood inflammatory Discitis for 3 names at least ..
1. Non-specific discitis
2. Discitis
3. Spondyloarthritis
4. Childhood intervertebral infection
*** Childhood inflammatory Discitis เป็น other form of vertebral osteomyelitis คือโดน Disc อย่างเดียว (อันนี้คิดเองนะ)
48
What are the purpose factor to developed childhood inflammatory Discitis ?
1. Owing to, the discal blood supply is exist until 20 years of age that provide the direct route to cause discitis.
2. Post-traumatic fragmentation of cartilagenous endplate
49
Do the following sentence are true ?
1) The responsible organism of childhood inflammatory Discitis is not alway isolated.
2) The most common organism is not S.aureus.
3) The posterior element is usually spare.
4) Usual to developed ankylosis.
1) True
2) False
3) True
4) False
50
Concerning about Childhood inflammatory Discitis.
- What is the age incidence ?
- Which gender is more predilection ?
- What are the clinical S&S and lab findings, do it more severe than Spinal OM ?
- What is the most common preceding history before developed Discitis ?
> Age incidence
- Less than Spinal OM about 1-16 years
Mean at 3 years.
> Male are more afflected.
> S&S same as Spinal OM but less severe
- Constituional Symptoms: Malaise, Low-grade Fever, Anorexia and irritability
- Young child Refuse to walk/ sit/ stand
Older child complaint back and hip pain
- Elevated ESR with normal WBC count
- Common Hx is head & neck infection, the most common is URI
51
Concerning about childhood inflammatory Discitis.
1. How long is the latent period of radiograph findings ?
2. What is the most sensitive modality in detection ?
3. What is the most common site in spine ?
4. What is the most earliest sign ?
1. About 3-4 wk
2. Bone Scan
3. Lumbar (75%) then Thoracic, rare C-spine
4. Narrowing of disc space
52
Please described the sequelae change of childhood inflammatory Discitis ..
- Earliest sign : Narrowing of disc space
- Fragmentation and destruction of subchondral endplate
- Progressive subchondral sclerosis
[Posterior element usually spare*]
- Mild spinal flexion deformity
[Unusual to developed ankylosis**]
53
About Septic Arthritis.
1. What is the age incidence ?
2. Common presented as oligo-, poly- or monoarticular ?
3. What are two common route of infection ?
4. What is secondary Septic arthritis ?
1.
54
About Septic Arthritis.
1. What are the two majority isolated organisms ?
2. What are other common organisms ?
3. What are occasionally isolated organism ?
1. S.aureus most common with Gonococcus
2. Haemophilus, E.coli, Salmonella, Brucella, Serratia, Pneumococcus and Alpha/Beta-hemolytic streptococcus
3. Nocardia, TB and fungal
55
Concerning about Septic Arthritis.
1. What are the S&S ?
2. Labaratory change ?
3. What are the treatment ?
4. Between Site (joint) involved, Age of Pt. and time for 1st diagnosis which one(s) not affected outcome of patient ?
1. Sign and symptoms:
> Restricted joint motion and function from pain and capsular edema
> Other symptoms - erythema, acute fever +/- chills
> Altered gait - if involved weight-bearing joint
> Restricted motion in non-weight-bearing joint
2. Labarotory change
> Elevated ESR, CRP,
Leukocytosis with left shifted
> +ve H/C
3. ATB with joint decompressin
4. Age and Site of involved not affected the outcome of patient
56
According to Resnick and Niwayama, please described the pathogenesis of septic arthritis ..
1. Organism lodge at vasculature of synovial membrane [ไม่ว่าปลิวมาจากที่ไกลๆ / จาก infected bone ใกล้ๆ].
2. Spread of infection from synovial membrane to fluid.
3. Accumulation of purulent exudate in synovial capsule (Distention of joint capsule)
4. Distention compromised normal cartilage nutrition --> death of chondrocyte.
5. Disintigrate of chondrocytes and inflammatory cells, release proteolytic enzyme further and progressive destruction of joint surface
6. Subchondral bone is penetrated and destruction of articular cortex.
7. Regional hyperemia with disuse cause juxta-articular osteoporosis
8. Bony or fibrous ankylosis is evident.
57
What is the causes of juxta-articular osteoporosis ?
Regional hyperemia with disuse
58
Concerning about septic arthritis..
1. Does gas formation in septic arthritis is common ?
2. What responsible organism cause gas in joint and soft-tissue?
3. What is the most common cause of gas in the soft tissue near joint ?
1. Rare
2. E.coli and Clostridium perfringens
3. Open wound or recent arthrocentesis
59
1. What are the most common joint of septic arthritis ?
| 2. What are the less common joint that developed septic arthritis ? And what are the most likely cause ?
1. 85% are Knee, hip and ankle
2. Less common joint :
Shoulder, Hand and Foot
From penetrating wound (animal or human bites)
60
Between clinical change and film change in septic arthritis which one change first ?
Clinical change first
61
Bone scan for septic arthritis change can be done as early as ?
24-48 hour
| Show increased uptake in both vascular and delayed scan
62
1. What is the early sign of soft tissue change in septic arthritis ?
2. In septic hip joint what could be seen in early change of soft tissue ?
3. What is specific named sign of joint effusion ?
1. Distention of joint capsule, seen as displacement of juxta-articular fat
2. Displacement of normal fat folds for the obturator internus, psoas major, gluteus medius
3. Waldenstrom's sign :
>> Distance from lateral aspect of Kohler's teardrop (inferior and medial surface of the acetabulum) to the medial margin of femoral head
>> +ve เมื่อระยะ > 11 mm หรือ สองข้างต่างกัน > 2 mm
[สามารถใช้เป็น early sign of infection ได้ เนื่องจาก early sign of septic joint ครือ capsular distention]
63
Please described sequence in pathologic change in septic joint ?
1. Capsular distention
2. Cartilage destruction
3. Bone change (moth-eaten)
4. Ankylosis (fibrous > bony)
64
What is the earliest sign of bone change in septic joint ?
Loss of normal subchondral bone
65
After subchondral bone destruction occurred what is the bone change after that ?
Medullary metaphyseal moth-eaten bone destruction
66
When the bone infection is extensive, disrupt outer cortical bone and irritate periosteal, what is the appearance of periosteal reaction ?
Laminated periosteal change
| ตอนต้นบทเขียนไว้ จิงๆ ก้อเป็น solid, Codman's triangle ได้นา
67
What is the late sequelae change of septic arthritis ?
Ankylosis
68
When the infection breakthough metaphysis and epiphysis to joint space, we called ?
Tom Smith's arthritis
69
1. Tom Smith's arthritis occurs at what site of bone ?
| 2. What are the common bone get involved and what are the joint that affected ?
1. Proximal metaphysis
2. Bone ที่โดน
- Proximal and Distal Femur
- Distal tibia
- Proximal and Distal humerus
Joint ที่โดน
- Shoulder, Elbow, hip, knee, ankle
70
What are the another name of non-suppurative OM ?
Tuberculous OM
71
What responsible organism (specie name) cause tuberculosis OM and septic arthritis by "ingestion" and what are the route of dissemination and what animal is carrier?
- Mycobacterium Bovis
- Hematogenous
- Cow
72
What are the most common organism isolated from non-suppurative OM ?
Mycobacterium tuberculosis
73
1) How much percentage of skeletal tuberculosis account for ?
2) What is the prevalence of skeletal tuberculosis ?
1) 2% of patient with tuberculosis
2) Most prevalence in the first three decades
Most frequently in prepubertal children
Exceeding rare in children < 1 year
74
Between Tuberculosis OM and Suppurative OM which one clinically insidious and chronic course ?
TB OM
75
In TB OM patient usually presented as fever, night sweats, toxicity and prostration (= หมดกำลัง).
Does the above statement is true ?
Nooo
76
What are the most common joint affected by TB ?
Knee and hip
| same as Suppurative arthritis except ม่ายมี ankle
77
1. What is the another name of TB spondylitis ?
| 2. When spinal tuberculosis developing paraplegia is referred to as .... ?
1. Pott's Disease
| 2. Pott's paraplegia
78
1) How much percentage of TB spine accont in skeletal TB ?
2) What is the most common site in spine do TB spine occured ?
3) What is the most likely route of spread of TB spine ?
1) 25-60%
2) Lower thoracic and upper lumbar spine with L1 being the favored segment
3) Venous pathway, Batson's plexus
79
1) What is the most likely initial pathologic focus of TB spondylitis ?
2) What is the often earliest change of Pott's disease ?
1) Anterior vertebral endplate
2) Narrowing of disc space
NOTE
Organism travel as emboli and lodge at arteriole and venules
(The vascular network of looping redundant vessels at anterior aspect of vertebral body create opportune environment to developed infection)
80
When does identifiable osteolytic lesion in spine will seen ?
about 2-5 months
81
In Discovertebral involvement in TB spondylitis
1. What are the primary site of infection ?
2. What are the primary change in the plain film ?
1. Anterior vertebral endplate infected first
then infected disc
2. Narrowing disc space
82
What are the suggestive alternative route of disc infection in TB spine for adult patient ?
1. Weaken of vertebral endplate from infection
| 2. Vertebral collapse make disc directly contaminate
83
What is MRI findings of TB spondylodiscitis in term of T1 and T2 ?
Low T1 High T2
84
Concerning about TB spondylitis ..
1. Does not common to involve posterior element and neural arch ?
2. How much (%) TB spondylitis involved pedicle and neural arch ?
3. In which patient group (climate) is more common to involved pedicle and neural arch ?
Yes uncommon
about 2%
Tropical climate
85
What are the form of paravertebral soft tissue involvement ?
1. Paraspinal abscess
2. Subligamentous dissection
3. Extensive granulomatous extension
86
For TB spondylitis with paraspinal abscess formation what are the radiographic appearance in
- Cervical spine
- Thoracic spine
- Lumbar spine
Cervical spine
- In anterior spread
>> Retropharyngeal or retrotracheal soft tissue
>> Potential for acute respiratory emergency
from obstruction or ruptured
Thoracic spine
- Anterolateral extension
>> Bilateral and large (Fusiform) soft-tissue displaced paraspinal line, out proportion to oseous and discal destruction
```
Lumbar spine
- Anterolateral extension
>> May unilateral or Bilateral
>> Directly to psoas muscle, referred as "Psoas abscess"
>>When developed draining sinus
, referred as "Empyema necessiatis"
```
87
What are the possible draining sinus of paraspinal abscess in TB spine ?
1. Paraspinal region
2. Inguinal region
3. Lesser Trochanter (along Psoas m.)
88
About Tuberculous psoas abscess
1. Which condition that abscess often precipitated calcium salt ?
2. What is the appearance of calcified Tuberculous psoas abscess ?
3. Which location is common found ?
4. How much it account for TB spondylitis ?
1. When Tuberculous psoas abscess able to Ca++
>> Uncontaminated with pyogenic organism
2. Appearance of calcified Tuberculous psoas abscess
>> Amorphous deposit, snow flake, dense type of calcification
3. Common location
>> Paraspinal region of L1 to L5
4. About 5% of TB spine
89
About Subligamentous spread of TB spondylitis..
Do the following statements are true or false ?
1. Common to occurred.
2. Occured when has predominated features of massive and extensive paraspinal abscess formation
3. Infectious focus is located at posterior surface of vertebral body and the posterior longitudinal ligament
4. Can produce shallow excavation of posterior aspect of vertebral spine
5. Typically affect 3 or more spinal segments
1. False, Uncommon, peculiar to TB
2. True, predominated features are massive and extensive paraspinal abscess formation.
3. False, Infectious focus is located at anterior surface of vertebral body and ALL
4. False, shallow excavation (รอยหวำ) of anterior aspect of vertebral spine
5. True, Typical affect 3 or more spinal segments
90
What is gouge defect ?
Anterior excavation of vertebral body from Subligamentous spread of TB spondylitis
91
What are the possible cause of anterior concave erosion lesion (gouge defect) of vertebral body ?
1. Aneurysmal pressure
2. Enlarged LN
3. Subligamentous spread of TB spondylitis
92
What is Pott's paraplegia ?
>> Paraplegia from TB spondylitis (Pott's disease)
>> Life-threatening Cx of advanced spinal TB
>> Mechanism
- จากที่มี กระดูกสันหลังทรุดหลายระดับ ร่วมกับ infected disc ไปกระตุ้นการเจริญของ Granulation tissue
- Granulation tissue + Osseous Debris (Sequestra) จาก vertebral bodies ทำให้ spinal canal แคบลง และเกิด paraplegia
93
The second common site of skeletal TB is ..?
Weight bearing-appendicular joints
94
Concerning about TB arthritis
1. What joints are the most common involvement ?
2. What patient group are get involved ?
3. What are the primary sites of infection ?
4. Common manifest as Monoarticular, Oligo or polyarticular ?
1. Hip and Knee (75%)
2. Middle-aged or elderly, many received intra-articular steroid injection
3. Metaphysis spread to joint and Synovium
4. Monoarticular as a rule
95
Please describe articular change in Tubercular arthritis...
1. Infected synovium become thickening..
2. Granulation tissue developed and spread to the area of free articular cartilage (Bare area)...
3. Early erosion of Bare area (ใน Yochum เขียน แต่ proximal femur), เหมือน early Rheumatoid arthritis !!!!
4. Developed non-uniform** destruction of the articular surface จนเกิด sequestrum
>> This process มักจะ involved joint surface 2 ด้าน, leading characteristic "kissing sequestrum"
5. มีการ increased vascularity กระตุ้นให้เกิด hyperemic osteoporosis ซึ่งมักจะ disproportionate with infection
>> ตรงข้ามกับ Suppurative OM
96
- How long is the latent period for radiographic findings of TB spine ?
- What are the early sign of radiographic findings of TB spine ?
- 21 days
| - Lytic destruction lesion at the anterior corner of vertebral endplate with recognizable loss of disc space
97
1. The appearance of wedging of vertebral spine with kyphotic angulation deformity, referring as ....
2. About angulation deformity which site of spine is the most acute angle ?
1. Gibbus Deformity
| 2. Thoracic spine and also more severe with more vertebral spine destruction
98
What is the long vertebra ?
>> Reversal of height to width ratio of vertebral bodies in patient with long-standing gibbus deformity from TB.
>> By tremendous mechanical stress on uninvolved vertebral body immediately caudal to the gibbus
>> This alteration found only in growth centers of vertebral body still not close
>> ??? In qudriplegic patient referred as tall vertebra
99
Are the following statement are true ?
1. Pyogenic and tubercular spondylitis usually differentiated by radiographically.
2. Joint aspiration is definitive Dx for Pyogenic and tubercular spondylitis.
3. Clinical indolent, insidious, slow onset of low back pain, pulmonary infiltrate, previous history and multiple segment involvement are favor TB spine.
4. Active pulmonary TB is about 20% of pt. with skeletal TB.
1. False,
>> Pyogenic and tubercular spondylitis often cannot be differentiated radiographically and clinical data are important for initial diagnosis.
2. True
>> Joint aspiration is definitive Dx
3. True
>> Clinical indolent, insidious, slow onset of low back pain, pulmonary infiltrate, previous history and multiple segment involvement are favor TB spine.
4. False
>> 50%
