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1. Spondylitis Tuberculosa

Spondylitis Tuberculosa

Oleh Dr H. Subagyo  SpB - SpOT

 

Pendahuluan

Spondilitis adalah suatu peradangan yang terjadi pada satu atau lebih vertebra. Penyebab tersering dari spondilitis adalah tuberkulosis.

Spondilitis tuberkulosa atau tuberkulosis spinal yang dikenal pula dengan nama Pott’s disease of the spine atau tuberculous vertebral osteomyelitis merupakan suatu penyakit yang banyak terjadi di seluruh dunia. Terhitung kurang lebih 3 juta kematian terjadi setiap tahunnya dikarenakan penyakit ini.

Penyakit ini pertama kali diutarakan oleh Percival Pott pada tahun 1779 yang menemukan adanya hubungan antara kelemahan alat gerak bawah dengan kurvatura tulang belakang, tetapi hal tersebut tidak dihubungkan dengan basil tuberkulosa hingga ditemukannya basil tersebut oleh Koch tahun 1882, sehingga etiologi untuk kejadian tersebut menjadi jelas.

Di waktu yang lampau, spondilitis tuberkulosa merupakan istilah yang dipergunakan untuk penyakit pada masa anak-anak, yang terutama berusia 3 – 5 tahun. Saat ini dengan adanya perbaikan pelayanan kesehatan, maka insidensi usia ini mengalami perubahan sehingga golongan umur dewasa menjadi lebih sering terkena dibandingkan anak-anak.

Terapi konservatif yang diberikan pada pasien tuberkulosa tulang belakang sebenarnya memberikan hasil yang baik, namun pada kasus – kasus tertentu diperlukan tindakan operatif serta tindakan rehabilitasi yang harus dilakukan dengan baik sebelum ataupun setelah penderita menjalani tindakan operatif.

 

Spondylitis Tuberculosa

 

Epidemiologi28,29,30,31,32,33

 

Incidence spondilitis tuberkulosa bervariasi di seluruh dunia dan biasanya berhubungan dengan kualitas fasilitas pelayanan kesehatan masyarakat yang tersedia serta kondisi sosial di negara tersebut. Saat ini spondilitis tuberkulosa merupakan sumber morbiditas dan mortalitas utama pada negara yang belum dan sedang berkembang, terutama di Asia, dimana malnutrisi dan kepadatan penduduk masih menjadi merupakan masalah utama.

Pada negara-negara yang sudah berkembang atau maju incidence ini mengalami penurunan secara dramatis dalam kurun waktu 30 tahun terakhir. Perlu dicermati bahwa di Amerika dan Inggris incidence penyakit ini mengalami peningkatan pada populasi imigran, tunawisma lanjut usia dan pada orang dengan tahap lanjut infeksi HIV (Medical Research Council TB and Chest Diseases Unit 1980). Selain itu dari penelitian juga diketahui bahwa peminum alkohol dan pengguna obat-obatan terlarang adalah kelompok beresiko besar terkena penyakit ini.

Di Amerika Utara, Eropa dan Saudi Arabia, penyakit ini terutama mengenai dewasa, dengan usia rata-rata 40-50 tahun sementara di Asia dan Afrika sebagian besar mengenai anak-anak (50% kasus terjadi antara usia 1-20 tahun). Pola ini mengalami perubahan dan terlihat dengan adanya penurunan insidensi infeksi tuberkulosa pada bayi dan anak-anak di Hong Kong.

Pada kasus-kasus pasien dengan tuberkulosa, keterlibatan tulang dan sendi terjadi pada kurang lebih 10% kasus. Walaupun setiap tulang atau sendi dapat terkena, akan tetapi tulang yang mempunyai fungsi untuk menahan beban (weight bearing) dan mempunyai pergerakan yang cukup besar (mobile) lebih sering terkena dibandingkan dengan bagian yang lain. Dari seluruh kasus tersebut, tulang belakang merupakan tempat yang paling sering terkena tuberkulosa tulang (kurang lebih 50% kasus) diikuti kemudian oleh tulang panggul, lutut dan tulang-tulang lain di kaki, sedangkan tulang di lengan dan tangan jarang terkena. Area thoraco-lumbal terutama thoracal bagian bawah (umumnya T 10) dan lumbal bagian atas merupakan tempat yang paling sering terkena karena pada area ini pergerakan dan tekanan dari weight bearing mencapai maksimum, lalu dikuti dengan area cervikal dan sacral.

Defisit neurologis muncul pada 10-47% kasus pasien dengan spondilitis tuberkulosa. Di negara yang sedang berkembang penyakit ini merupakan penyebab paling sering terjadi paraplegia non traumatik.

Insidensi paraplegia, terjadi lebih tinggi pada orang dewasa dibandingkan dengan anak-anak. Hal ini berhubungan dengan incidence usia terjadinya infeksi tuberkulosapada tulang belakang, kecuali pada dekade pertama dimana sangat jarang ditemukan keadaan ini.

 

Etiologi28,33,34

Penyakit ini disebabkan oleh karena bakteri berbentuk basil (basilus). Bakteri yang paling sering menjadi penyebabnya adalah Mycobacterium tuberculosis, walaupun spesies Mycobacterium yang lainpun dapat juga bertanggung jawab sebagai penyebabnya, seperti Mycobacterium africanum (penyebab paling sering tuberkulosa di Afrika Barat), bovine tubercle baccilus, ataupun non-tuberculous mycobacteria (banyak ditemukan pada penderita

HIV). Perbedaan jenis spesies ini menjadi penting karena sangat mempengaruhi pola resistensi obat.

Mycobacterium tuberculosis merupakan bakteri berbentuk batang yang bersifat acid-fastnon-motile dan tidak dapat diwarnai dengan baik melalui cara yang konvensional. Dipergunakan teknik Ziehl-Nielson untuk memvisualisasikannya. Bakteri tumbuh secara lambat dalam media egg-enriched dengan periode 6-8 minggu. Produksi niasin merupakan karakteristik Mycobacterium tuberculosis dan dapat membantu untuk membedakannnya dengan spesies lain.

 

Patogenesis12,13,15,18,19,21

 

Ada empat fase dalam perjalanan penyakit tuberkulosis.

  1. Pertama adalah fase tuberkulosis primer. Setelah masuk ke paru, basil berkembang biak tanpa menimbulkan reaksi pertahanan tubuh. Sarang pertama ini disebut afek primer. Basil kemudian masuk ke kelenjar limfe di hilus paru dan menyebabkan limfadenitis regionalis. Reaksi yang khas adalah terjadinya granuloma sel epiteloid dan nekrosis pengejuan di lesi primer dan di kelenjar limfe hilus. Afek primer dan limfadenitis regional ini disebut kompleks primer yang bisa mengalami resolusi dan sembuh tanpa meninggalkan cacat atau membentuk fibrosis dan kalsifikasi. Sekalipun demikian, kompleks primer dapat mengalami komplikasi berupa penyebaran miliar melalui pembuluh darah dan penyebaran melalui bronkus. Penyebaran miliar menyebabkan tuberkulosis di seluruh paru-paru, tulang, meningen, dan lain-lain.
  2. Penyebaran hematogen itu bersamaan dengan perjalanan tuberkulosis primer ke paru merupakan fase kedua.
  3. Infeksi ini dapat berkembang terus dan dapat mengalami resolusi dengan pembentukan jaringan parut dan basil selanjutnya "tidur".Fase dengan kuman yang tidur ini yang disebut fase laten (fase ketiga). Basil yang tidur ini bisa terdapat di tulang panjang, vertebra, otak, serta ginjal. Kuman ini bisa tetap tidur selama bertahun-tahun, bahkan seumur hidup (infeksi laten), tetapi bisa mengalami reaktivasi bila terjadi perubahan keseimbangan daya tahan tubuh, misalnya pada tindak bedah besar atau pada infeksi HIV.
  4. Tuberkulosis fase keempat dapat terjadi di paru atau di luar paru. Dalam perjalanan selanjutnya, proses ini dapat sembuh tanpa cacat, sembuh dengan meninggalkan fibrosis dan kalsifikasi, atau membentuk kavitas. Penyebaran ke tulang adalah ke daerah metafisis tulang panjang dan ke tulang spongiosa yang menyebabkan tuberkulosis tulang ekstrartikuler.

Patogenesis penyakit ini sangat tergantung dari kemampuan bakteri menahan enzim lisosomal dan kemampuan host untuk memobilisasi immunitas celuler. Jika bakteri tidak dapat diinaktivasi, maka bakteri akan bermultiplikasi dalam sel dan membunuh sel itu. Komponen lipid, protein serta polisakarida sel basil tuberkulosa bersifat immunogenik, sehingga akan merangsang pembentukan granuloma dan mengaktivasi macrophage. Beberapa antigen yang dihasilkannya juga dapat juga bersifat immunosupresif (Wood and Anderson 1988; Dunlop and Briles 1993).

Spondilitis tuberkulosis biasanya terjadi sekunder dari infeksi yang berasal dari luar tulang belakang (ekstra spinal). Kelainan dasar dari Spondilitis tuberkulosis adalah kombinasi dari osteomielitis dan artritis. Biasanya terjadi pada lebih dari satu tulang belakang. Daerah yang biasanya terkena adalah bagian anterior dari corpus vertebra yang berada di sebelah lempengan subkondral. Tuberkulosis dapat menyebar dari area tersebut ke diskus intervertebralis yang disampingnya.10,11,14,20,23

 

Gambar Spondilitis Corpus Vertebrae

Pada dewasa, tuberkulosis pada diskus adalah sekunder dari penyebaran infeksi yang berasal dari corpus vertebra. Pada anak-anak infeksi diskus intervertebralis dapat menjadi infeksi primer, karena daerah ini masih mendapat perdarahan. Destruksi tulang yang progresif menyebabkan kolapsnya vertebra dan terjadinya kifosis.

Kanalis spinalis dapat menyempit karena abses, granulasi jaringan, atau invasi dura secara langsung. Hal ini menyebabkan kompresi dari sumsum tulang belakang dan defisit neurologis. Deformitas yang berupa kifosis terjadi sebagai konsekuensi dari kolapsnya bagian anterior dari vertebra. Kerusakan di vertebra torakalis lebih dapat menyebabkan kifosis dari pada vertebra lumbalis.

Abses dingin dapat terjadi jika infeksi menyebar ke ligamentum di sebelahnya dan jaringan lunak. Abses pada daerah lumbal dapat turun ke sarang dari psoas ke regio trigonum femorale dan keluar ke kulit.

 

Gambar Kifosis Spondilitis

Virulensi basil tuberkulosa dan kemampuan mekanisme pertahanan host akan menentukan perjalanan penyakit. Pasien dengan infeksi berat mempunyaiprogresi yang cepat ; demam, retensi urine dan paralisis flacid dapat terjadi dalam hitungan hari. Respon seluler dan kandungan protein dalam cairan serebrospinal akan tampak meningkat, tetapi basil tuberkulosa sendiri jarang dapat diisolasi. Pasien dengan infeksi bakteri yang kurang virulen akan menunjukkan  perjalanan penyakit yang lebih lambat progresifitasnya, jarang menimbulkanmeningitis serebral dan infeksinya bersifat terlokalisasi dan terorganisasi (Kocenand Parsons 1970). Kekuatan pertahanan pasien untuk menahan infeksi bakteri tuberkulosatergantung dari:36

1. Usia dan jenis kelamin

Terdapat sedikit perbedaan antara anak laki-laki dan anak perempuanhingga masa pubertas. Bayi dan anak muda dari kedua jenis kelaminmempunyai kekebalan yang lemah. Hingga usia 2 tahun infeksi biasanyadapat terjadi dalam bentuk yang berat seperti tuberkulosis milier danmeningitis tuberkulosa, yang berasal dari penyebaran secara hematogen.Setelah usia 1 tahun dan sebelum pubertas, anak yang terinfeksi dapat terkenapenyakit tuberkulosa milier atau meningitis, ataupun juga bentuk kronis laindari infeksi tuberkulosa seperti infeksi ke nodus limfatikus, tulang atau sendi.

Sebelum pubertas, lesi primer di paru merupakan lesi yang berada di arealokal, walaupun kavitas seperti pada orang dewasa dapat juga dilihat padaanak-anak malnutrisi di Afrika dan Asia, terutama perempuan usia 10-14tahun.Setelah pubertas daya tahan tubuh mengalami peningkatan dalammencegah penyebaran secara hematogen, tetapi menjadi lemah dalammencegah penyebaran penyakit di paru-paru.Angka kejadian pada pria terus meningkat pada seluruh tingkat usia tetapipada wanita cenderung menurun dengan cepat setelah usia anak-anak,incidence ini kemudian meningkat kembali pada wanita setelah melahirkananak. Puncak usia terjadinya infeksi berkisar antara usia 40-50 tahun untukwanita, sementara pria bisa mencapai usia 60 tahun.

2.     Nutrisi

        Kondisi malnutrisi (baik pada anak ataupun orang dewasa) akanmenurunkan resistensi terhadap penyakit.

3.     Faktor toxic

        Perokok tembakau dan peminum alkohol akan mengalami penurunan dayatahan tubuh. Demikian pula dengan pengguna obat kortikosteroid atauimmunosupresan lain.

4.     Penyakit

Adanya penyakit seperti infeksi HIV, diabetes, leprosi, silikosis, leukemiameningkatkan resiko terkena penyakit tuberkulosa.

5.     Lingkungan yang buruk (kemiskinan)

Kemiskinan mendorong timbulnya suatu lingkungan yang buruk denganpemukiman yang padat dan kondisi kerja yang buruk disamping juga adanyamalnutrisi, sehingga akan menurunkan daya tahan tubuh.

6.     Ras

Ditemukan bukti bahwa populasi terisolasi contohnya orang Eskimo atauAmerika asli, mempunyai daya tahan tubuh yang kurang terhadap penyakit ini.

Tuberkulosa pada tulang belakang dapat terjadi karena penyebaran hematogen atau penyebaran langsung nodus limfatikus para aorta atau melalui jalur limfatik ke tulang dari fokus tuberkulosa yang sudah ada sebelumnya di luar tulang belakang. Pada gambarannya, fokus infeksi primer tuberkulosa dapat bersifat tenang. Sumber infeksi yang paling sering adalah berasal dari sistem pulmoner dan genitourinarius. Pada anak-anak biasanya infeksi tuberkulosa tulang belakang berasal dari fokus primer di paru-paru sementara pada orang dewasa penyebaran terjadi dari fokus ekstrapulmoner (usus, ginjal, tonsil). 33,34,35

Penyebaran basil dapat terjadi melalui arteri intercostal atau a.lumbales yang memberikan suplai darah ke dua vertebrae yang berdekatan, yaitu setengah bagian bawah vertebra diatasnya dan bagian atas vertebra di bawahnya atau melalui pleksus Batson’s yang mengelilingi columna vertebralis yang menyebabkan banyak vertebra yang terkena. Hal inilah yang menyebabkan pada kurang lebih 70% kasus, penyakit ini diawali dengan terkenanya dua vertebra yang berdekatan, sementara pada 20% kasus melibatkan tiga atau lebih vertebra. Berdasarkan lokasi infeksi awal pada korpus vertebra dikenal tiga bentuk spondilitis:

(1)   Spondilitis peridiskal / paradiskal

Infeksi pada daerah yang bersebelahan dengan diskus (di area metafise dibawah ligamentum longitudinal anterior / area subkondral). Banyakditemukan pada orang dewasa. Dapat menimbulkan kompresi, iskemia dannekrosis diskus. Terbanyak ditemukan di regio lumbal.

(2)     Spondilitis sentral

Infeksi terjadi pada bagian sentral korpus vertebra, terisolasi sehinggadisalahartikan sebagai tumor. Sering terjadi pada anak-anak. Keadaan inisering menimbulkan kolaps vertebra lebih dini dibandingkan dengan tipe lainsehingga menghasilkan deformitas spinal yang lebih hebat. Dapat terjadikompresi yang bersifat spontan atau akibat trauma. Terbanyak di temukan diregio thoracal.

(3)     Spondilitis anterior

Infeksi yang terjadi karena perjalanan perkontinuitatum dari vertebra di atasdan dibawahnya. Gambaran radiologisnya mencakup adanya scalloped karenaerosi di bagian anterior dari sejumlah vertebra (berbentuk baji). Pola inididuga disebabkan karena adanya pulsasi aortik yang ditransmisikan melaluiabses prevertebral dibawah ligamentum longitudinal anterior atau karenaadanya perubahan lokal dari suplai darah vertebral.

(4)     Bentuk atipikal :

        Dikatakan atipikal karena terlalu tersebar luas dan fokus primernya tidak dapatdiidentifikasikan. Termasuk didalamnya adalah tuberkulosa spinal denganketerlibatan lengkung syaraf saja dan granuloma yang terjadi di canalisspinalis tanpa keterlibatan tulang (tuberkuloma), lesi di pedicle, lamina,proc transversus dan proc spinosus, serta lesi artikuler yang berada di sendiintervertebral posterior. Incidence tuberkulosa yang melibatkan elemenposterior tidak diketahui tetapi diperkirakan berkisar antara 2%-10%.

Infeksi tuberkulosa pada awalnya mengenai tulang cancellous darivertebra. Area infeksi secara bertahap bertambah besar dan meluas, berpenetrasike dalam korteks tipis korpus vertebra sepanjang ligamen longitudinal anterior,melibatkan dua atau lebih vertebrae yang berdekatan melalui perluasan di bawahligamentum longitudinal anterior atau secara langsung melewati discusintervertebralis. Kadang-kadang dapat ditemukan fokus yang multipel yang dipisahkanoleh vertebra yang normal, atau infeksi dapat juga berdiseminasi ke vertebra yangjauh melalui abses paravertebral.

Terjadinya nekrosis yang meluas mencegah pembentukan tulangbaru dan pada saat yang bersamaan menyebabkan tulang menjadi avascularsehingga menimbulkan tuberculous sequestra, terutama di regio thoracal.

Discusintervertebralis, yang avaskular, relatif lebih resisten terhadap infeksi tuberkulosa.Penyempitan rongga diskus terjadi karena perluasan infeksi paradiskal ke dalamruang diskus, hilangnya tulang subchondral disertai dengan kolapsnya corpusvertebra karena nekrosis dan lisis ataupun karena dehidrasi diskus, sekunderkarena perubahan kapasitas fungsional dari end plate. Suplai darah juga akansemakin terganggu dengan timbulnya endarteritis yang menyebabkan tulangmenjadi nekrosis.

Destruksi progresif tulang di bagian anterior dan kolapsnya bagiantersebut akan menyebabkan hilangnya kekuatan mekanis tulang untuk menahanberat badan sehingga kemudian akan terjadi kolaps vertebra dengan sendiintervertebral dan lengkung syaraf posterior tetap intak, jadi akan timbuldeformitas berbentuk kifosis yang progresifitasnya (angulasi posterior) tergantungdari derajat kerusakan, level lesi dan jumlah vertebra yang terlibat. Bila sudahtimbul deformitas ini, maka hal tersebut merupakan tanda bahwa penyakit inisudah meluas.

Di regio thoracal kifosis tampak nyata karena adanya kurvatura dorsal yangnormal; di area lumbar hanya tampak sedikit karena adanya normal lumbarlordosis dimana sebagian besar dari berat badan ditransmisikan ke posteriorsehingga akan terjadi parsial kolaps; sedangkan di bagian cervical, kolaps hanyabersifat minimal, kalaupun tampak hal itu disebabkan karena sebagian besar beratbadan disalurkan melalui processus artikular.Dengan adanya peningkatan sudut kifosis di regio thoracal, tulang-tulangiga akan menumpuk menimbulkan bentuk deformitas rongga dada berupa barrelchest.Proses penyembuhan kemudian terjadi secara bertahap dengan timbulnyafibrosis dan kalsifikasi jaringan granulomatosa tuberkulosa. Kadang-kadang jaringanfibrosa itu mengalami osifikasi, sehingga mengakibatkan ankilosis tulang vertebra yang kolaps.

Pembentukan abses paravertebral terjadi hampir pada setiap kasus.Dengan kolapsnya korpus vertebra maka jaringan granulasi tuberkulosa, bahanperkijuan, dan tulang nekrotik serta sumsum tulang akan menonjol keluar melaluikorteks dan berakumulasi di bawah ligamentum longitudinal anterior.

Coldabcesss ini kemudian berjalan sesuai dengan pengaruh gaya gravitasi sepanjangbidang fasial dan akan tampak secara eksternal pada jarak tertentu dari tempat lesi aslinya. Di regio lumbal abses berjalan sepanjang otot psoas dan biasanya berjalanmenuju lipat paha dibawah ligamen inguinal.

Di regio torakal, ligamentumlongitudinal menghambat jalannya abses, tampak pada radiogram sebagaigambaran bayangan berbentuk fusiform radioopak pada atau sedikit dibawah levelvertebra yang terkena, jika terdapat tegangan yang besar dapat terjadi ruptur kedalam mediastinum, membentuk gambaran abses paravertebral yang menyerupai‘sarang burung’. Kadang-kadang abses thoracal dapat mencapai dinding dada anteriordi area parasternal, memasuki area retropharingeal atau berjalan sesuai gravitasi kelateral menuju bagian tepi leher.Sejumlah mekanisme yang menimbulkan defisit neurologis dapat timbulpada pasien dengan spondilitis tuberkulosa. Kompresi syaraf sendiri dapat terjadikarena kelainan pada tulang (kifosis) atau dalam canalis spinalis (karena perluasanlangsung dari infeksi granulomatosa) tanpa keterlibatan dari tulang (sepertiepidural granuloma, intradural granuloma, tuberculous arachnoiditis).

Salah satu defisit neurologis yang paling sering terjadi adalah paraplegiayang dikenal dengan nama Pott’s paraplegia. Paraplegia ini dapat timbul secaraakut ataupun kronis (setelah hilangnya penyakit) tergantung dari kecepatanpeningkatan tekanan mekanik kompresi medula spinalis. Pada penelitian yangdilakukan Hodgson di Cleveland, paraplegia ini biasanya terjadi pada pasienberusia kurang dari 10 tahun (kurang lebih 2/3 kasus) dan tidak ada predileksiberdasarkan jenis kelamin untuk kejadian ini.

Pott’s Paraplegia

Sorrel-Dejerine mengklasifikasikan Pott’s paraplegia menjadi :29,33,37

1.  Early onset paresis

    Terjadi kurang dari dua tahun sejak onset penyakit

2.  Late onset paresis

    Terjadi setelah lebih dari dua tahun sejak onset penyakit

 

Sementara itu Seddon dan Butler memodifikasi klasifikasi Sorrel menjadi tiga tipe:

1.  Type I (paraplegia of active disease)

     Onset dini, terjadi dalam dua tahun pertama sejak onset penyakit, dan dihubungkan dengan penyakit yang aktif. Dapat membaik (tidak permanen).

2.  Type II

     Onsetnya juga dini, dihubungkan dengan penyakit yang aktif, bersifat permanen bahkan walaupun infeksi tuberkulosa menjadi tenang.

 

Penyebab timbulnya paraplegia pada tipe I dan II dapat disebabkan oleh karena :

a.  Tekanan eksternal pada korda spinalis dan duramater

Dapat disebabkan oleh karena adanya granuloma di kanalis spinalis, adanya abses, material perkijuan, sekuestra tulang dan diskus atau karena subluksasi atau dislokasi patologis vertebra. Secara klinis pasien akan menampakkan kelemahan alat gerak bawah dengan spastisitas yang bervariasi, tetapi tidak tampak adanya spasme otot involunter dan reflek withdrawal.

 

b.  Invasi duramater oleh tuberkulosa

Tampak gambaran meningomielitis tuberkulosa atau araknoiditis tuberkulosa. Secara klinis pasien tampak mempunyai spastisitas yang berat dengan spasme otot involunter dan reflek withdrawal. Prognosis tipe ini buruk dan bervariasi sesuai dengan luasnya kerusakan korda spinalis. Secara umum dapat terjadi inkontinensia urin dan feses, gangguan sensoris dan paraplegia.

 

 

3.  Type III

Onset paraplegi terjadi pada fase lanjut. Tidak dapat ditentukan apakah dapat membaik. Bisa terjadi karena tekanan corda spinalis oleh granuloma epidural, fibrosis meningen dan adanya jaringan granulasi serta adanya tekanan pada corda spinalis, peningkatan deformitas kifotik ke anterior, reaktivasi penyakit atau insufisiensi vaskuler (trombosis pembuluh darah yang mensuplai corda spinalis).

 

Klasifikasi untuk penyebab Pott’s paraplegia ini sendiri dijabarkan oleh Hodgson menjadi :

I.    Penyebab ekstrinsik :

1. Penyakit yang aktif :

a. abses (cairan atau perkijuan)

b. jaringan granulasi

c. sekuester tulang dan diskus

d. subluksasi patologis

e. dislokasi vertebra

 

2. Penyakit yang sedang dalam proses penyembuhan :

a. transverse ridge dari tulang anterior ke corda spinalis

b. fibrosis duramater

 

II.   Penyebab intrinsik :

Menyebarnya peradangan tuberkulosa melalui duramater melibatkan meningen dan corda spinalis.

 

III. Penyebab yang jarang :

(1) Trombosis corda spinalis yang infektif

(2) Spinal tumor syndrome

 

Diagnosa 27,28,29,30

Gambaran klinis spondilitis tuberkulosa bervariasi dan tergantung pada banyak faktor. Biasanya onset Pott's disease berjalan secara mendadak dan berevolusi lambat. Durasi gejala-gejala sebelum dapat ditegakkannya suatu diagnosa pasti bervariasi dari bulan hingga tahun; sebagian besar kasus didiagnosa sekurangnya dua tahun setelah infeksi tuberkulosa.

Anamnesa dan inspeksi :

1.   Gambaran adanya penyakit sistemik : kehilangan berat badan, keringat malam, demam yang berlangsung secara intermitten terutama sore dan malam hari serta cachexia. Pada pasien anak-anak, dapat juga terlihat berkurangnya keinginan bermain di luar rumah. Sering tidak tampak jelas pada pasien yang cukup gizi sementara pada pasien dengan kondisi kurang gizi, maka demam (kadang-kadang demam tinggi), hilangnya berat badan dan berkurangnya nafsu makan akan terlihat dengan jelas.

2.   Adanya riwayat batuk lama (lebih dari 3 minggu) berdahak atau berdarah disertai nyeri dada. Pada beberapa kasus di Afrika terjadi pembesaran dari nodus limfatikus, tuberkel di subkutan, dan pembesaran hati dan limpa.

3.   Nyeri terlokalisir pada satu regio tulang belakang atau berupa nyeri yang menjalar. Infeksi yang mengenai tulang servikal akan tampak sebagai nyeri di daerah telinga atau nyeri yang menjalar ke tangan. Lesi di torakal atas akan menampakkan nyeri yang terasa di dada dan intercostal. Pada lesi di bagian torakal bawah maka nyeri dapat berupa nyeri menjalar ke bagian perut. Rasa nyeri ini hanya menghilang dengan beristirahat. Untuk mengurangi nyeri pasien akan menahan punggungnya menjadi kaku.

4.   Pola jalan merefleksikan rigiditas protektif dari tulang belakang. Langkah kaki pendek, karena mencoba menghindari nyeri di punggung.

5.   Bila infeksi melibatkan area cervikal maka pasien tidak dapat menolehkan kepalanya, mempertahankan kepala dalam posisi ekstensi dan duduk dalam posisi dagu disangga oleh satu tangannya, sementara tangan lainnya di oksipital. Rigiditas pada leher dapat bersifat asimetris sehingga menyebabkan timbulnya gejala klinis torticollis. Pasien juga mungkin mengeluhkan rasa nyeri di leher atau bahunya. Jika terdapat abses, maka tampak pembengkakan di kedua sisi leher. Abses yang besar, terutama pada anak, akan mendorong trakhea ke sternal notch sehingga akan menyebabkan kesulitan menelan dan adanya stridor respiratoar, sementara kompresi medulla spinalis pada orang dewasa akan menyebabkan tetraparesis (Hsu dan Leong 1984). Dislokasi atlantoaksial karena tuberkulosa jarang terjadi dan merupakan salah satu penyebab kompresi cervicomedullary di negara yang sedang berkembang. Hal ini perlu diperhatikan karena gambaran klinisnya serupa dengan tuberkulosa di regio servikal (Lal et al. 1992).

6.   Infeksi di regio torakal akan menyebabkan punggung tampak menjadi kaku. Bila berbalik ia menggerakkan kakinya, bukan mengayunkan dari sendi panggulnya. Saat mengambil sesuatu dari lantai ia menekuk lututnya sementara tetap mempertahankan punggungnya tetap kaku (coin test). Jika terdapat abses, maka abses dapat berjalan di bagian kiri atau kanan mengelilingi rongga dada dan tampak sebagai pembengkakan lunak dinding dada. Jika menekan abses ini berjalan ke bagian belakang maka dapat menekan korda spinalis dan menyebabkan paralisis.

7.   Di regio lumbar : abses akan tampak sebagai suatu pembengkakan lunak yang terjadi di atas atau di bawah lipat paha. Jarang sekali pus dapat keluar melalui fistel dalam pelvis dan mencapai permukaan di belakang sendi panggul. Pasien tampak berjalan dengan lutut dan hip dalam posisi fleksi dan menyokong tulang belakangnya dengan meletakkan tangannya diatas paha. Adanya kontraktur otot psoas akan menimbulkan deformitas fleksi sendi panggul.

8.   Tampak adanya deformitas, dapat berupa : kifosis (gibbus/angulasi tulang belakang), skoliosis, bayonet deformity, subluksasi, spondilolistesis, dan dislokasi.

9.   Adanya gejala dan tanda dari kompresi medula spinalis (defisit neurologis). Terjadi pada kurang lebih 10-47% kasus. Insidensi paraplegia pada spondilitis lebih banyak di temukan pada infeksi di area torakal dan servikal. Jika timbul paraplegia akan tampak spastisitas dari alat gerak bawah dengan refleks tendon dalam yang hiperaktif, pola jalan yang spastik dengan kelemahan motorik yang bervariasi. Dapat pula terjadi gangguan fungsi kandung kemih dan anorektal.

10.Pembengkakan di sendi yang berjalan lambat tanpa disertai panas dan nyeri akut seperti pada infeksi septik. Onset yang lambat dari pembengkakan tulang ataupun sendi mendukung bahwa hal tersebut disebabkan karena tuberkulosa.

 

Palpasi :

1.   Bila terdapat abses maka akan teraba massa yang berfluktuasi dan kulit diatasnya terasa sedikit hangat (disebut cold abcess, yang membedakan dengan abses piogenik yang teraba panas). Dapat dipalpasi di daerah lipat paha, fossa iliaka, retropharynx, atau di sisi leher (di belakang otot sternokleidomastoideus), tergantung dari level lesi. Dapat juga teraba di sekitar dinding dada. Perlu diingat bahwa tidak ada hubungan antara ukuran lesi destruktif dan kuantitas pus dalam cold abscess.

2.   Spasme otot protektif disertai keterbatasan pergerakan di segmen yang terkena.

 

Perkusi :

Pada perkusi secara halus atau pemberian tekanan diatas processus spinosus vertebrae yang terkena, sering tampak tenderness.

Pemeriksaan Penunjang :

1.   Laboratorium :

1.1     Laju endap darah meningkat (tidak spesifik), dari 20 sampai lebih dari 100mm/jam.

1.2     Tuberculin skin test / Mantoux test / Tuberculine Purified Protein

          Derivative (PPD) positif. Hasil yang positif dapat timbul pada kondisi pemaparan dahulu maupun yang baru terjadi oleh mycobacterium. Tuberculin skin test ini dikatakan positif jika tampak area berindurasi, kemerahan dengan diameter ³ 10mm di sekitar tempat suntikan 48-72 jam setelah suntikan. Hasil yang negatif tampak pada ± 20% kasus (Tandon and Pathak 1973; Kocen 1977) dengan tuberkulosis berat (tuberkulosis milier) dan pada pasien yang immunitas selulernya tertekan (seperti baru saja terinfeksi, malnutrisi atau disertai penyakit lain)

1.3     Kultur urine pagi (membantu bila terlihat adanya keterlibatan ginjal), sputum dan bilas lambung (hasil positif bila terdapat keterlibatan paruparu yang aktif)

1.4     Apus darah tepi menunjukkan leukositosis dengan limfositosis yang bersifat relatif.

1.5     Tes darah untuk titer anti-staphylococcal dan anti-streptolysin haemolysins, typhoid, paratyphoid dan brucellosis (pada kasus-kasus yang sulit dan pada pusat kesehatan dengan peralatan yang cukup canggih) untuk menyingkirkan diagnosa banding.

1.6     Cairan serebrospinal dapat abnormal (pada kasus dengan meningitis tuberkulosa). Normalnya cairan serebrospinal tidak mengeksklusikan kemungkinan infeksi TBC. Pemeriksaan cairan serebrospinal secara serial akan memberikan hasil yang lebih baik.

          Cairan serebrospinal akan tampak:

  • Xantokrom
  • Bila dibiarkan pada suhu ruangan akan menggumpal.
  • Pleositosis (dengan dominasi limfosit dan mononuklear). Pada tahap akut responnya bisa berupa neutrofilik seperti pada meningitis piogenik (Kocen and Parsons 1970; Traub et al 1984).
  • Kandungan protein meningkat.
  • Kandungan gula normal pada tahap awal tetapi jika gambaran klinis sangat kuat mendukung diagnosis, ulangi pemeriksaan.
  • Pada keadaan arachnoiditis tuberkulosa (radiculomyelitis), punksi lumbal akan menunjukkan genuine dry tap. Pada pasien ini adanya peningkatan bertahap kandungan protein menggambarkan suatu blok spinal yang mengancam dan sering diikuti dengan kejadian paralisis. Pemberian steroid akan mencegah timbulnya hal ini (Wadia 1973). Kandungan protein cairan serebrospinal dalam kondisi spinal terblok spinal dapat mencapai 1-4g/100ml.
  • Kultur cairan serebrospinal. Adanya basil tuberkel merupakan tes konfirmasi yang absolut tetapi hal ini tergantung dari pengalaman pemeriksa dan tahap infeksi.

 

2.   Radiologis

Gambarannya bervariasi tergantung tipe patologi dan kronisitas infeksi.

  • Foto rontgen dada dilakukan pada seluruh pasien untuk mencari bukti adanya tuberkulosa di paru (2/3 kasus mempunyai foto rontgen yang abnormal).
  • Foto polos seluruh tulang belakang juga diperlukan untuk mencari bukti adanya tuberkulosa di tulang belakang. Tanda radiologis baru dapat terlihat setelah 3-8 minggu onset penyakit.
  • Jika mungkin lakukan rontgen dari arah antero-posterior dan lateral.
  • Tahap awal tampak lesi osteolitik di bagian anterior superior atau sudut inferior corpus vertebrae, osteoporosis regional yang kemudian berlanjut sehingga tampak penyempitan diskus intervertebralis yang berdekatan, serta erosi corpus vertebrae anterior yang berbentuk scalloping karena penyebaran infeksi dari area subligamentous.
  • Infeksi tuberkulosa jarang melibatkan pedikel, lamina, processus transversus atau processus spinosus.
  • Gangguan bagian lateral corpus vertebra akan menyebabkan timbulnya deformitas scoliosis (jarang)
  • Pada pasien dengan deformitas gibbus karena infeksi sekunder tuberkulosa yang sudah lama akan tampak tulang vertebra yang mempunyai rasio tinggi lebih besar dari lebarnya (vertebra yang normal mempunyai rasio lebar lebih besar terhadap tingginya). Bentuk ini dikenal dengan nama long vertebra atau tall vertebra, terjadi karena adanya stress biomekanik yang lama di bagian kaudal gibbus sehingga vertebra menjadi lebih tinggi. Kondisi ini banyak terlihat pada kasus tuberkulosa dengan pusat pertumbuhan korpus vertebra yang belum menutup saat terkena penyakit tuberkulosa yang melibatkan vertebra torakal.
  • Dapat terlihat keterlibatan jaringan lunak, seperti abses paravertebral dan psoas. Tampak bentuk fusiform atau pembengkakan berbentuk globular dengan kalsifikasi. Abses psoas akan tampak sebagai bayangan jaringan lunak yang mengalami peningkatan densitas dengan atau tanpa kalsifikasi pada saat penyembuhan. Deteksi (evaluasi) adanya abses epidural sangatlah penting, oleh karena merupakan salah satu indikasi tindakan operasi (tergantung ukuran abses).

3.   Computed Tomography – Scan (CT)

      Terutama bermanfaat untuk memvisualisasi regio thoracal dan keterlibatan iga yang sulit dilihat pada foto polos. Gangguan lengkung syaraf posterior seperti pedicle tampak lebih baik dengan CT Scan.

4.   Magnetic Resonance Imaging (MRI)

      Mempunyai manfaat besar untuk membedakan komplikasi yang bersifat kompresif dengan yang bersifat non kompresif pada tuberkulosa tulang belakang. Bermanfaat untuk :

  • Ø Membantu memutuskan pilihan manajemen apakah akan bersifat konservatif atau operatif.
  • Ø Membantu menilai respon terapi.

      Kerugiannya adalah dapat terlewatinya fragmen tulang kecil dan kalsifikasi di abses.

5.   Neddle biopsi / operasi eksplorasi (costotransversectomi) dari lesi spinal mungkin diperlukan pada kasus yang sulit tetapi membutuhkan pengalaman dan pembacaan histologi yang baik (untuk menegakkan diagnosa yang absolut)(berhasil pada 50% kasus).

6.   Diagnosis juga dapat dikonfirmasi dengan melakukan aspirasi pus paravertebral yang diperiksa secara mikroskopis untuk mencari basil tuberkulosa dan granuloma, lalu kemudian dapat diinokulasi di dalam guinea babi31,32,33,34,35,36

Komplikasi

1.   Cedera corda spinalis (spinal cord injury). Dapat terjadi karena adanya tekanan ekstradural sekunder karena pus tuberkulosa, sekuestra tulang, sekuester dari diskus intervertebralis (contoh : Pott’s paraplegia – prognosa baik) atau dapat juga langsung karena keterlibatan korda spinalis oleh jaringan granulasi tuberkulosa (contoh : meningomyelitis – prognosa buruk). Jika cepat diterapi sering berespon baik (berbeda dengan kondisi paralisis pada tumor). MRI dan mielografi dapat membantu membedakan paraplegi karena tekanan atau karena invasi dura dan corda spinalis.

2.   Empyema tuberkulosa karena rupturnya abses paravertebral di torakal ke dalam pleura.30,36,39

Diagnosa Banding

1.   Infeksi piogenik (contoh : karena staphylococcal/suppurative spondylitis).

      Adanya sklerosis atau pembentukan tulang baru pada foto rontgen menunjukkan adanya infeksi piogenik. Selain itu keterlibatan dua atau lebih corpus vertebra yang berdekatan lebih menunjukkan adanya infeksi tuberkulosa daripada infeksi bakterial lain.

2.   Infeksi enterik (contoh typhoid, parathypoid).

      Dapat dibedakan dari pemeriksaan laboratorium.

3.   Tumor/penyakit keganasan (leukemia, Hodgkin’s disease, eosinophilic granuloma, aneurysma bone cyst dan Ewing’s sarcoma). Metastase dapat menyebabkan destruksi dan kolapsnya corpus vertebra tetapi berbeda dengan spondilitis tuberkulosa karena ruang diskusnya tetap dipertahankan. Secara radiologis kelainan karena infeksi mempunyai bentuk yang lebih difus sementara untuk tumor tampak suatu lesi yang berbatas jelas.

4.   Scheuermann’s disease mudah dibedakan dari spondilitis tuberkulosa oleh karena tidak adanya penipisan korpus vertebrae kecuali di bagian sudut superior dan inferior bagian anterior dan tidak terbentuk abses paraspinal.30,32,33,39

Manajemen terapi28,33,34

Tujuan terapi pada kasus spondilitis tuberkulosa adalah :

(1)  Mengeradikasi infeksi atau setidaknya menahan progresifitas penyakit

(2)  Mencegah atau mengkoreksi deformitas atau defisit neurologis

Untuk mencapai tujuan itu maka terapi untuk spondilitis tuberkulosa terbagi menjadi :

TERAPI KONSERVATIF

1.   Pemberian nutrisi yang bergizi

2.   Pemberian kemoterapi atau terapi anti tuberkulosa28,30,33,34

      Pemberian kemoterapi anti tuberkulosa merupakan prinsip utama terapi pada seluruh kasus termasuk tuberkulosa tulang belakang. Pemberian dini obat antituberkulosa dapat secara signifikan mengurangi morbiditas dan mortalitas. Hasil penelitian Tuli dan Kumar dengan 100 pasien di India yang menjalani terapi dengan tiga obat untuk tuberkulosa tulang belakang menunjukkan hasil yang memuaskan. Mereka menyimpulkan bahwa untuk kondisi negara yang belum berkembang secara ekonomi manajemen terapi ini merupakan suatu pilihan yang baik dan kesulitan dalam mengisolasi bakteri tidak harus menunda pemberian terapi.

      Adanya pola resistensi obat yang bervariasi memerlukan adanya suatu pemantauan yang ketat selama pemberian terapi, karena kultur dan uji sensitivitas terhadap obat anti tuberculosa memakan waktu lama (kurang lebih 6-8 minggu) dan perlu biaya yang cukup besar sehingga situasi klinis membuat dilakukannya terapi terlebih dahulu lebih penting walaupun tanpabukti konfirmasi tentang adanya tuberkulosa. Adanya respon yang baik terhadap obat antituberculosa juga merupakan suatu bentuk penegakkan diagnostik.

Resistensi terhadap obat antituberkulosa dapat dikelompokkan menjadi :

(1)     Resistensi primer

        Infeksi dengan organisme yang resisten terhadap obat pada pasien yang sebelumnya belum pernah diterapi. Resistensi primer terjadi selalu terhadap satu obat baik itu SM ataupun INH ( Isoniazid ). Jarang terjadi resistensi terhadap RMP ( Rifampisin ) atau EMB ( Ethambutol ) (Glassroth et al. 1980). Regimen dengan dua obat yang biasa diberikan tidak dapat dijalankan pada kasus ini.

(2)     Resistensi sekunder

        Resistensi yang timbul selama pemberian terapi pasien dengan infeksi yang awalnya masih bersifat sensitif terhadap obat tersebut. The Medical Research Council telah menyimpulkan bahwa terapi pilihan untuk tuberkulosa spinal di negara yang sedang berkembang adalahkemoterapi ambulatori dengan regimen isoniazid dan rifamipicin selama 6 – 9 bulan. Pemberian kemoterapi saja dilakukan pada penyakit yang sifatnya dini atau terbatas tanpa disertai dengan pembentukan abses. Terapi dapat diberikan selama 6-12 bulan atau hingga foto rontgen menunjukkan adanya resolusi tulang. Masalah yang timbul dari pemberian kemoterapi ini adalah masalah kepatuhan pasien.

        Durasi terapi pada tuberkulosa ekstrapulmoner masih merupakan hal yang kontroversial. Terapi yang lama, 12-18 bulan, dapat menimbulkan ketidakpatuhan dan biaya yang cukup tinggi, sementara bila terlalu singkat akan menyebabkan timbulnya relaps. Pasien yang tidak patuh akan dapat mengalami resistensi sekunder.

        Obat anti tuberkulosa yang utama adalah isoniazid (INH), rifamipicin (RMP), pyrazinamide (PZA), streptomycin (SM) dan ethambutol (EMB).

        Obat antituberkulosa sekuder adalah para-aminosalicylic acid (PAS), ethionamide, cycloserine, kanamycin dan capreomycin.

        Di bawah adalah penjelasan singkat dari obat anti tuberkulosa yang primer:

  1. a.        Isoniazid (INH)
  • Bersifat bakterisidal baik di intra ataupun ekstraseluler
  • Tersedia dalam sediaan oral, intramuskuler dan intravena.
  • Bekerja untuk basil tuberkulosa yang berkembang cepat.
  • Berpenetrasi baik pada seluruh cairan tubuh termasuk cairan serebrospinal.
  • Efek samping : hepatitis pada 1% kasus yang mengenai lebih banyakpasien berusia lanjut usia, peripheral neuropathy karena defisiensipiridoksin secara relatif (bersifat reversibel dengan pemberian suplemenpiridoksin).
  • Relatif aman untuk kehamilan
  • Dosis INH adalah 5 mg/kg/hari – 300 mg/hari
  1. b.       Rifampisin (RMP)
  • Bersifat bakterisidal, efektif pada fase multiplikasi cepat ataupun lambatdari basil, baik di intra ataupun ekstraseluler.
  • Keuntungan : melawan basil dengan aktivitas metabolik yang palingrendah (seperti pada nekrosis perkijuan).
  • Lebih baik diabsorbsi dalam kondisi lambung kosong dan tersedia dalambentuk sediaan oral dan intravena.
  • Didistribusikan dengan baik di seluruh cairan tubuh termasuk cairanserebrospinal.
  • Efek samping yang paling sering terjadi : perdarahan pada traktusgastrointestinal, cholestatic jaundice, trombositopenia dan dose dependentperipheral neuritis. Hepatotoksisitas meningkat bila dikombinasi dengan
  1. c.        Pyrazinamide (PZA)
  • Bekerja secara aktif melawan basil tuberkulosa dalam lingkungan yangbersifat asam dan paling efektif di intraseluler (dalam macrophage) ataudalam lesi perkijuan.
  • Berpenetrasi baik ke dalam cairan serebrospinalis.
  • Dosis : 15-30mg/kg/hari
  • Efek samping :
  1. 1.        Hepatotoksisitas dapat timbul akibat dosis tinggi obat ini yangdipergunakan dalam jangka yang panjang tetapi bukan suatu masalahbila diberikan dalam jangka pendek.
  2. 2.        Asam urat akan meningkat, akan tetapi kondisi gout jarang tampak.Arthralgia dapat timbul tetapi tidak berhubungan dengan kadar asamurat.
  3. d.       Ethambutol (EMB)
  • Bersifat bakteriostatik intraseluler dan ekstraseluler
  • Tidak berpenetrasi ke dalam meningen yang normal
  • Efek samping : toksisitas okular (optic neuritis) dengan timbulnya kondisibuta warna, berkurangnya ketajaman penglihatan dan adanya centralscotoma.
  • Relatif aman untuk kehamilan
  • Dipakai secara berhati-hati untuk pasien dengan insufisiensi ginjal
  • Dosis : 15-25 mg/kg/hari
  1. e.        Streptomycin (STM)
  • Bersifat bakterisidal
  • Efektif dalam lingkungan ekstraseluler yang bersifat basa sehinggadipergunakan untuk melengkapi pemberian PZA.
  • Tidak berpenetrasi ke dalam meningen yang normal
  • Efek samping : ototoksisitas (kerusakan syaraf VIII), nausea dan vertigo(terutama sering mengenai pasien lanjut usia)
  • Dipakai secara berhati-hati untuk pasien dengan insufisiensi ginjal
  • Dosis : 15 mg/kg/hari – 1 g/kg/hari

 

Peran steroid pada terapi medis untuk tuberculous radiculomyelitis masih kontroversial. Obat ini membantu pasien yang terancam mengalami spinal block disamping mengurangi oedema jaringan (Ogawa et.al 1987). Pada pasien-pasien yang diberikan kemoterapi harus selalu dilakukan pemeriksaan klinis, radiologis dan pemeriksaan laboratorium secara periodik.

(3)     Istirahat tirah baring (resting)

  • Terapi pasien spondilitis tuberkulosa dapat pula berupa local rest pada turning frame / plaster bed atau continous bed rest disertai dengan pemberian kemoterapi. Tindakan ini biasanya dilakukan pada penyakit yang telah lanjut dan bila tidak tersedia keterampilan dan fasilitas yang cukup untuk melakukan operasi radikal spinal anterior, atau bila terdapat masalah teknik yang terlalu membahayakan.
  • Istirahat dapat dilakukan dengan memakai gips untuk melindungi tulang belakangnya dalam posisi ekstensi terutama pada keadaan yang akut atau fase aktif. Pemberian gips ini ditujukan untuk mencegah pergerakan dan mengurangi kompresi dan deformitas lebih lanjut. Istirahat di tempat tidur dapat berlangsung 3-4 minggu, sehingga dicapai keadaan yang tenang dengan melihat tanda-tanda klinis, radiologis dan laboratorium. Secara klinis ditemukan berkurangnya rasa nyeri, hilangnya spasme otot paravertebral, nafsu makan dan berat badan meningkat, suhu badan normal. Secara laboratoris menunjukkan penurunan laju endap darah, Mantoux test umumnya < 10 mm. Pada pemeriksaan radiologis tidak dijumpai bertambahnya destruksi tulang, kavitasi ataupun sekuester.
  • Pemasangan gips bergantung pada level lesi. Pada daerah servikal dapat diimobilisasi dengan jaket Minerva; pada daerah vertebra thoracal, thoracolumbal dan lumbal atas diimobilisasi dengan body cast jacket; sedangkan pada daerah lumbal bawah, lumbosakral dan sakral dilakukan immobilisasi dengan body jacket atau korset dari gips yang disertai dengan fiksasi salah satu sisi panggul. Lama immobilisasi berlangsung kurang lebih 6 bulan, dimulai sejak penderita diperbolehkan berobat jalan.
  • Terapi untuk Pott’s paraplegia pada dasarnya juga sama yaitu immobilisasi di plaster shell dan pemberian kemoterapi. Pada kondisi ini perawatan selama tirah baring untuk mencegah timbulnya kontraktur pada kaki yang mengalami paralisa sangatlah penting. Alat gerak bawah harus dalam posisi lutut sedikit fleksi dan kaki dalam posisi netral. Dengan regimen seperti ini maka lebih dari 60% kasus paraplegia akan membaik dalam beberapa bulan. Hal ini disebabkan oleh karena terjadinya resorpsi cold abscess intraspinal yang menyebabkan dekompresi.
  • Seperti telah disebutkan diatas bahwa selama pengobatan penderita harus menjalani kontrol secara berkala, dilakukan pemeriksaan klinis, radiologis dan laboratoris. Bila tidak didapatkan kemajuan, maka perlu dipertimbangkan hal-hal seperti adanya resistensi obat tuberkulostatika, jaringan kaseonekrotik dan sekuester yang banyak, keadaan umum penderita yang jelek, gizi kurang serta kontrol yang tidak teratur serta disiplin yang kurang.

 

 

B. TERAPI OPERATIF

Sebenarnya sebagian besar pasien dengan tuberkulosa tulang belakang mengalami perbaikan dengan pemberian kemoterapi saja (Medical Research Council 1993). Intervensi operasi banyak bermanfaat untuk pasien yang mempunyai lesi kompresif secara radiologis dan menyebabkan timbulnya kelainan neurologis. Setelah tindakan operasi pasien biasanya beristirahat di tempat tidur selama 3-6 minggu.

Tindakan operasi juga dilakukan bila setelah 3-4 minggu pemberian terapi obat antituberkulosa dan tirah baring (terapi konservatif) dilakukan tetapi tidak memberikan respon yang baik sehingga lesi spinal paling efektif diterapi dengan operasi secara langsung dan tumpul untuk mengevakuasi “pus” tuberkulosa, mengambil sekuester tuberkulosa serta tulang yang terinfeksi dan memfusikan segmen tulang belakang yang terlibat.28,34,36.48.49,50,51

Selain indikasi diatas, operasi debridement dengan fusi dan dekompresi juga diindikasikan bila :

1.   Diagnosa yang meragukan hingga diperlukan untuk melakukan biopsi

2.   Terdapat instabilitas setelah proses penyembuhan

3.   Terdapat abses yang dapat dengan mudah didrainase

4.   Untuk penyakit yang lanjut dengan kerusakan tulang yang nyata dan mengancam atau kifosis berat saat ini

5.   Penyakit yang rekuren

Pott’s paraplegia sendiri selalu merupakan indikasi perlunya suatu tindakan operasi (Hodgson) akan tetapi Griffiths dan Seddon mengklasifikasikan indikasi operasi menjadi :

A. Indikasi absolut

  1. 1.        Paraplegia dengan onset selama terapi konservatif; operasi tidak dilakukan bila timbul tanda dari keterlibatan traktur piramidalis, tetapi ditunda hingga terjadi kelemahan motorik.
  2. 2.        Paraplegia yang menjadi memburuk atau tetapi statis walaupun diberikan terapi konservatif
  3. 3.        Hilangnya kekuatan motorik secara lengkap selama 1 bulan walaupun telah diberi terapi konservatif
  4. 4.        Paraplegia disertai dengan spastisitas yang tidak terkontrol sehingga tirah baring dan immobilisasi menjadi sesuatu yang tidak memungkinkan atau terdapat resiko adanya nekrosis karena tekanan pada kulit.
  5. 5.        Paraplegia berat dengan onset yang cepat, mengindikasikan tekanan yang besar yang tidak biasa terjadi dari abses atau kecelakaan mekanis; dapat juga disebabkan karena trombosis vaskuler yang tidak dapat terdiagnosa
  6. 6.        Paraplegia berat; paraplegia flasid, paraplegia dalam posisi fleksi, hilangnya sensibilitas secara lengkap, atau hilangnya kekuatan motorik selama lebih dari 6 bulan (indikasi operasi segera tanpa percobaan pemberikan terapi konservatif)

 

B.  Indikasi relatif

  1. 1.        Paraplegia yang rekuren bahwa dengan paralisis ringan sebelumnya
  2. 2.        Paraplegia pada usia lanjut, indikasi untuk operasi diperkuat karena kemungkinan pengaruh buruk dari immobilisasi
  3. 3.        Paraplegia yang disertai nyeri, nyeri dapat disebabkan karena spasme atau kompresi syaraf
  4. 4.        Komplikasi seperti infeksi traktur urinarius atau batu

 

 

C. Indikasi yang jarang

  1. 1.        Posterior spinal disease
  2. 2.        Spinal tumor syndrome
  3. 3.        Paralisis berat sekunder terhadap penyakit servikal
  4. 4.        Paralisis berat karena sindrom kauda ekuina

 

 

Tindakan bedah dengan pendekatan klasik untuk spondilitis tuberkulosis adalah melalui bagian anterior tulang belakang. Operasi ini pertama kali diperkenalkan oleh Hodgson and Stock pada tahun 1956. Pendekatan anterior melalui dinding dada atau melalui pendekatan retroperitoneal ke vertebra torakolumbar ateu vertebra lumbar untuk mengeluarkan semua yang terinfeksi dan devitalisasi tulang dan bahan yang membuat infeksi. Pengeluaran tulang dan diskus secara total penting untuk melakukan rekonstruksi,

Debridemen mengeluarkan seluruh korpus vertebra sampai kira-kira ligamentum longitudinale posterior, abses epidurai atau jaringan granulasi yang menekan saraf.

Jajaran tulang belakang dikoreksi secara manual dan topangan (strut) ditempatkan di antara sisa korpus vertebra yang sehat untuk mempertahankan kestabilan tulang belakang. Dulu 'strut graft' diambil dari krista iliaca pasien itu sendiri, namun baru-baru ini menggunakan allograft bone

Setelah rekonstruksi anterior strut graft, operasi kedua biasanya dibutuhkan untuk stabilisasi tulang belakang dan supaya pasien dapat berjalan atau berakitivitas seawal mungkin.

Posterior instrumentation and fusion mengikuti dekompresi dan rekonstruksi anterior, untuk mencegah berulangnya kifosis dan melindungi konstruksi anterior yang sudah kolaps. Prosedur anterior dan posterior ini bisa memperbaiki fungsi neurologis dimana pernah terjadi defisit neurologis sebagian, dan untuk mencegah atau mengoreksi kifosis pada penderita spondilitis tuberkulosis. Setelah prosedur kedua dilakukan lengkap, pasien bisa naik turun tempat tidur untuk berjalan dan rehabilitasi.

Pada awal paraplegia kadang-kadang dianjurkan pembedahan. Bedah kostotransversektomi dilakukan berupa debrideman dan penggantian korpus vertebra yang rusak dengan tulang spongiosa atau kortikospongiosa. Tulang ini sekaligus berfungsi menjembatani vertebra yang sehat, di atas dan di bawah yang terkena tuberkulosis. Pada paraplegia, terapi ini dilakukan untuk dekompresi medula spinalis. Keuntungan tindakan bedah, yaitu dapat menentukan diagnosis dengan pemeriksaan mikrobiologis dan patologi serta mengintensifkan terapi medis.

 

Gambar  (a) vertebektomi dan drainase abses.                             (b)posterior instrumentation with longitudinal rods,

                                                                                       combined with fixation hooks and screw.

Metode rekonstruksi yang sesuai tergantung setinggi vertebra yang terkena dan tergantung dari kerusakan tulang itu sendiri. Lokasi lesi, luasnya kerusakan vertebra dan adanya kompresi medula spinalis atau deformitas tulang belakang dapat membedakan dalam penggunaan pendekatan teknik operasi. Kerusakan vertebra dipertimbangkan 50% menyebabkan kolapsnya korpus vertebra dan deformitas tulang belakang lebih dari 5°. Pendekatan konvensional yang sering digunakan adalah anterior radical focal debridement dan posterior stabilization with instrumentation.

Kontraindikasi tindakan bedah meliputi adalah vertebra kolaps dengan jarak yang tidak begitu bermakna karena masih bisa ditangam dengan obat-obatan dan biasanya progesifitasnya lambat. Hal yang perlu diperhatikan juga adalah perlunya konsultasi dengan ahli bedah ortopedik, bedah saraf dan tim rehabilitasi.

Tindakan bedah dipertimbangkan jika terdapat ketidakstabilan dari tulang belakang atau gejala-gejala neurologis yang progresif dengan deformitas dan kompresi dari sumsum tulang belakang yang jelas. Dahulu, drainase abses dingin paraspinal dilakukan dengan alasan bahwa prosedur ini mempercepat perbaikan kondisi pasien. Belakangan ini, pengalaman di senter-senter yang merawat kasus-kasus TB spinal dengan abses besar menduga drainase rutin dari abses ini mempunyai efek yang sedikit atau tidak ada sama sekali terhadap perbaikan kondisi pasien.

Secara serupa, debridemen melalui pembedahan pada tulang dan jaringan lunak yang terkena mungkin mempunyai pengaruh pada pembersihan infeksi. Terdapat bukti-bukti yang jelas, bahwa debridemen sederhana dari fokus yang terinfeksi memperbaiki kemoterapi. Saat adanya deformitas, kelainan neurologis dan ketidakstabilan, peran dari dekompresi, debridemen prekonstruksi dan stabilisasi dari jaringan yang terkena terlihat jelas.

Seperti infeksi dan tipe-tipe lainnya, kebanyakan mereka mempengaruhi spinal bagian tengah dari corpus vertebra. Akibatnya, dekompresi, debridemen dan rekonstruksi dari columna anterior dan tengah yang terkena memerlukan pendekatan anterior atau anterolateral. Untuk lesi servikal, prosedur standar untuk penyakit multilevel anterior dapat diaplikasikan. Untuk pasien dengan deformitas yang berarti yang tidak dapat dikoreksi sepenuhnya dari depan, tambahan fiksasi posterior mungkin perlu dipertimbangkan.

Yang setinggi torakal biasanya diakses melalui torakotomi yang mana cukup untuk melakukan debridemen anterior dan rekonstruksi anterior. Jika elemen posterior masih baik dan kifosis tidak berarti, biasanya hal ini sudah cukup.

Sebagai alternatif, jika kifosis cukup bermakna dengan kompresi spinal di regio torakal (T4-L1), pendekatan ekstracavitori lateral mungkin cukup efektif untuk mengusahakan penglihatan untuk melakukan dekompresi spinal dan memungkinkan rekonstruksi posterior untuk koreksi deformitas dengan lapangan operasi tunggal.

Rekonstruksi anterior menggunakan tulang iga yang autolog atau strut allograft, umumnya dapat dilakukan dengan pendekatan ini. Akhirnya pembedahan dengan pendekatan anterior dan posterior yang dilakukan secara berurutan dalam satu sesi mungkin diperlukan untuk menghasilkan debridemen yang optimal, koreksi deformitas dan stabilitas jangka panjang.

Hogdson dan Stock adalah salah satu yang pertama untuk mendeskripsikan anterior dekompresi yang sukses pada pasien dengan penyakit Pott, dengan perkembangan di daiam diagnosis dan antibiotik, sebagian besar kasus osteomielitisvertebralis dan diskitis sekarang dapat diterapi secara efektif tanpa intervensi bedah.

Sebanyak 90% pasien merespon terhadap terapi antibiotik intravena dan immobilisasi. Pengobatan secara konservatif yang gagal mungkin memerlukan debndemen secara pembedahan dan stabilisasi. Bukti-bukti dari kegagalan antibiotik termasuk peningkatan LED, leukositosis, nyeri yang persisten, secara radiologis terbukti berkembang ke arah yang tidak baik dan bakteremia yang terus menerus. Infeksi jarang menyebar ke bagian ventral dari ruang epidural. Kurang dari 20% dari abses epidural spinal terjadi di bagian anterior dari sumsum tulang belakang.

Kelainan neurologis dapat merupakan akibat dari peradangan pembuluh darah meduler atau radikuler dan tidak selalu merupakan indikasi untuk melakukan pembedahan,

Debridemen secara bedah adalah penting untuk mendapatkan kultur diagnostik dan pada kasus dimana pengobatan gagal melalui obat-obatan, kelainan neurologis yang berhubungan dengan penumpukan di bagian ventral dan destruksi dari corpus vertebra yang menyebabkan deformitas yang berarti. Disamping adanya infeksi aktif dimasukkannya graft strut dan konstruksi instrumentasi tidak meningkatkan insidensi dari infeksi post operatif.

Penanganan Spondilitis Tuberkulosis yang Tidak Disertai Paraplegia

Baru-baru ini penanganan tuberkulosis tulang belakang dengan bedah radikal atau dengan arthrodesis awal biasanya dilakukan supaya abses paraspinal tertekan secara spontan, kemudian dilakukan drainase dan dilanjutkan dengan fusi tulang belakang. Selain itu bisa juga diterapi dengan pemberian obat antituberkulosis yang dilanj utkan dengan tindakan drainase abses paraspinal, kemudian bisa dilakukan bone grafts ke bagian yang mengalami kerusakan setelah dilakukan debridement.

Menurut Hodgson, melakukan debridement dan anterior arthrodesis seawal mungkin setelah diagnosis ditegakkan akan memberikan prognosis yang baik. Selain Hodgson, ada peneliti lain, yaitu Roaf yang melakukan penanganan bedah pada spondilitis tuberkulosis dalam 2 tahap, yaitu (1) evakuasi abses, kemudian dilanjutkan dengan (2) arthrodesis posterior.

 

Gambar Bone Graft

ABSES TUBERKULOSIS TULANG BELAKANG

Abses tuberkulosis tulang belakang bisa dipalpasi tergantung ukuran dan vertebra yang terkena serta distribusi dari fascia dan ototnya. Abses tuberkulosis tulang belakang biasanya tidak menimbulkan manifestasi klinis sampai absesnya besar dan menekan organ-organ disekitarnya seperti faring, atau spinal cord,

Abses tuberkulosis tulang belakang bisa mengenai bagian servikal, torakal, maupun bagian lumbar. Berikut akan dibahas abses tuberkulosis yang mengenai bagian-bagian dari tulang belakang beserta penanganannya.16,48,49

A.    Abses Tuberkulosis pada Vertebra Cervical

        Jika yang terkena adalah vertebra cervikal, abses bisa ada di retrofaringeal di posterior dari trigonum leher atau area supraclavicular atau detritus tuberkulosis dapat gravitasi ke bawah di bawah fascia prevertebral membentuk abses mediastinal.

        Drainase abses retrofaringeal

        Drainase abses retrofaringeal melalui insisi dinding posterior faring dilakukan hanya jika gawat darurat, diindikasikan karena ada sianosis dan kesukaran bernafas. Biasanya drainase dilakukan dengan ekstraoral approach.

        Insisi 7,5 cm sepanjang garis posterior otot sternocleidomastoideus. Kemudian insisi lapisan superfisial dari fascia servikal dan lindungi nervus accessory spinal yang menembus otot sternocleidomastoideus dan insisi oblique menyeberang trigonum posterior.

 

Gambar Drainase abses tuberkulosis pada pada vertebra servikal.

Dilanjutkan dengan retraksi otot sternocleidomastoideus ke medial atau bagi secara melintang. Dengan diseksi tumpul, paparkan otot levator scapulae dan otot splenius, pindah vena jugularis interna ke anterior dan palpasi abses di depan prosesus transversus dan corpus vertebra.

Kemudian lakukan punksi abses dan evakuasi abses. Jika abses besar dan gejala sangat akut, jangan tutup luka, tapi tutup lapisan luka. Trakeotomi dilakukan jika ada kesukaran bernafas oleh karena edema laring atau raptur abses ke faring. 16,48,49

Drainase abses trigonum posterior leher

Insisi oblique kulit dan fascia superfisial kurang lebih 6 cm sepanjang garis posterior otot sternocleidomastoideus. Retraksi otot ke medial dan lindungi nervus frenikus. Lokasikan dan bagi antara otot scalenus anterior dan otot longus colli dengan diseksi obliq tumpul ke dalam abses di bawah fascia paravertebral. Evakuasi rongga dan tutup luka.

 

B.    Abses Tuberculosis pada Vertebra Thoracalis

        Abses di vertebra dorsal dievakuasi dengan costotransversectomy. Prosedur ini diperkenalkan oleh Haidenhaim dan digambarkan oleh Menar tahun 1894.

 

 

Gambar Costotransversectomy to drain tuberculous abscess of dorsal spine

Teknik:

Insisi midline sepanjang tiga prosesus spinosus. Refleksikan ke lateral periosteum dan jaringan lunak dari prosesus spinosus dan lamina disisi yang berisi abses. Paparkan prosesus transversus tengah dan reseksi dasarnya. Setelah refleksi periosteum dari iga yang berdekatan, reseksi medial dengan membagi 5 cm dari puncak prosesus transversus. Miringkan akhir iga, hati-hati pleuraterpunksi. Buka abses dengan diseksi tumpul ke corpus vertebra. Yang dibuka hams cukup besar untuk mempermudah eksplorasi rongga abses dan membuang semua debris. Jika reseksi lebih dari satu iga, perbesar permukaan insisi. Setelah reseksi iga-iga, lakukan ligasi neurovaskular. Tutup lapisan operasi.16,48,49

 

Teknik Seddon

• Insisi kulit semicircular di garis tengah kurang lebih 10 cm proksimal ke apex dari kifosis. lengkungkan secara distal dan lateral ke titik 10 cm dari garis tengah pada apex dan dilanjutkan ke distal dan medial ke garis tengah titik 10 cm distal apex.

 

Gambar Incision for costotransversectomy or an-tcrolateral decompression. {From Seddon, H. J,: In Platt, H., editor: Modern trends in orthopedics, second series, London, 1956, Butterworth & Co., Ltd.)

 

  • Angkat skin flap dan retraksi ke medial.
  • Potong otot superfisial dan putar sesuai arah diseksi dan sesuai dengan
    tingkat lesi.
  • Bagi   muskulus   erector   spinae   melintang   berlawanan   dengan   apex deformitas.
  • Dengan reseksi diatermi, paparkan medial tidak lebih dari tiga iga dan
    dihubungkan dengan prosesus transversus dan sepertiga lateral dari lamina.

Gambar.Exposure of ribs and resection of trans­verse processes. (From Seddon, H. J.: In Platt, H., editor: Modern trends in orthopedics, second series, London, 1956, Butterworth & Co., Ltd.)

  • Reseksi iga yang ada absesnya yang tampak pada foto rontgen
  • Setelah membagi ligamentum costotransversus, buang prosesus transversus
    dalam satu potongan dengan bone cutting forceps.
  • Menggunakan   diseksi    subperiosteal,   paparkan   iga,    hati-hati   bisa
    menyebabkan perforasi pleura.
  • Jika terjadi perforasi, tempatkan swab kecil dan tutup segera.
  • Transesksi   iga   pada   titik   kurang   dari   5   cm   (dewasa)   lateral   ke
    costotransverse joint.
  • Dengan menggunakan curve gouge untuk membebaskan ujung medial iga,
    dorong gouge ke anterior dan medial sampai ketemu kepala iga atau
    kolumna vertebralis.
  • Rotasi ujung medial iga dan gunakan gouge untuk membelah perlekatan.
  • Jika operasi berhasil, pus akan keluar.
  • Eksplorasi abses dengan jari, cari corpus vertebra, buka rongga yang berisi
    bahan necrotic.
  • Jika abses  besar,  buang  prosesus  transversus  kedua dan  iga untuk
    pemaparan.
  • Hilangkan material tuberkulosis dari rongga abses dan jaringan superfisial.
  • Luka tersebut ditaburi dengan serbuk streptomisin.
  • Tutup otot dan kulit tanpa drain.

C.  Abses Tuberkulosis pada Vertebra Lumbar

      Bila mengenai vertebra lumbar, akan tampak massa di lumbar atau paravertebral. Biasanya detritus tuberkulosis sampai ke otot iliopsoas sehingga membentuk abses iliac di atas ligamentum Pouparti atau bisa juga sampai ke Petit's triangle di permukaan anterior atau di regio adduktor paha atau di regio gluteal.16,48,49

1.     Drainase abses paravertebral

      Insisi longitudinal 8-10 cm, dan kira-kira 5-7 cm lateral ke midline paralel dengan prosesus spinalis. Insisi diperdalam ke fascia lumbodorsal secara tumpul mengelilingi batas lateral dan anterior dari otot erector spinae ke prosesus transversus.

 

Gambar Drainase abses paravertebral.

Biasanya abses segera tampak, namun jika tidak, dilakukan punksi lapisan fascia Iumbodorsal yang memisahkan otot quadratus lumborum dari otot erector spinae dan batas anterior dari prosesus transversus. Setelah evakuasi abses, lapisan insisi ditutup.

2.     Drainase abses psoas

Abses psoas terletak di extraperitoneal dan berada mengikuti ruas otot iliopsoas.

Gambar Abses psoas

Drainase dilakukan dari posterior melalui Petit's triangle, dengan dilakukan insisi lateral di sepanjang krista ilium atau bagian anterior ligamentum Pouparti bagian bawah. Tindakan ini dilakukan tergantung dari ukuran abses dan area yang tampak. Kadang-kadang abses bersembunyi di bawah ligamentum Pouparti dan terletak di subkutis sepertiga proksimal dari regio adduktor paha.

 

Gambar Drainase abses psoas

 

3.        Drainase melalui Petit's triangle

Batas lateral Petit's triangle dibentuk oleh batas lateral otot latissimus dorsi dan batas medial dari muskulus obliquus abdominis extemus serta dasar dari krista ilium. Lantai dari triangle ini adalah muskulus obliquus abdominis internus.

Buat insisi kurang lebih 8 cm. Kemudian 2,5 cm ke proksimal dan sejajar dengan krista ilium posterior, dimulai dari lateral muskulus erector spinae. Setelah tampak Petit's triangle, dilakukan diseksi tumpul melalui muskulus obliquus abdominis internus secara langsung ke abses tersebut. Setelah evakuasi abses, lapisan insisi ditutup.

 

Gambar Drainase abses Petit's triangle.

Setelah penanganan melalui Petit's triangle biasanya terjadi kontraktur fleksi dari panggul. Untuk mengatasinya dilakukan ekstensi Buck's untuk mengoreksi deformitas dan melemaskan otot spastik panggul.

4.     Drainase dengan insisi lateral

Insisi dibuat kurang lebih 10 cm sepanjang sepertiga tengah dari krista ilium, kemudian bebaskan perlekatan muskulus obliquus abdominis interims dan eksternus. Abses dapat dipalpasi di bagian sayap ilium sebagai massa ekstraperitoneal yang fluktuatif. Kemudian dilakukan punksi abses. Selanjutnya insisi abses ditutup.

5.      Orainase dengan insisi anterior

Mulai dengan insisi kulit longitudinal di vertebra anterosuperior dan diteruskan ke distal kurang lebih 5-7,5 cm di anterior paha. Identifikasi otot sartorius dan diseksi dalam ke batas medial setinggi anteroinferior spinae.

Hati-hati terkena nervus femoralis di medial area tersebut. Kemudian sisipkan a long hemostat di sepanjang permukaan medial sayap ilium di bawah ligamentum Pouparti dan dilakukan punksi abses. Setelah evakuasi abses selesai, lapisan insisi ditutup.

6.      Drainase dengan insisi Ludloff

Jika abses psoas di subkutis regio adduktor paha dengan insisi Ludloff. Dilakukan jika eksisi abses psoas sederhana gagal dilakukan dikarenakan ukuran abses atau adanya infeksi bakteri multipel.

7.    Drainase abses pelvic

Menurut Lougheed and White, tuberkulosis tulang belakang melibatkan lumbar bawah dan area lumbosacral. Jaringan lunak abses dapat sampai ke pelvic karena pengaroh gravitasi,rnembentuk abses besar anterior ke sakrum. Abses ini ke kulit bagian anterior paha atau di atas krista iliaka.

Namun, drainase ini saja tidak cukup memuaskan kerena menyebabkan sinus drainase abses kronik akibat pemberian obat antituberkulosis dalam jangka waktu lama. Abses pelvic biasanya terlihat pada gambaran rontgen. Dilakukan drainase posterior dengan coccygectomy. Biasanya luka menyembuh dalam 6-8 minggu dan lesi spinal menjadi inaktif.

Teknik Loughed and White. Dilakukan insisi clips kurang lebih 15 cm sepanjang coccyx. Kemudian bebaskan coccyx dari Jaringan lunak, kemudian disartikulasi dari sakrum. Diseksi ke atas secara hati-hati sampai menembus rongga abses. Setelah evakuasi bahan purulen, sisipkan kateter irigasi ke bagian atas rongga dan bungkus luka dengan iodoform gauze. Dalam 2-3 minggu luka dialirkan melalui kateter beberapa kali dalam sehari dengan larutan streptomisin.16,48,49

ANTERIOR THORACIC INSTRUMENTATION16,25

Pengertian yang jelas tentang anatomi regional sangat diperlukan untuk dilakukannya pembedahan. Thoracic inlet pada setinggi pertemuan servikotorakal mempunyai diameter sagital sekitar 5 cm dan diameter koronal rata-rata sekitar 10 cm.

Lateral Extracavitary Approach

Lateral Extracavitary approach diperkenalkan oleh Larson dkk pada tahun 1976, adalah pengembangan dari costotransveresectomi lateral yang merupakan pendekatan yang ideal untuk lesi yang berada dan meluas ke arah paraspinalis anterior dengan atau tanpa mempengaruhi komponen intraspinal yang berarti. Pendekatan ini menyediakan pemaparan yang familiar bagi para dokter bedah spinal dan akses yang luas pada ketiga kompartemen spinalis. Pendekatan ini seluruhnya berada di luar vertebra dan dapat menghindari komplikasi perioperatif yang berhubungan dengan pemaparan transtorakal, disamping itu, stabilisasi sirkumferensial dari tulang belakang dapat dilakukan dengan satu insisi. Pendekatan ini juga beragam dan dapat dimodifikasi tergantung dari ukuran tumor, banyaknya vertebra yang terlibat, hubungannya dengan struktur saraf dan keperluan untuk stabilisasi spinal.

Teknik Operasi

Setelah induksi anestesi dilakukan, pasien diposisikan tiga per empat tengkurap. Untuk pemaparan awal, meja operasi dimiringkan ke bagian yang patologis sehingga pasien benar-benar berada pada posisi tengkurap. Lalu diambil radiografi anteroposterior saat akan dilakukan operasi untuk mengidentifikasi tinggilesi pada vertebra, lalu area operasi dipersiapkan dengan menutup lapangan operasi yang tidak diperlukan.

Sebuah insisi hockey-stick dilakukan di bagian tengah lesi vertebra-vertebra patologis. Pemaparan bagian kaudal diperlukan sebelurn insisi diperluas ke lateral atau perluasan ke arah kaudal akan sangat terbatas, terutama jika direncanakan untuk dilakukan instrumentasi posterior atau laminektomi. Insisi ke lateral dikurvekan ke bagian yang patologis, memanjang 8 sampai 10 cm dari garis tengah. Insisi di garis tengah diteruskan sampai ke prosesus spinosus dan fascia torakodorsalis melewati jaringan subkutan.

Dilakukan diseksi subperiosteal dari muskulus paraspinalis dengan menggunakan disektor cobb dan kauter monopolar. Hal ini dilakukan secara bilateral jika diperlukan pemaparan posterior untuk dilakukan laminektomi atau instrumentasi, jika tidak pemaparan unilateral sudah cukup. Bagian lateral dari insisi dibuka dengan mentransksesksi muskulus yang menyilang (latisimus dorsi, trapezius, dan rhomboid) di garis insisi. Flap myocutaneus memaparkan muskulus erektor spinae.

Muskulus paraspinalis berjalan pada jalur yang dibuat oleh iga, prosesus transversus, pedikel, dan sambungan facet. Batas lateral dari erector spina dikenali dan didiseksi ke arah medial untuk memaparkan iga yang berada di bawahnya. Diseksi ini diperdalam sampai sendi facet, seringkali berhubungan dengan diseksi posterior.

Mobilisasi dari musculus erector spinalis memungkinkan untuk masuk ke kompartemen lateral dari tulang belakang, muskulus longitudinalis dibungkus dengan kasa basah dan dapat diposisikan ke medial atau lateral, sehingga memungkinkan ahli bedah untuk bekerja di kedua sisi.

Gambar  Mobilisasi muskulus erector spinae

 

Diseksi penuh dari elemen vertebra di atas dan di bawah level yang patologis menjamin pemaparan bagian ventral yang cukup. Permukaan iga dorsalis dan lateralis dipaparkan dengan elevator cobb ke sambungan dari corpus vertebra. Jaringan lunak di bagian ventral didiseksi sehingga batas dengan disector iga Doyne. Prosesus transversus yang berada setinggi yang patologis, beserta 6-8 cm dari iga yang coresponding, diseksi dengan pemotong iga.

Sendi costotransversus dan costo vertebra dilepaskan dan ditranseski secara tajam. Reseksi dari kepala iga memaparkan sisi anterolateral dari tulang belakang, termasuk pedikulus dari formaen intervertebralis. Pada ketinggian di atas dan di bawah, sebagian dari iga juga dipotong untuk memudahkan pemaparan bagian ventral. Hanya 3-4 cm dari iga pada ketinggian ini yang direseksi pada level ini untuk menghindari flailchest.

Setelah iga dan prosesus transversus dikeluarkan, bundle neurovascular yang berada dia antara fascia endotoraks diidentifikasi di dalam otot-otot interkostal. Nervus segmental di atas dan setinggi level patologis didiseksi sehingga bebas dan dipisahkan. Tidak seperti pada lumbal, saraf-saraf di torakal dapat dikorbankan dengan tanpa adanya kelainan yang dapat didieteksi. Sekali sarafnya bebas, pleura parietalis dimobilisasi ke ventral untuk memungkinkan akses ke kompartemen anterior spinalis. Pleural parietalis dipisahkan dari lapangan operasi dengan retractor yang lebar dan paddle untuk menghindari dari robekan pleura.

Pada saat ini meja operasi dikembalikan pada posisi tengkurap sebenarnya, sehingga memudahkan visualisasi bagian ventral. Pleural peritealis dan diagfragma atau keduanya dibebaskan secara diseksi tumpul dari aspek ventrolateral corpus vertebra dengan elevator cobb. Diseksi tajam mungkin diperlukan di vertebra setinggi ruang diskus jika terdapat banyak sekali Jaringan ikat. Rantai simpatikus harus diidentifikasi, rantai ini terapat di bagian ventrolateral dari vertebra. Kami comunicantes ditranseksi pada segmen spinal yang terkena dan rantai simpatisdimobilisasi melalui diseksi melalui diseksi subperiosteal. Pembuluh-pembuluh dorsal dan foraminal diidentifikasi dan di kauterisasi, dan di transeksi.

Ujung saraf-saraf yang telah dielevasi menfasilitasi diseksi ke foramen dan pedikulus. Reseksi dari pedikulus memungkinkan identifikasi dari kanalis spinalis ventralis. Keuntungan yang jelas dari pendekatan ini adalah dapat diaksesnya kompartemen spinal anterolateral dan posterior. Kanalis spinalis dapat dipaparkan melalui reseksi dari elemen anterior atau elemen posterior ataupun keduanya. Tergantung dari derajat patologisnya, korpektomi dilakukan sebagai sebuah standar.

 

Gambar  Corpectomy.

Jika dilakukan reseksi dari bagian yang patologis, sebuah prosedur untuk stabilisasi spinal mungkin diperlukan. Tulang iga yang dikeluarkan menyediakan sebuah bahan yang sangat baik untuk dijadikan graft. Dengan memposisikan bagian yang cekung dari tulang iga menghadap bagian dorsal menggantikan kifosis normal dari vertebra torakalis. Pemasangan flat di ventral diikuti oleh instrumentasi yang sesuai di bagian dorsal.

Pleura parietalis diinspeksi, apakah terdapat kebocoran udara atau tidak. Kebocoroan kecil dapat direparasi secara primer. Jika terdapat kebocoran yang cukupberarti mungkin diperlukan pemasangan chest tube untuk periode post operasi. Setelah pleura diinspeksi dan diperbaiki, yang lainnya ditutup lapis demi lapis.

Torakotomi Retropleural

Teknik kontemporer untuk anterolateral approach pada vertebra torakal adalah bagian dari penanganan operatif Hodgson dan Stock's untuk penyakit Pott. Torakotomi retropleural sesuai untuk lesi patologi yang melibatkan dua segmen. A left-sided approach lebih disukai karena adanya aorta lebih mudah untuk mobilisasi dibandingkan jika di sisi vena cava dan hepar tidak mengganggu lapangan operasi.

Lumen ganda pada tabung endotrakeal digunakan pada prosedur patologi di bawah T6. Tidak seperti lateral extracavitary approach, retropleural and transpleural approach memberikan lapangan pandang operasi yang lebih luas untuk mengakses kompartemen posterior.

Gambar Torakotomi retropleural.

Teknik Operasi

Pasien dibaringkan dengan posisi lateral dengan axillary roll dan lapisan bantalan yang sesuai untuk mencegah neuropati akibat tekanan. Pendekatan ini ditentukan dengan radiograf intraoperatif. Karena adanya angulasi dari iga bagiankaudal, insisi untuk anterolateral approach harus dibuat setinggi dua diatasnya dari lesi patologi. Misalnya lesi di T8 maka insisi dibuat di T6. Insisi pada retropleural approach mulai di kurang lebih 4 cm dari garis tengah costae yang bersangkutan dan diperluas sampai ke garis midaksilaris.

 

 

                          Gambar Insisi kulit retropleural. (A) upper thoracic. (B) midthoracic. (C) thoracolumbar.

 

Kemudian jaringan subkutan dan otot ditranseksi dengan kauterisasi monopolar untuk mengekspos periosteum dari iga. Jaringan lunak sekelilingnya disobek dari dorsal iga menggunakan disektor Addison, untuk melindungi neurovaskular intercostal. Disektor Doyne digunakan untuk membebaskan periosteum ventral sepanjang costae. Diseksi ini diperluas ke medial sampai memungkinkan, biasanya 1-2 cm lateral dari costotransverse joint. Bagian iga direseksi dan dilindungi untuk grafting,

Gambar  Reseksi iga untuk grafting.

ascia endotorakal diidentifikasi sebagai lapisan yang mengkilat yaitu bagian dalam periosteum iga dan bagian superfisial dari pleura parietal. Lapisan fascia ini insisinya diperdalam sesuai dengan garis kulit insisi. Pleura parietal dibebaskan ke segala arah dengan diseksi tumpul dengan jari atau disektor busa.

Manuver ini mengekspos costotransverse joint dan aspek anterolateral dari corpus vertebra. Untuk mencapai regio torakal bagian bawah dan thoracolumbar junction, lateral attachment diafragma dipisahkan sehingga ruang retropleural dan retroperitoneal tampak jelas.

Gambar  Insisi fascia endotorakal

Insisi diafragma melingkar dari dinding dada anterior, perlekatan iga ke-11 dan ke-12 ke diafragma didiseksi subperiosteal yang lebih kaudal dari pandangan diafragma yang sudah terbuka. Diseksi ini dilanjutkan ke medial untuk mengangkat bagian lateral dan medial ligament arcuata yang melekat pada otot. Pada potongan melintang LI, otot dikesebelah kiri-kan untuk menyeseuaikan kembali diafragma. Akhirnya left crus dibagi secara lengkap antara rongga retropleural dan rongga retroperitoneal.

 

 

Gambar Diseksi Tumpul Pleura

Peritoneum dibersihkan dari dinding abdomen posterior, dengan perhatian khusus bahwa areanya dekat dengan tendon central, dimana periosteum lebih tipis. Vena hemiazygos dan vena acessory azygos diidentifikasikan dan memerlukan kauterisasi. Kepala costa bagian proksimal direseksi secara tajam, untuk mengekspos aspek lateral dari corpus vertebra, Retraktor diposisikan dan digunakan untuk retraksi paru dan isi peritoneum. Dengan menggunakan mata pisau refraktor dengan bantalan yang baik mencegah trauma dari stuktur yang ada.

 

Gambar Diseksi tajam kepala iga bagian proximal

Jika fusi dan fiksasi sudah lengkap, bagian yang dibedah diirigasi dan di inspeksi. Jika diafrgama terinsisi, pinggirnya di ikat dengan jahitan absorable dan dicantelkan kembali ke psoas, transverse process of LI, quadratus dan intercostal cuff. Perbaikan primer dibutuhkan untuk sobekan pleura dan chest tube disisipkan jika terjadi kebocoran udara. Insisi primer ditutup lapis demi lapis sambil berhati-hati untuk mencegah trauma pada nervus intercostalis.

 

ThoracotomyTranspleural

Transpleural approach sama seperti yang digambarkan pada retropleural approach. Pasien dibaringkan dalam posisi lateral dan insisi kulit dibuat dua tingkat diatas lesi. Tidak seperti pada retropleural approach, pleura parietal diinsisi segaris dengan fascia endotorakal setelah costa direseksi sehingga mudah mengakses ke rongga pleura. Paru-paru di kempiskan diretraksi secara tumpul. Jika diafragma hendak diinsisi, 1 cm manset diperkirakan kembali secara utuh pada akhir prosedur.

posterior thoracic instrumentation16,25

Techniques of Posterior Internal Fixation

Teknik fiksasi internal ini digunakan pada pasien yang tidak bisa dengan anterior approach atau pada pasien yang lesinya di posterior. Kolumna anterior bisa dekompresi melalui posterolateral approach. Radiks saraf pada vertebra torakal bisa saja terluka. Kolumna anterior diganti dengan metaacrylate atau structural graft seperti allograft. Posterior approach pada vertebra torakal mempunyai tingkat morbiditas yang kecil, terutama dalam menangani lesi yang berada di vertebra torakal bagian atas dan pada cervicothoracic junction.

Menempatkan pedicle screws sebelum terjadi dekompresi adalah tindakan yang menguntungkan karena dekrompresi bisa menandakan ketidakstabilan. Pedicle screws dapat ditempatkan pada tmgkat yang dilakukan laminektomi, adanya fraktur lamina, pembuangan pedicle sebagian. Pedicle screws tidak membutuhkan tempat implantasi di kanalis spinalis, tidak seperti dengan hooks dan sublaminar wire. Pedicle screw lebih kaku sehingga tingkat keberhasilan untuk fusi lebih tinggi.

Tempat awal untuk menyisipkan pedicle screws pada vertebra torakal bagian atas yaitu 1 mm dibawah bagian tengah dari facet joint. Titik mulai untuk Tl dan T2 kurang lebih 7-8 mm medial ke lateral dari facet superior dan 3-4 mm superior ke garis tengah proses lintang, sedangkan titik mulai T3-T12 adalah 4-5 mm medial ke lateral pinggir facet dan 5-8 mm superior ke garis tengah proses lintang.

Untuk mencegah trauma pada medula spinalis, radiks saraf dan trauma vaskular pada pemasangan pedicle screws, maka diperlukan koreksi pedicle screws angulation. Screws dibuat sudut 10-20 derajat lebih rendah. Walaupun demikian panjangnya screw lebih besar daripada lebarnya, pengecualian pada pedikel Tl dan T2 titik menyisipkannya pada bidang medio-lateral, yaitu tegak lurus bidang posterior dari facet. Atau bisa juga dengan menyisipkan screw dengan sudut 30-40 derajat pada Tl dan 12, 20-25 derajat pada T3-T11 dan 10 derajat pada T12. (lihat gambar 73). Insertion angles ini bervariasi pada setiap individu sehingga berbeda pula dalam menentukan titik mulai untuk menyisipkan pedicle screw.

Gambar (A) posterior tension band digunakan screw untuk mengoreksi kifosis. (B) restorasi corpus vertebra tanpa mengganti fragmen fraktur.

Pilihan approach  operasi dilakukan berdasarkan lokasi lesi, bisa melaluiapproach dari arah anterior atau posterior. Secara umum jika lesi utama dianterior maka operasi dilakukan melalui approach arah anterior dananterolateral sedangkan jika lesi di posterior maka dilakukan operasi denganapproach dari posterior. Saat ini terapi operasi dengan menggunakanapproach dari arah anterior (prosedur HongKong) merupakan suatu proseduryang dilakukan hampir di setiap pusat kesehatan.

Walaupun dipilih tindakan operatif, pemberian kemoterapi antituberkulosatetaplah penting. Pemberian kemoterapi tambahan 10 hari sebelum operasi telahdirekomendasikan. Pendapat lain menyatakan bahwa kemoterapi diberikan 4-6minggu sebelum fokus tuberkulosa dieradikasi secara langsung denganapproach anterior. Area nekrotik dengan perkijuan yang mengandung tulangmati dan jaringan granulasi dievakuasi yang kemudian rongga yangditinggalkannya diisi oleh autogenous bone graft dari tulang iga. Approachlangsung secara radikal ini mendorong penyembuhan yang cepat dan tercapainyastabilisasi dini tulang belakang dengan memfusikan vertebra yang terkena. Fusispinal posterior dilakukan hanya bila terdapat destruksi dua atau lebih korpusvertebra, adanya intabilitas karena destruksi elemen posterior atau konsolidasitulang terlambat serta tidak dapat dilakukan approach dari anterior.

Pada kasus dengan kifosis berat atau defisit neurologis, kemoterapitambahan dan bracing merupakan terapi yang tetap dipilih, terutama pada pusatkesehatan yang tidak mempunyai perlengkapan untuk operasi spinal anterior.Terapi operatif juga biasanya selain tetap disertai pemberian kemoterapi,dikombinasikan dengan 6-12 bulan tirah baring dan 18-24 bulan selanjutnyamenggunakan spinal bracing.

Pada pasien dengan lesi-lesi yang melibatkan lebih dari dua vertebra, suatuperiode tirah baring diikuti dengan sokongan eksternal dalam TLSO ( Thoracolumbosacral orthosis ) direkomendasikan hingga fusi menjadi berkonsolidasi.

 

Gambar Bilateral TLSO

Gambar X-Ray Pemakaian TLSO

Operasi pada kondisi tuberculous radiculomyelitis tidak banyak membantu.Pada pasien dengan intramedullary tuberculoma, operasi hanya diindikasikan jikaukuran lesi tidak berkurang dengan pemberian kemoterapi dan lesinya bersifatsoliter.Hodgson dan kawan-kawan menghindari tindakan laminektomi sebagaiprosedur utama terapi Pott’s paraplegia dengan alasan bahwa eksisi lamina danelemen neural posterior akan mengangkat satu-satunya struktur penunjang yangtersisa dari penyakit yang berjalan di anterior. Laminektomi hanya diindikasikanpada pasien dengan paraplegia karena penyakit di laminar atau keterlibatan cordaspinalis atau bila paraplegia tetap ada setelah dekompresi anterior dan fusi, sertamielografi menunjukkan adanya sumbatan.

Cara pemasangan  CTSD24

  1. Posisi setengah duduk
  2. Tangan dipegang asisten
  3. Asepsis antisepsis, desinfeksi lapangan operasi
  4. Pasang duk steril
  5. Anestesi lokal di posisi linea axilaris anterior di ICS 9-10
  6. Insisi 2-3cm sesuai arah dari costae
  7. Lakukan jahitan seperti matras, lakukan simpul hidup sebelum dijahit
  8. Dengan clem crom dibuka M.intercostalis, dibuka pelan-pelan sampai tembus masuk intrapleural.
  9. Ambil thoracal suction, dengan krom klem dimasukkan ke dalam paru-paru, penjahitan dilakukan dengan simpul hidup.
  10. Setelah dibuka selangnya, hubungkan dengan mesin CTSD dengan tekanan 12-15 cm H2O ( dewasa ), 8-10 cm H2O ( anak ).

 

Gambar CTSD

Pencegahan28,36

Vaksin Bacillus Calmette-Guerin (BCG) merupakan suatu strain Mycobacterium bovis yang dilemahkan sehingga virulensinya berkurang. BCG akan menstimulasi immunitas, meningkatkan daya tahan tubuh tanpa menimbulkan hal-hal yang membahayakan. Vaksinasi ini bersifat aman tetapi efektifitas untuk pencegahannya masih kontroversial.

Percobaan terkontrol di beberapa negara Barat, dimana sebagian besar anakanaknya cukup gizi, BCG telah menunjukkan efek proteksi pada sekitar 80% anak selama 15 tahun setelah pemberian sebelum timbulnya infeksi pertama. Akan tetapi percobaan lain dengan tipe percobaan yang sama di Amerika dan India telah gagal menunjukkan keuntungan pemberian BCG. Sejumlah kecil penelitian pada bayi di negara miskin menunjukkan adanya efek proteksi terutama terhadap kondisi tuberkulosa milier dan meningitis tuberkulosa.

Pada tahun 1978, The Joint Tuberculosis Committee merekomendasikan vaksinasi BCG pada seluruh orang yang uji tuberkulinnya negatif dan pada seluruh bayi yang baru lahir pada populasi immigran di Inggris(Glassroth et al. 1980). Saat ini WHO dan International Union Against Tuberculosis and Lung Disease tetap menyarankan pemberian BCG pada semua infant sebagai suatu yang rutin pada negara-negara dengan prevalensi tuberkulosa tinggi (kecuali pada beberapa kasus seperti pada AIDS aktif). Dosis normal vaksinasi ini 0,05 ml untuk neonatus dan bayi sedangkan 0,1 ml untuk anak yang lebih besar dan dewasa.

Oleh karena efek utama dari vaksinasi bayi adalah untuk memproteksi anak dan biasanya anak dengan tuberkulosis primer biasanya tidak infeksius, maka BCG hanya mempunyai sedikit efek dalam mengurangi jumlah infeksi pada orang dewasa. Untuk mengurangi insidensinya di kelompok orang dewasa maka yang lebih penting adalah terapi yang baik terhadap seluruh pasien dengan sputum berbasil tahan asam (BTA) positif karena hanya bentuk inilah yang mudah menular. Diperlukan kontrol yang efektif dari infeksi tuberkulosa di populasi masyarakat sehingga seluruh kontak tuberkulosa harus diteliti dan diterapi. Selain BCG, pemberian terapi profilaksis dengan INH berdosis harian 5mg/kg/hari selama 1 tahun juga telah dapat dibuktikan mengurangi resiko infeksi tuberkulosa.

Prognosa33

Prognosa pasien dengan spondilitis tuberkulosa sangat tergantung dari usia dan kondisi kesehatan umum pasien, derajat berat dan durasi defisit neurologis serta terapi yang diberikan.

a.   Mortalitas

      Mortalitas pasien spondilitis tuberkulosa mengalami penurunan seiring dengan ditemukannya kemoterapi (menjadi kurang dari 5%, jika pasien didiagnosa dini dan patuh dengan regimen terapi dan pengawasan ketat).

b.   Relaps

      Angka kemungkinan kekambuhan pasien yang diterapi antibiotik dengan regimen medis saat ini dan pengawasan yang ketat hampir mencapai 0%.

c.   Kifosis

      Kifosis progresif selain merupakan deformitas yang mempengaruhi kosmetis secara signifikan, tetapi juga dapat menyebabkan timbulnya defisit neurologis atau kegagalan pernafasan dan jantung karena keterbatasan fungsi paru.

      Rajasekaran dan Soundarapandian dalam penelitiannya menyimpulkan bahwa terdapat hubungan nyata antara sudut akhir deformitas dan jumlah hilangnya corpus vertebra. Untuk memprediksikan sudut deformitas yang mungkin timbul peneliti menggunakan rumus :

 

Y = a + bX

dengan keterangan :

Y = sudut akhir dari deformitas                                                                                                                  

X = jumlah hilangnya corpus vertebrae

a dan b adalah konstanta dengan a = 5,5 dan b= 30, 5.

Dengan demikian sudut akhir gibbus dapat diprediksi, dengan akurasi 90% pada pasien yang tidak dioperasi. Jika sudut prediksi ini berlebihan, maka operasi sedini mungkin harus dipertimbangkan.

d.   Defisit neurologis

Defisit neurologis pada pasien spondilitis tuberkulosa dapat membaik secara spontan tanpa operasi atau kemoterapi. Tetapi secara umum, prognosis membaik dengan dilakukannya operasi dini.

e.   Usia

Pada anak-anak, prognosis lebih baik dibandingkan dengan orang dewasa

f.    Fusi

Fusi tulang yang solid merupakan hal yang penting untuk pemulihan permanen spondilitis tuberkulosa.

 

 

Kesimpulan

 

  • Spondilitis adalah suatu peradangan yang terjadi pada satu atau lebih vertebra.
  • Penyebab tersering dari spondilitis adalah tuberkulosis.
  • Penyakit ini pertama kali diutarakan oleh Percival Pott pada tahun 1779 yang menemukan adanya hubungan antara kelemahan alat gerak bawah dengan kurvatura tulang belakang, tetapi hal tersebut tidak dihubungkan dengan basil tuberkulosa hingga ditemukannya basil tersebut oleh Koch tahun 1882, sehingga etiologi untuk kejadian tersebut menjadi jelas.
  • Terapi konservatif yang diberikan pada pasien tuberkulosa tulang belakang sebenarnya memberikan hasil yang baik, namun pada kasus – kasus tertentu diperlukan tindakan operatif serta tindakan rehabilitasi yang harus dilakukan dengan baik sebelum ataupun setelah penderita menjalani tindakan operatif.

 

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