185794 Pott's disease in rural, western Kenya: Challenging the status quo to provide exceptional care

Tuesday, October 28, 2008: 10:30 AM

Robert K. Parker, BS , Tenwek Hospital, Bomet, Kenya
Russell E. White, MD MPH FACS , Tenwek Hospital, Bomet, Kenya
Background: Extrapulmonary tuberculosis of the spine (EPTbS), Pott's disease, has been well-studied for centuries. With adequate, early treatment in resource-rich countries, it is neglected despite the rise in tuberculosis alongside HIV. Untreated EPTbS compresses the spinal cord causing symptoms of weakness, sensation loss, and eventually paralysis. In resource-poor settings, such as rural Kenya, EPTbS surgery is rare. Medical management, chemotherapy and bed rest for months, is currently considered adequate due to cost. However, surgery is indicated, yet underutilized, for severe symptoms.

Methods: We conducted a descriptive, retrospective chart review for all EPTbS surgical interventions at a tertiary-care center in Bomet, Kenya. From 2002-2007, age, gender, presentation, hospital course, costs, and follow-up were recorded.

Results: Seventeen patients (10 female), median age 26 years (3-76), underwent EPTbS surgery. All had significant, progressive neurological deficits at presentation with 15 unable to ambulate for median 1 month (2days-5months) on varying durations of medical treatment (0-4 months). At discharge (median hospital stay of 16 days [8-48]), 16 demonstrated improvement and 14 ambulated with assistance. There were no intra-operative or post-operative mortalities. Median cost was 43,423 shillings, USD$629 ($181-$1,110).

Conclusion: Surgical intervention for EPTbS is the necessary, appropriate treatment for patients with neurological compromise or deterioration on anti-tuberculosis medications. Centers in resource-poor settings should be aware of the benefits of surgery, which is economically performed and far outweighs the cost of paralysis. Comprehensive, unbiased protocols are required for a neglected problem that can be adequately addressed, even in resource-limited settings, with proper experience and concern.

Learning Objectives:
1. Identify the burden imposed from spinal tuberculosis on the patient and the community and recognize deficiencies in current therapy. 2. Discuss the reduction of health disparities, masked behind arguments of cost-effectiveness, through exemplary care in a resource-limited setting. 3. Recognize the importance of reconsidering and rectifying a neglected problem in order to provide adequate, appropriate care.

Keywords: Tuberculosis, Health Care Quality

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a fourth year medical student at Indiana University who has taken a year leave for a detached study program in western Kenya, where this specific study has been conducted. I have been involved with a number of research projects while here. Of these, I have presented and/or published on 5 different topics during this year. I have gained a decent first-hand understanding of the treatment of Pott's disease within Kenya, watching as patients arrive to the hospital paralyzed and leave walking. Additionally, I now appreciate the necessity to reconsider and rectify the structural injustice behind the current inadequate treatment for Pott's disease.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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