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Angular Kyphosis As an Indicator of the Prevalence of Pott's Disease In It is hoped that this report will stimulate interest and initiate community outreach programmes to help prevent the Angular kyphosis as an unnecessary deaths of young adults. Additional research is needed to understand the underlying aspects which relate to indicator of the prevalence the causes of violence in the community. of Pott's disease in The authors thank Drs D. Yach (MRC) and E. N. Khomo (MOH, Soweto), Ms M. de Beer (Johannesburg City Council), Transkei and Mr A. Butchart (Psychology Unit, UNISA) for their critical comments. We also thank M. H. Moeti for computerisation John W. Ogle, Frank C. Wilson, C. C. P. McConnachie of the data. To understand better the prevalence, distribution and REFERENCES major causes of sagittal spinal deformity in a rural 1. Van Zyl JA. Estimated population and structural aspects of housing in Soweto (Report No. 165). Pretoria: Bureau of Market Research, UN1SA. 1989. homeland, the authors conducted a study of angular 2. Davies JCA, Walker AR? We need more accurate data on causes of sickness and kyphosis in the spines of 2 329 Transkei patients. Thirty­ death (Opinion). 5 Air Med J 1990; 77: 227-228. 3. Botha JL, Bradshaw D. African vital statistics - a black hole? S Atr Med J 1985; one (1,33%) had angular kyphosis. Lateral chest 67: 977-981. 4. Kielkowski D, Steinberg M. Barron P. Life after death - mortality statistics and radiographs were obtained from 22 of these patients. Air Med J the public health. S 1989; 76: 672-675. 0 0 5. Walker AA?, Walker BF. Problems over death certificates. S Atr Med J 1986; 70: Radiographic kyphotic angles ranged from 28 to 130 438. 6. Bradshaw D. Botha H, Joubert G, Pretorius JP, Van Wyk R, Yach D. Review of (mean: 70,3 :t 7,6). The vast majority (81 %) demonstrated South African Mortality (1984). Parowvallei, CP: South African Medical Research classical clinical and/or radiographic findings of Council, 1987. 7. Yach D, Zwarenstein M, Chetty K. Application of 'Health for all' in South Africa ­ tuberculous aetiology. Less frequent aetiologies included focus on equity. Commun Med Educ 1989; 7: 1309-1317. 8. Butchart A. Epidemiology of trauma in Johannesburg-Soweto. Urbanisation and fractures (2), osteoporosis (1), congenital malformation (1) Health Newsletter No. 7; Dec. 1990. 9. Muckart DJJ. Trauma - the malignant epidemic. S Atr Med J i 991; 79: 93-95. and kyphosis of unknown origin (2). Eleven of the kyphotic 10. Butchart A, Nell V, Yach D, Johnson K, Radebe B. Epidemiology of non-fatal patients were seeking care for unrelated problems and injuries due to external causes in Johannesburg-Soweto. I. Methodology and materials. 5 Atr Med J 1991; 79: 472-479. were asymptomatic in respect of their kyphoses. As a 11. Butchart A, Nell V, Yach D, Johnson K, Radebe B. Epidemiology of non-fatal injuries due to external causes in Johannesburg-Soweto. 11. Incidents and subset, the asymptomatic individuals demonstrated a determinants. 5 Atr Med J 1991; 79: 466-471. 12. Fanon F. The Wretched of the Earth. New York: Grove Press, 1968. similar aetiological distribution, with 73% strongly 13. Bulhan HA. Franz Fanon and the Psychology of Oppression. New York: Plenum Press, 1985. suggestive of tuberculous aetiology. The prevalence of 14. World Health Organisation. Manual of the International Statistical Classification of asymptomatic angular kyphosis in this unselected Diseases, Injuries and Causes of Death. 9th revision. Geneva: WHO, 1977. 15. Dean AG, Dean JA, Dicher RC. Epilnfo Version 5: A Word Processing, Database, Transkei patient population was 0,47% :t 0,14%. In this and Statistics Program for Epidemiology on Microcomputers. Atlanta, Ga: Centers for Disease Control, 1990. hospital-based study, angular kyphosis proved a valuable 16. Human Rights Commission Area Repression Report, December 1990 (ARAB) Braamfontein, Johannesburg. marker for spinal tuberculosis. Because tuberculous 17. Human Rights Commission Area Repression Report, September 1990 (ARR6) Braamfontein, Johannesburg. spondylitis is more successfully treated when detected 18. Van der Merwe S, Yach D, Metcalf CA. Peering into the black hole - the qua!ity early, spinal palpation should be included in the routine of black mortality data in Port Elizabeth and the rest of South Africa. S Afr Med J 1991; 79: 419-422. physical examination of patients or populations at risk for 19. Wyndham CH. Trends with time of cardiovascular mortality rates in the populations 01 the R5A in the period 1968-1977. 5 Air Med J 1982; 61: 987-993. tuberculosis. 20. Bac DJ. Causes of death at the Donald Fraser Hospital. Venda. South Air J Epidemiol Iniect 1989; 4: 25-27. S Atr Med J 1994; 84: 614-618. 21. Lopez AD. Causes of death: an assessment of global patterns of mortality around 1985. World Health 5tat Q 1990; 43: 91-103. 22. Regulations in terms of Births and Deaths Registration Act, 1992 (Act No. 51 of 1992). Government Gazette 1992; 327: 1-20. Kyphosis is defined as any increased sagittal spinal Accepted 7 Jun 1993. curvature with anterior concavity. It can be classified as 'rounded' or 'angular'. Rounded kyphosis is common and includes physiological, osteoporotic, postural and Scheuermann's kyphoses. Angular kyphosis, in contrast, is characterised by an abrupt increase in the dorsal angulation of the spine within the span of a few vertebrae. Angular Division of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA John W. Ogle. MEDICAL STUDENT Frank C. Wilson, M.D. Department of Orthopaedic Surgery, Umtata General Hospital, and University of Transkei, Umtata, Transkei C. C. P. McConnachie, MD. __ Volume 84 No.9 September 1994 SAMJ SAMJ ARTICLES kyphosis results from focal collapse or malformation of Diagnostic methods vertebral bodies in a limited segment of the spine. This Diagnoses were based on radiography, clinical history and deformity is often subtle and hard to detect except by direct response to antituberculosis chemotherapy. Radiology was palpation. Angular kyphoses are clinically apparent because they are usually accompanied by a palpable 'gibbus', a the principal diagnostic modality. Radiological criteria for prominent spinous process at the posterior apex of the active vertebral tuberculosis infection were: (i) typical kyphosis. Fractures and tuberculous spondylitis, also called vertebral lesions (anterior, end plate or central lysis) with 'Pott's disease', are the most common causes of angular accompanying disc involvement; and (if) fusiform soft tissue kyphosis worldwide, but tuberculosis has nearly swelling caused by 'cold' paraspinal abscesses disappeared as a cause in developed areas. We conducted (anteroposterior radiograph). a hospital-based study to learn more about the prevalence, To classify a patient as haVing 'TB spine', the angular distribution and causes of angular kyphosis in Transkei, a kyphosis had to be accompanied by at least one of the rural black homeland with a population of 3,1 million.' following: (I) radiographic evidence of active infection, as defined above; (if) vertebral lesions with typical radiological findings of healed tuberculosis (spontaneous fusion) and a documented history of a prior isoniazid response; or (iif) Methods positive biopsy at surgical spinal debridement. We classified those patients with inactive disease and ~o During June and July 1991, 2 329 patients were screened documented tuberculosis history as having 'probable TB for angular kyphosis at Umtata General Hospital. Patients spine' if radiographs revealed classic tuberculous lesions. were sequentially entered into the study from three The radiological criterion for excluding metastatic disease in outpatient clinic sources: orthopaedics (17%; 402), family both the 'TB spine' and 'probable TB spine' categories was medicine (54%; 1 254), and paediatrics (29%; 673). A the presence of narrowed disc spaces. The clinical course subsequent review of hospital records revealed that one­ and antibiotic response were used to exclude pyogenic third of all patients seen at the family medicine and osteomyelitis. BCG vaccinations rendered skin reactivity orthopaedic clinics arid all patients seen at the paediatric tests non-contributory. clinic during the investigation period had been inclUded. The family medicine and orthopaedic physicians who chose to participate reported their assigned patients with only occasional random oversights. Patients sent to non­ Results participating physicians accounted for the large group (two­ thirds of the patient load) not included. Because patients Sample characteristics were allocated to physicians randomly, patients were equally likely to be assigned a non-participating physician and be The mean age of the sample population was 24,3 ± 0,01 excluded from the study; therefore, inclusion bias was years (range: 3 days to 94 years; SO: 19,81 years); this age minimal. profile was representative of the Transkei population.' The The initial survey was a modified Gaines' examination,' 1989 female/male ratio for Transkei' was 1,4:1; the sample where patients were visually and manually inspected from ratio was 1,24:1 (55,4% female). This proportion of women 2 the side while standing comfortably erect and while bending was significantly smaller than expected (Mantel-Haenszel X : forward. Those with a gibbus were checked for neurological P < 0,00001). deficits. Lateral and anteroposterior spinal radiographs were obtained for 22 (71 %) of the 31 patients with a gibbus; Characteristics of patients with a however, lateral radiographs were unobtainable for 9 patients because of logistical problems unrelated to clinical gibbus . kyphotic severity or aetiology. Thirty-one (1,33%) had a gibbus. The mean age of the patients with a gibbus (26,4 ± 4,02 years) was 2,1 years Measurement of the kyphotic angle older than the sample mean age (not significant). The average kyphotic angle among the patients for whom In this study we used the widely accepted Medical lateral radiographs were available was 70,3° ± 7,57° (range: Research Council method3(modified after Konstam and 28 - 130; 22). Kyphosis was most often centred in the lower Blesovsky') to measure the kyphotic angle from the lateral six thoracic vertebrae (64% of radiographed patients).
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