Pott disease

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Tuberculosis of the spine in an Egyptian mummy

Pott disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind
of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott (1714-
1788), a London surgeon. Scientifically, it is called tuberculous spondylitis and it is most
commonly localized in the thoracic portion of the spine.

Signs and symptoms

• back pain
• fever
• night sweating
• anorexia
• weight loss
• Spinal mass, sometimes associated with numbness, tingling, or muscle weakness
of the legs

Diagnosis
• blood tests - elevated erythrocyte sedimentation rate
• tuberculin skin test
• radiographs of the spine
• bone scan
• CT of the spine
• bone biopsy
• MRI
Late complications
• Vertebral collapse resulting in kyphosis
• Spinal cord compression
• sinus formation
• paraplegia (so called Pott's paraplegia)

Prevention
Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and
arthritis. Patients who have a positive PPD test (but not active tuberculosis) may decrease
their risk by properly taking medicines to prevent tuberculosis. To effectively treat
tuberculosis, it is crucial that patients take their medications exactly as prescribed.

Therapy
• non-operative - antituberculous drugs
• analgesics
• immobilization of the spine region by rod (Hull)
• Surgery may be necessary, especially to drain spinal abscesses or to stabilize the
spine
• Richards intramedullary hip screw - facilitating for bone healing
• Kuntcher Nail - intramedullary rod
• Austin Moore - intrameduallary rod (for Hemiarthroplasty)

Pott's Disease (Spine)

Synonyms: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis
secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's
disease

Description

Pott's disease is tuberculous caries or osteitis of the spinal column and must not be
confused with Pott's fracture of the ankle.
The source of infection is usually outside the spine. It is most often spread from the lungs
via the blood. There is a combination of osteomyelitis and infective arthritis. Usually
more than one vertebra is involved. The area most affected is the anterior part of the
vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area
to adjacent intervertebral discs. In adults, disc disease is secondary to the spread of
infection from the vertebral body but in children it can be a primary site, as the disc is
vascular in children.

It is the commonest place for tuberculosis to affect the skeletal system although it can
affect the hips and knees too. The usual sites to be involved are the lower thoracic and
upper lumbar vertebrae.

The infection spreads from two adjacent vertebrae into the adjoining disc space. If only
one vertebra is affected, the disc is normal, but if two are involved the disc between them
collapses as it is avascular and cannot receive nutrients. Caseation occurs, with vertebral
narrowing and eventually vertebral collapse and spinal damage. A dry soft tissue mass
often forms and superinfection is rare.

Epidemiology

• Pott's disease is rare in the UK but in developing countries it represents about 2%

of cases of tuberculosis and 40 to 50% of musculoskeletal tuberculosis.
• Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths
per year.
• Over 90% of TB occurs in poorer countries, but a global resurgence is affecting
richer ones.
• India, China, Indonesia, Pakistan and Bangladesh have the largest number of
cases but there has been a marked increase in the number of cases in the former
Soviet Union and in sub-Saharan Africa in parallel with the spread of HIV.
• The disease affects males more than females in a ratio of between 1.5 and 2:1. In
the USA it affects mostly adults but in the countries where it is commonest it
affects mostly children.

Risk factors

• Endemic tuberculosis
• Poor socio-economic conditions
• HIV infection

Presentation

Symptoms

The onset is gradual.

• Back pain is localised

• Fever
• Night sweats
• Anorexia
• Weight loss
Signs

• There may be kyphosis

• A paravertebral swelling may be seen
• They tend to assume a protective upright, stiff position
• If there is neural involvement there will be neurological signs
• A psoas abscess (may present as a lump in the groin and resemble a hernia)

Psoas abscess

A psoas abscess comes from a tuberculous abscess of the lumbar vertebra that tracks from
the spine inside the sheath of the psoas muscle.

• Other causes include extension of renal sepsis and posterior perforation of the
bowel.
• There is a tender swelling below the inguinal ligament and they are usually
apyrexial.
• The condition may be confused with a femoral hernia or enlarged inguinal lymph
nodes.

Differential diagnosis

• Pyogenic osteitis of the spine

• Spinal tumours

Investigations

• Elevated ESR
• Strongly positive Mantoux skin test
• Spinal x-ray may be normal in early disease as 50% of the bone mass must be lost
for changes to be visible on x-ray. Plain x-ray can show vertebral destruction and
narrowed disc space.
• MRI scanning may demonstrate the extent of spinal compression and can show
changes at an early stage. Bone elements visible within the swelling, or abscesses,
are strongly suggestive of Pott's disease rather than malignancy. CT scans and
nuclear bone scans can also be used but MRI is best to assess risk to the spinal
cord.
• A needle biopsy of bone or synovial tissue is usual. If it shows tubercle bacilli this
is diagnostic but usually culture is required. Culture should include mycology.

Associated diseases

Tuberculosis co-infection with HIV has become common. It is up to 11% in some areas
of the UK and over 60% in countries such as Zambia, Zimbabwe and South Africa.

In the developed world, the disease is more common in certain sections of society such as
alcoholics, the undernourished, ethnic communities, the elderly, and HIV infected people.
The disease is also more common in patients after gastrectomy for peptic ulcer.

Distribution

The lower thoracic region is the most common area of involvement at 40 to 50%, with
the lumbar spine in a close second place at 35 to 45%. The cervical spine accounts for
about 10%. The commonest area affected is T10 to L1.

Management

Non-drug

Immobilisation of the spine is usually for 2 or 3 months.

Drugs

This is covered in the article on Management of Tuberculosis.

Surgical

Surgery plays an important part in the management. It confirms the diagnosis, relieves
compression if it occurs, permits evacuation of pus, and reduces the degree of
deformation and the duration of treatment.1 However, a Cochrane review found that
routine surgery in addition to chemotherapy had not been shown to improve outcome but
the problem was that the evidence was poor.2 A study from India suggested that surgery is
not mandatory.3

Complications

• Progressive bone destruction leads to vertebral collapse and kyphosis:

o The spinal canal can be narrowed by abscesses, granulation tissue, or
direct dural invasion. This leads to spinal cord compression and
neurological signs (Pott's paralysis).
o Kyphosis occurs because of collapse in the anterior spine and can be
severe
o Lesions in the thoracic spine have a greater risk of kyphosis than those in
the lumbar spine
o Neurological problems can be prevented by early diagnosis and prompt
treatment. It can reverse paralysis and minimise disability.
o A combination of conservative management and surgical decompression
gives success in most patients
o Late onset paraplegia is best avoided by prevention of the development of
severe kyphosis
o Patients with tuberculosis of the spine who are likely to have severe
kyphosis should have surgery in the active stage of disease.4
 o The degree of kyphosis, the area of affected vertebrae and lack of
sphincter control all correlate with the chance of recovery from
paraplegia.5
• A cold abscess can occur if the infection extends to adjacent ligaments and soft
tissues. Abscesses in the lumbar region may descend down the sheath of the psoas
to the femoral trigone region and eventually erode into the skin and form sinuses.

Prognosis

The progress is slow and lasts for months or even years. Kyphosis is common. Prognosis
is better if caught early and modern regimes of chemotherapy are more effective. A study
from London showed that diagnosis can be difficult and is often late.6 Therapy may need
to exceed 6 months. Around two thirds of subjects in developed countries are immigrants,
as shown from both London6 and Paris7 and spinal tuberculosis may be quite a common
presentation.

Prevention

As for all tuberculosis. BCG vaccination. Improvement of socio-economic conditions.

Prevention of HIV and AIDS.

http://www.slideshare.net
 Acknowledgement

The researchers would like to thank their school for letting us to have this Case
Presentation in our Nursing Care Management 103 for this summer.

We would like also to thank Davao Medical Center for having this opportunity in your
institution.

To the staff of Ortho Ward thank you foe lending us a very helpful hand. Thank you all,
for without all of your help this Case Study would have not been successful.

To our Clinical Instructors, Mr. Kent Aderes, RN and Miss Christella Dae Tenepre, RN
for providing the necessary knowledge that contributed to the completion of this case
presentation.

To our parents, who were always there by our side in supporting our financial, physical,
emotional, and spiritual needs into making this case study possible.
 Identification of the Case

A. Personal Background

Name: Mrs. M

Sex: Female

Age: 48 years old

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Address: ULA, Tugbok (POB) Davao City

Father’s Name: Mr. Joseph

Mother’s Name: Mrs. Rosenda

Date and Time Admitted: April 14, 2009

Date and Time Discharge: ss(still in after 3 days of duty)

Admitting Diagnosis: Pott’s Disease, C7- T2

Admitting Physician: Dr. Bryan Gil L. De Manuel

Chief Complaint: Body Weakness

Ward: Ortho Ward (Female)

B. Background History

DM HTN CA ASTHMA UTI

Paternal X X X X X

Maternal X X X X X

Table shows that there is no paternal and maternal background.

Medical History

Patient suffers from cough, fever, chicken pox, and measles during her childhood
days. She treats her illness by taking medicines such as paracetamol and neozep. Her
menstruation started at the age of 14 with regular visits.

Operation: she didn’t undergo any surgical procedures before.

Injury: she haven’t experience any injury.

History of Present Illness

Our patient was admitted 3 years PTC, onset of numbness of lower extremities, MRI
of Thoracic spine – (+) mass replacing the C7 and T1 vertebral bodies. 2 years PTC
patient later developed loss of sensation on both lower extremities, (+) weakness of both
lower extremities, (+) loss of bladder and bowel control. CT scan of cervical spine- intra
spinal mass with lysis of vertebral spine C6 to T3 malignancy considered .Biopsy done
which revealed pott’s disease as claimed.
Socio- Economic Background

Our patient is a housekeeper, while her husband is a part time job receiving a salary
of P 3,ooo/mos. Her husband provides their daily needs and its enough for them to eat at
least 3 times a day. And they had only one child.
 Nursing Theories

Florence Nightingale viewed manipulation of the physical environment as a major

component of nursing care. She identified ventilation, warmth, noise, variety, cleanliness
of rooms and walls, and nutrition as major areas of the environment the nurse could
control. The patient must use increased energy to encounter the environmental stress.
These stresses drain the patient of energy needed for healing. She stated that patients
should never be waked intentionally or accidentally during the first part of sleep. She
asserted that whispered or long conversations about patients are thoughtless and cruel.

She considered it stressful for a patient to hear opinions after only brief observation
had been made. False hope was depressing the patient, she felt and caused them to worry
and became fatigued. She encouraged the nurse to heed what is being said by visitors,
believing that sick persons should hear good news that would assist them in becoming
healthier. Nightingale’s Theory emphasized the importance of client and safety
environment of a sick. She also implies that this will alleviate the risk of acquiring and of
any disease that comes from the environment. A good environment is a good factor that
will help or aid a person from any communicable diseases.

Virginia Henderson stated that nursing is primarily assisting the individual (sick or
well) in the performance of those activities contributing to health, or its recovery that she
would perform unaided if she had the necessary strength, will or knowledge. It is likewise
the unique contribution of nursing to help the individual to be independent of such
assistance as soon as possible. She suggest that a nurse who is unable to fully interpret or
supply all the requirement for the individuals well being. At best the nurse can merely
assist the individual in meeting human needs. She believes sensitivity to non verbal
communication is essential to encourage the expansion of feeling. Furthermore,
prerequisite to validate a patients needs is a constructive nurse patient relationship.

Dorothea Orem, Each person has a need for self care in order to maintain optimal
health and wellness. Each person possesses the ability and responsibility to care for
themselves and dependants. She also says that every mature person has the ability to
meet self care needs, but when a person experiences the inability to do so due to
limitations, thus exists a self care deficit, maturing and mature person initiate and
perform w/in time frames, on their own behalf, and in the interest of maintaining life and
helpful functioning and continuing personal development and well being. The patient has
a self care deficit since she doesn’t know how to care or even manage herself. The results
are not adequate to know self care demand. Explains not only when nursing is needed but
also how people can be assisted through the methods of helping.
 Prognosis

A. Ideal

The progress is slow and lasts for months or even years. Kyphosis is common. Prognosis
is better if caught early and modern regimes of chemotherapy are more effective. A study
from London showed that diagnosis can be difficult and is often late. Therapy may need
to exceed 6 months. Around two thirds of subjects in developed countries are immigrants,
as shown from both London and Paris and spinal tuberculosis may be quite a common
presentation.
B. Actual

Criteria GOOD FAIR POOR JUSTIFICATION

The patient was diagnosed with

1. Duration  pott’s disease last April 14 ,2009
when she is admitted in Davao
Medical Center.
During her recovery period she was
2. Onset of Illness  in an unstable feeling which is not
so good.

The patient compliance to

3. Compliance to  medication is good because she
Medication complying the entire therapeutic
medication regimen.
The family support is good because
4.Family Support  they showed concerned and
sympathy to the patient. They
support her not only financially but
also morally, emotionally and
spiritually.
The environment is poor because it
5. Environment  is not well ventilated and unfree
from allergens.

6. Age

The precipitating factors are fair

7. Precipitating  many factors still to be considered
Factor through test.