Pott's disease, which is also known as Pott’s caries, David's disease, and Pott's curvature,

is a medical condition of the spine. Individuals suffering from Pott's disease typically
experience back pain, night sweats, fever, weight loss, and anorexia. They may also
develop a spinal mass, which results in tingling, numbness, or a general feeling of
weakness in the leg muscles. Often, the pain associated with Pott's disease causes the
sufferer to walk in an upright and stiff position.

Pott’s disease is caused when the vertebrae become soft and collapse as the result of
caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a
person with Pott's disease often develops kyphosis, which results in a hunchback. This is
often referred to as Pott’s curvature. In some cases, a person with Pott's disease may also
develop paralysis, referred to as Pott’s paraplegia, when the spinal nerves become
affected by the curvature.

A person with Pott's disease may experience additional complications as a result of the
curvature. For example, an infection can more easily spread from the paravertebral tissue,
which can cause abscesses to occur. Regardless of the complications that may occur,
Pott's disease is typically slow spreading and can last for several months or years.

A person who has been diagnosed with Pott's disease may be treated through a variety of
options. He or she may utilize analgesics or antituberculous drugs to get the infection
under control. It may also be necessary to immobilize the area of the spine affected by the
disease, or the person may need to undergo surgery in order to drain any abscesses that
may have formed or to stabilize the spine.

Since Pott's disease is caused by a bacterial infection, prevention is possible through

proper control. The best method for preventing the disease is reduce or eliminate the
spread of tuberculosis. In addition, testing for tuberculosis is an important preventative
measure, as those who are positive for purified protein derivative (PPD) can take
medication to prevent tuberculosis from forming. A tuberculin skin test is the most
common method used to screen for tuberculosis, though blood tests, bone scans, bone
biopsies, and radiographs may also be used to confirm the disease.

Pott's 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 who trained at St Bartholomew's Hospital, London. The
lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected.
Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the
thoracic portion of the spine. Pott’s disease results from haematogenous spread of
tuberculosis from other sites, often pulmonary. The infection then 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 intervertebral disc, which is avascular, cannot
receive nutrients and collapses. The disc tissue dies and is broken down by caseation,
leading to vertebral narrowing and eventually to vertebral collapse and spinal damage. A
dry soft tissue mass often forms and superinfection is rare.
Signs and symptoms
• back pain
• fever
• night sweating
• anorexia
• weight loss
• Spinal mass, sometimes associated with numbness, paraesthesia, 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)
Background

Pott disease, also known as tuberculous spondylitis, is one of the oldest demonstrated
diseases of humankind, having been documented in spinal remains from the Iron Age and
in ancient mummies from Egypt and Peru.1 In 1779, Percivall Pott, for whom Pott disease
is named, presented the classic description of spinal tuberculosis.2

Since the advent of antituberculous drugs and improved public health measures, spinal
tuberculosis has become rare in developed countries, although it is still a significant cause
of disease in developing countries. Tuberculous involvement of the spine has the
potential to cause serious morbidity, including permanent neurologic deficits and severe
deformities. Medical treatment or combined medical and surgical strategies can control
the disease in most patients.

Pathophysiology

Pott disease is usually secondary to an extraspinal source of infection. The basic lesion
involved in Pott disease is a combination of osteomyelitis and arthritis that usually
involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the
subchondral plate is area usually affected. Tuberculosis may spread from that area to
adjacent intervertebral disks. In adults, disk disease is secondary to the spread of
infection from the vertebral body. In children, because the disk is vascularized, it can be a
primary site.3

Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal
can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to
spinal cord compression and neurologic deficits. The kyphotic deformity is caused by
collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to
kyphosis than those in the lumbar spine. 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.

Frequency

United States

• Although the incidence of tuberculosis increased in the late 1980s to early 1990s,
the total number of cases has decreased in recent years.
• The frequency of extrapulmonary tuberculosis has remained stable.
• Bone and soft-tissue tuberculosis accounts for approximately 10% of
extrapulmonary tuberculosis cases and between 1% and 2% of total cases.
• Tuberculous spondylitis is the most common manifestation of musculoskeletal
tuberculosis, accounting for approximately 40-50% of cases.4
International

Approximately 1-2% of total tuberculosis cases are attributable to Pott disease.

In the Netherlands between 1993 and 2001, tuberculosis of the bone and joints accounted
for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin and 2.3-6.3%
in patients of non-European origin).5

Mortality/Morbidity

• Pott disease is the most dangerous form of musculoskeletal tuberculosis because it

can cause bone destruction, deformity, and paraplegia.
• Pott disease most commonly involves the thoracic and lumbosacral spine.
However, published series have show some variation.6,7,8,9 Lower thoracic
vertebrae is the most common area of involvement (40-50%), followed closely by
the lumbar spine (35-45%). In other series, proportions are similar but favor
lumbar spine involvement.10
• Approximately 10% of Pott disease cases involve the cervical spine.

Race

• Data from Los Angeles and New York show that musculoskeletal tuberculosis
primarily affects African Americans, Hispanic Americans, Asian Americans, and
foreign-born individuals.
• As with other forms of tuberculosis, the frequency of Pott Disease is related to
socioeconomic factors and historical exposure to the infection.

Sex

Although some series have found that Pott disease does not have a sexual predilection,
the disease is more common in males (male-to-female ratio of 1.5-2:1).

Age

• In the United States and other developed countries, Pott disease occurs primarily
in adults.
• In countries with higher rates of Pott disease, involvement in young adults and
older children predominates.

Clinical
History

• The presentation of Pott disease depends on the following:

o Stage of disease
 o Affected site
o Presence of complications such as neurologic deficits, abscesses, or sinus
tracts
• The reported average duration of symptoms at diagnosis is 4 months7 but can be
considerably longer, even in most recent series.11,9 This is due to the nonspecific
presentation of chronic back pain.
• Back pain is the earliest and most common symptom.
o Patients with Pott disease usually experience back pain for weeks before
seeking treatment.
o The pain caused by Pott disease can be spinal or radicular.
• Potential constitutional symptoms of Pott disease include fever and weight loss.
• Neurologic abnormalities occur in 50% of cases and can include spinal cord
compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or
cauda equina syndrome.
• Cervical spine tuberculosis is a less common presentation but is potentially more
serious because severe neurologic complications are more likely.
o This condition is characterized by pain and stiffness.
o Patients with lower cervical spine disease can present with dysphagia or
stridor.
o Symptoms can also include torticollis, hoarseness, and neurologic deficits.
• The clinical presentation of spinal tuberculosis in patients infected with the
human immunodeficiency virus (HIV) is similar to that of patients who are HIV
negative; however, spinal tuberculosis seems to be more common in persons
infected with HIV.12

Physical

• The examination should include the following:

o Careful assessment of spinal alignment
o Inspection of skin, with attention to detection of sinuses
o Abdominal evaluation for subcutaneous flank mass
o Meticulous neurologic examination
• Although both the thoracic and lumbar spinal segments are nearly equally
affected in persons with Pott disease, the thoracic spine is frequently reported as
the most common site of involvement. Together, they comprise 80-90% of spinal
tuberculosis sites. The remaining cases correspond to the cervical spine.
• Almost all patients with Pott disease have some degree of spine deformity
(kyphosis).
• Large cold abscesses of paraspinal tissues or psoas muscle may protrude under the
inguinal ligament and may erode into the perineum or gluteal area.
• Neurologic deficits may occur early in the course of Pott disease. Signs of such
deficits depend on the level of spinal cord or nerve root compression.
• Pott disease that involves the upper cervical spine can cause rapidly progressive
symptoms.
o Retropharyngeal abscesses occur in almost all cases.
 o Neurologic manifestations occur early and range from a single nerve palsy
to hemiparesis or quadriplegia.
• Many persons with Pott disease (62-90% of patients in reported series6,7 ) have no
evidence of extraspinal tuberculosis, further complicating a timely diagnosis.
• Information from imaging studies, microbiology, and anatomic pathology should
help establish the diagnosis.

Differential Diagnoses
Actinomycosis Multiple Myeloma
Blastomycosis Mycobacterium Avium-Intracellulare
Brucellosis Mycobacterium Kansasii
Candidiasis Nocardiosis
Cryptococcosis Paracoccidioidomycosis
Histoplasmosis Septic Arthritis
Metastatic Cancer, Unknown Primary SiteSpinal Cord Abscess
Miliary Tuberculosis Tuberculosis

Other Problems to Be Considered

Spinal tumors

Workup
Laboratory Studies

• Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-
95% of patients with Pott disease who are not infected with HIV.
• The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100
mm/h).
• Microbiology studies are used to confirm diagnosis. Bone tissue or abscess
samples are obtained to stain for acid-fast bacilli (AFB), and organisms are
isolated for culture and susceptibility. CT-guided procedures can be used to guide
percutaneous sampling of affected bone or soft-tissue structures. These study
findings are positive in only about 50% of the cases.

Imaging Studies

• Radiography
• Radiographic changes associated with Pott disease present relatively late.
The following are radiographic changes characteristic of spinal
tuberculosis on plain radiography:13
• Lytic destruction of anterior portion of vertebral body
• Increased anterior wedging
• Collapse of vertebral body
 • Reactive sclerosis on a progressive lytic process
• Enlarged psoas shadow with or without calcification
• Additional radiographic findings may include the following:
• Vertebral end plates are osteoporotic.
• Intervertebral disks may be shrunk or destroyed.
• Vertebral bodies show variable degrees of destruction.
• Fusiform paravertebral shadows suggest abscess formation.
• Bone lesions may occur at more than one level.
• CT scanning14

ο CT scanning provides much better bony detail of irregular lytic lesions,

sclerosis, disk collapse, and disruption of bone circumference.
ο Low-contrast resolution provides a better assessment of soft tissue,
particularly in epidural and paraspinal areas.
ο CT scanning reveals early lesions and is more effective for defining the
shape and calcification of soft-tissue abscesses.
ο In contrast to pyogenic disease, calcification is common in tuberculous
lesions.
 MRI
ο MRI is the criterion standard for evaluating disk-space infection and
osteomyelitis of the spine and is most effective for demonstrating the
extension of disease into soft tissues and the spread of tuberculous debris
under the anterior and posterior longitudinal ligaments. MRI is also the
most effective imaging study for demonstrating neural compression.15,16
ο MRI findings useful to differentiate tuberculous spondylitis from pyogenic
spondylitis include thin and smooth enhancement of the abscess wall and
well-defined paraspinal abnormal signal, whereas thick and irregular
enhancement of abscess wall and ill-defined paraspinal abnormal signal
suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be
important in the differentiation of these two types of spondylitis.17

Other Tests

• Radionuclide scanning findings are not specific for Pott disease.

• Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%,
respectively).18

Procedures

• Use a percutaneous CT-guided needle biopsy of bone lesions to obtain tissue

samples.
o This is a safe procedure that also allows therapeutic drainage of large
paraspinal abscesses.
o Obtain a tissue sample for microbiology and pathology studies to confirm
diagnosis and to isolate organisms for culture and susceptibility.
 • Some cases of Pott disease are diagnosed following an open drainage procedure
(eg, following presentation with acute neurologic deterioration).

Histologic Findings

Because microbiologic studies may be nondiagnostic of Pott disease, anatomic pathology

can be significant. Gross pathologic findings include exudative granulation tissue with
interspersed abscesses. Coalescence of abscesses results in areas of caseating necrosis.

Medical Care

• Before the advent of effective antituberculosis chemotherapy, Pott disease was

treated with immobilization using prolonged bed rest or a body cast. At the time,
Pott disease carried a mortality rate of 20%, and relapse was common (30%).
• The duration of treatment, surgical indications, and inpatient care have since
evolved.
• Studies performed by the British Medical Research Council indicate that
tuberculous spondylitis of the thoracolumbar spine should be treated with
combination chemotherapy for 6-9 months.4
• According to the most recent recommendations issued in 2003 by the US Centers
for Disease Control and Prevention, the Infectious Diseases Society of America,
and the American Thoracic Society, a 4-drug regimen should be used empirically
to treat Pott disease.1
• Isoniazid and rifampin should be administered during the whole course of
therapy. Additional drugs are administered during the first 2 months of therapy.
These are generally chosen among the first-line drugs, which include
pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is
indicated in cases of drug resistance.
• Regarding the duration of therapy, the British Medical Research Council studies
did not include patients with multiple vertebral involvement, cervical lesions, or
major neurologic involvement. Because of these limitations, many experts still
recommend chemotherapy for 9-12 months.
• Opinions differ regarding whether the treatment of choice should be conservative
chemotherapy or a combination of chemotherapy and surgery. The treatment
decision should be individualized for each patient. Routine surgery does not to
seem to be indicated. Most common indications for surgical procedures are
discussed below.

Surgical Care

• Indications for surgical treatment of Pott disease generally include the

following:22,23
o Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)
o Spinal deformity with instability or pain
o No response to medical therapy (continuing progression of kyphosis or
instability)
 o Large paraspinal abscess
o Nondiagnostic percutaneous needle biopsy sample
• Resources and experience are key factors in the decision to use a surgical
approach.
• The lesion site, extent of vertebral destruction, and presence of cord compression
or spinal deformity determine the specific operative approach (kyphosis,
paraplegia, tuberculous abscess).
• Vertebral damage is considered significant if more than 50% of the vertebral body
is collapsed or destroyed or a spinal deformity of more than 5° exists.
• The most conventional approaches include anterior radical focal debridement and
posterior stabilization with instrumentation.24,10
• In Pott disease that involves the cervical spine, the following factors justify early
surgical intervention:
o High frequency and severity of neurologic deficits
o Severe abscess compression that may induce dysphagia or asphyxia
o Instability of the cervical spine
• Contraindications: Vertebral collapse of a lesser magnitude is not considered an
indication for surgery because, with appropriate treatment and therapy
compliance, it is less likely to progress to a severe deformity.

Consultations

• Orthopedic surgeons
• Neurosurgeons
• Rehabilitation teams

Activity

• Despite questionable efficacy, prolonged recumbence and the use of frames,

plaster beds, plaster jackets, and braces are still used.
• Cast or brace immobilization was a traditional form of treatment but has generally
been discarded. Patients with Pott disease should be treated with external bracing.

Medication
• A 4-drug regimen should be used empirically to treat Pott disease. Treatment can
be adjusted when susceptibility information becomes available.
• Isoniazid and rifampin should be administered during the whole course of
therapy. Additional drugs are administered during the first 2 months of therapy.
These are generally chosen among the first-line drugs, which include
pyrazinamide, ethambutol, and streptomycin.
• A 3-drug regimen usually includes isoniazid, rifampin, and pyrazinamide.
• The use of second-line drugs is indicated in cases of drug resistance.
• The duration of treatment is somewhat controversial. Although some studies favor
a 6- to 9-month course, traditional courses range from 9 months to longer than 1
 year. The duration of therapy should be individualized and based on the resolution
of active symptoms and the clinical stability of the patient.

Antituberculous drugs

These agents inhibit growth and proliferation of causative organism.

Further Inpatient Care

• Once the diagnosis of Pott disease is established and treatment is started, the
duration of hospitalization depends on the need for surgery and the clinical
stability of the patient.

Further Outpatient Care

• Patients with Pott disease should be closely monitored to assess their response to
therapy and compliance with medication. Directly observed therapy may be
required.
• The development or progression of neurologic deficits, spinal deformity, or
intractable pain should be considered evidence of poor therapeutic response. This
raises the possibility of antimicrobial drug resistance as well as the necessity for
surgery.
• Because of the risk of deformity exacerbations, children with Pott disease should
undergo long-term follow-up until their entire growth potential is completed.25

Complications

• Abscess
• Spine deformities
• Neurologic deficits and paraplegia

Prognosis

• Current treatment modalities are highly effective if not complicated by severe

deformity or established neurologic deficit.
• Therapy compliance and drug resistance are additional factors that significantly
affect individual outcomes.
• Paraplegia resulting from the active disease causing cord compression usually
responds well to chemotherapy.
• If medical therapy does not result in rapid improvement, operative decompression
will greatly increase the recovery rate.
• Paraplegia can manifest or persist during healing because of permanent spinal
cord damage.
Patient Education

• Patients with Pott disease should be instructed on the importance of therapy

compliance.
• For excellent patient education resources, visit eMedicine's Bacterial and Viral
Infections Center. Also, see eMedicine's patient education article Tuberculosis.

Miscellaneous
Medicolegal Pitfalls

• A large proportion of patients with Pott disease do not present with extraskeletal
disease. In reported series, only 10-38% of cases of Pott disease are associated
with extraskeletal tuberculosis.
• The diagnosis of tuberculous spondylitis should be investigated if strong clinical
suspicion exists, even if suggestive pulmonary radiology findings are absent.
• Other features suggestive of tuberculosis include the following:
o Positive PPD result
o Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
o Presence of risk factors for tuberculosis
• Spinal tuberculosis should always be suspected when radiographs demonstrate a
destructive spine process.

Multimedia
Media file 1: MRI of a 31-year-old man with tuberculosis
of the spine. Images show the thoracic spine before and
after an infusion of intravenous gadolinium contrast. The
abscess and subsequent destruction of the T11-T12 disc
interspace is marked with arrowheads. Vertebral body
alignment is normal. Courtesy of Mark C. Diamond, MD,
and J. Antonio Bouffard, MD, Detroit, Mich.

(Enlarge Image)
[ CLOSE WINDOW ]
MRI of a 31-year-old man with tuberculosis of the spine. Images show
the thoracic spine before and after an infusion of intravenous
gadolinium contrast. The abscess and subsequent destruction of
the T11-T12 disc interspace is marked with arrowheads.
Vertebral body alignment is normal. Courtesy of Mark C.
Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich.
Media file 2: MRI of the T11 in a 31-year-old man with
tuberculosis of the spine (the same patient as in picture 1).
Extensive bone destruction consistent with tuberculous
osteomyelitis is evident. The spinal cord has normal caliber
and signal. No evidence of spinal cord compression or
significant spinal stenosis is distinguishable. Courtesy of
Mark C. Diamond, MD, and J. Antonio Bouffard, MD,
Detroit, Mich.

(Enlarge Image)

As a form of extrapulmonary tuberculosis that impacts the spine, Pott’s disease has an
effect that is sometimes described as being a sort of arthritis for the vertebrae that make
up the spinal column. More properly known as tuberculosis spondylitis, Pott’s disease is
named after Dr. Percivall Pott, an eighteenth century surgeon who was considered an
authority in issues related to the back and spine.
Pott's disease is often experienced as a local phenomenon that begins in the thoracic
section of the spinal column. Early signs of the presence of Pott’s disease generally begin
with back pain that may seem to be due to simple muscle strain. However, in short order,
the symptoms will begin to multiply. Night sweats may become common, along with a
running a fever during the day. As the condition worsens, it is not unusual to experience a
loss of appetite, resulting in an anorexic state and the resulting weight loss. There is also
often periods in which there is a tingling or numb sensation in the legs, accompanied with
a sense of not having much strength in the legs.

Fortunately, there are several ways to determine if Pott’s disease is the root cause of the
symptoms. Blood tests can help determine if there is an elevation in the rate of
erythrocyte sedimentation. A bone scan will determine if there is some indication of
problems, which may lead to the scheduling of a bone biopsy. Conducting a CT scan as
well as a radiograph of the spine is also likely to provide valuable information about the
presence and current status of Pott’s disease.

Once the presence of Pott’s disease is confirmed, there are several treatment options
available. The first line of defense will involve the use of analgesics and various
antituberculous drugs, which can help to arrest the progress of the disease, as well as
begin to alleviate symptoms. In some cases, it may be necessary to insert a rod into the
area of the spine, providing needed stability. This is often the case if some degree of
spinal cord compression has been noted. Finally, more ambitious surgery may be
required, especially in situations where there is a need to drain fluid from pockets or
abscesses that have formed, or if conditions indicate impending collapse of the vertebrae
in the spinal column.

Study design: Case reports and survey of literature.

Objective: Case reports of two women with tuberculosis (TB) of the spine (Pott's
disease) presenting with severe back pain and diagnosed as compression fracture
are described. Physicians should include Pott's disease in the differential diagnosis
when patients present with severe back pain and evidence of vertebral collapse.

Setting: Ohio, USA

Methods: A review of the literature on the pathogenesis, pathophysiology, clinical

presentation, diagnostic methods, treatment and prognosis of spinal TB was
conducted.

Results: After initial delay, proper diagnosis of spinal TB was made in our patients.
Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical
treatment was initiated.

Conclusions: Although uncommon, spinal TB still occurs in patients from developed

countries, such as the US and Europe. Back pain is an important symptom.
Vertebral collapse from TB may be misinterpreted as 'compression fractures'
especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent
procedure for the diagnosis of TB spine. However, microbiologic diagnosis is
essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise,
biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain
for M. tuberculosis. Clinicians should consider Pott's disease in the differential
diagnosis of patients with back pain and destructive vertebral lesions. Proper
diagnosis and anti-tuberculosis treatment with or without surgery will result in
cure.

Spinal Cord (2002) 40, 604−608. doi:10.1038/sj.sc.3101365

Keywords

tuberculosis; Pott's disease; tuberculosis of spine; compression fracture

Introduction

Tuberculosis (TB) is an uncommon disease in the US and the developed world.

Extrapulmonary TB may involve any organ systems and signs are non-specific. The
presenting symptom of spinal TB (Pott's disease) is usually back pain. When
roentgenogram of the spine shows vertebral collapse, it may be mistaken for compression
fractures, delaying the true diagnosis of Pott's disease. We report herein two women who
had spinal TB, initially treated as compression fractures.

Case reports

Case One

A 73-year-old woman was admitted to another hospital for treatment of congestive heart
failure and compression fractures of the spine. She was also found to have a fever with no
obvious source. She was referred for work-up because of weakness, malaise, fever, and
sweating for several weeks duration. Other symptoms included non-productive cough and
backache. She had a history of diabetes mellitus, myocardial infarction, post
percutaneous transluminal coronary angioplasty (PTCA), mitral and aortic regurgitation,
congestive heart failure and chronic obstructive pulmonary disease (COPD). She had a
history of 40 pack years of smoking.

On examination the temperature was 102°F. There was no lymphadenopathy. Rales were
noted in right upper lung field, and the heart rate was regular, with a soft precordial
systolic murmur. The abdomen was soft, with no organomegaly or tenderness noted, and
pedal edema was absent. Neurological examination revealed no focal motor weakness.
The reflexes were equal bilaterally at 2+, and Babinski's reflex was absent. She had mild
kyphosis.
Complete blood counts, electrolytes, BUN, creatinine, albumin were normal. The alkaline
phosphatase was 36 U/L. The alanine aminotransferase was 140 U/L, aspartate
aminotransferase 68 U/L. Erythrocyte sedimentation rate (ESR) was 82 mm/h.
Urinanalysis was normal. Serum electrophoresis showed mild increase in IgG, normal
IgA. PPD skin test was negative. Two blood cultures had no growth. Sputum was
negative for malignant cells and acid-fast bacilli (AFB). Computed tomographic (CT)
scan of the chest showed pulmonary infiltrates and fibrosis in the right lung. Abdominal
CT scan was normal. Roentgenogram of the thoracic spine showed marked kyphosis of
the thoracic spine. Collapse of the mid-thoracic vertebral bodies with marked erosive
changes involving the anterior and inferior portions were noted (Figure 1). Vertebral
lesion biopsy showed caseating granulomas with multinucleated giant cells. Stain for
AFB was positive. Anti-tuberculosis treatment was started with isoniazid (INH),
pyrazinamide, and rifampin. The patient underwent bronchoscopy; bronchial washings
subsequently grew M. tuberculosis susceptible to all drugs tested. The patient was
discharged and sent to a rehabilitation hospital and later received 12 months of anti-
tuberculosis treatment. The patient did well over the next 4 years of follow-up.

Case Two

A 54-year-old Filipino immigrant was found positive during a PPD skin test administered
during her routine medical check-up. Chest radiograph was unremarkable. INH
prophylaxis was initiated. Three months later, the patient complained of back pain; no
neurological deficit was noted. Subsequently she developed severe weakness of the right
leg and difficulty ambulating. She denied fever, rigors, chills, cough and hemoptysis. She
was referred to a hospital for management of progressive neurological deficit and
persistent back pain. She was found to have compression fractures of T12-L1 and
underwent insertion of Harrington rod.

Lesion biopsy of the disc between T12-L1 and bone were negative for AFB by
flourochrome stain; gram stain and routine culture were also negative. After the operation
she had some weakness in the right lower extremity and some improvement in the pain.
She was discharged to a rehabilitation hospital for spinal cord rehabilitation.

On examination, the patient was afebrile. She had good strength in both the upper and left
lower extremities, but the right lower extremity showed three over five strength in hip
and knee flexion and extension, with four over five in ankle flexion and extension. The
lungs were clinically clear, and cardiac examination was normal. Lumbosacral
radiography revealed Harrington rod placed at T12 to L3 levels with apparent fusion of
bodies of T12 to L2 levels. Bodies of L1-2 were poorly visualized due to super-imposed
metallic structures. Chest film showed cardiomegaly with no infiltrates. During her stay
in the rehabilitation hospital, the patient continued to have severe pain, despite being
given adequate doses of narcotics and muscle relaxant.

Because of strong clinical suspicion and continued patient deterioration, repeat biopsy of
the lesion between the T12-L1 vertebral bodies was performed; the specimen grew M.
tuberculosis. She was started on a daily regimen of INH, rifampin, pyrazinamide, and
ethambutol. The patient's back pain gradually improved. Ethambutol was discontinued
when testing revealed that the organism was susceptible to INH, rifampin, and
pyrazinamide. She successfully completed 12 months of anti-tuberculosis treatment with
resolution of her symptoms. She was well during the 4 year follow-up interval.

Discussion

TB of the spine is an ancient disease. In 1782, Sir Percival Pott described spinal TB and
surgical treatment of paravertebral abscess. Hence, spinal TB was called 'Pott's Disease'.
Spinal TB accounts for 50% of the cases of skeletal TB, 15% of the cases of
extrapulmonary TB and 2% of all cases of TB.1,2,3 Spinal TB is on the decline in the
United States and other developed countries. Most cases of spinal TB in developed
countries are seen primarily in immigrants from Africa and Southeast Asia, as noted in
our second case. In a study done in London between 1985−1992, 95% of cases of spinal
tuberculosis were found in immigrants.4

Nowadays, spinal TB is a disease of children in developing nations and the elderly in the
United States and Europe.5 While the HIV pandemic has led to a resurgence of
tuberculosis, it has had little impact on the epidemiology of spinal tuberculosis. In a large
French study, none of 82 cases of spinal tuberculosis were HIV infected.6 In other large
longitudinal studies among HIV infected patients, few cases of spinal tuberculosis were
reported, even after long term follow-up.7,8 A study conducted in a New York City
hospital between 1985−1995 described 26 patients with spinal tuberulosis. Twenty-seven
per cent of them were HIV positive.9

In a series of patients from the southern United States, identified between 1952 and 1972,
the average age of patients with spinal TB was 51 years.10 In 1966, Friedman noted that
the majority of patients in his series from Cleveland, Ohio were over the age of 40
years.11 The lower thoracic and thoracolumbar spine were the most common areas
involved, comprising 48% to 67% of lesions.10,11,12

The initial route of entry of M. tuberculosis is usually the respiratory tract, followed by
hematogenous dissemination. Secondary hematogenous seeding can occur from a silent
focus elsewhere in the body (eg gut, kidney, and tonsil). Another mode of M.
tuberculosis spread to the vertebral bodies is from involved contiguous para-aortic lymph
nodes. Vertebral involvement may be due to hematogenous dissemination via intercostal
lumbar arteries. Batson's plexus, which surrounds the vertebral column, has also been
implicated in those cases in which an alternating pattern of vertebral involvement has
been described.

The tubercle bacillus begins its destruction in cancellous bone and eventually extends to
the cortex. The infection gradually spreads to adjacent vertebra via the disc space. In
advanced stages of the disease, progressive vertebral collapse occurs, resulting in
kyphosis and gibbus formation.
In spinal TB, onset of symptoms is usually insidious and disease progression slow. The
usual presentation consists of pain overlying the affected vertebrae, low-grade fevers,
chills, weight loss, and nonspecific constitutional symptoms of varying duration.
Paraplegia can be the first sign of spinal disease. Varying degrees of weakness, nerve-
root compression and sensory involvement can occur. Duration of symptoms prior to
diagnosis ranges from 2 weeks to several years. Historically, this interval was at least 12
months on average, decreasing to between 3 and 6 months in the recent era.5 Weight loss
has been recorded in 58% of patients,13 and 90% to 100% of patients had back pain.14,15
Neurological involvement has varied in different studies from 32% to 76% with notable
differences in severity.15,16,17

Recognition of spinal TB in developed countries can be difficult because it is uncommon.

It presents in a similar fashion to malignant deposits in the spine, which are encountered
more frequently. The patient usually presents with pain, systemic symptoms like weight
loss and raised ESR. This presentation is similar to cases of spinal metastasis.

Other conditions, which should be differentiated from TB of the spine include pyogenic
and fungal osteomyelitis, multiple myeloma and eosinophilic granuloma. In our patients,
spinal TB was initially mistaken for compression fractures.

A positive PPD skin test has been reported in 62−100% of TB spine cases.14,17 Even
though a positive tuberculin skin test supports the diagnosis, a negative test should not be
considered as evidence excluding tuberculosis infection. In patients where there is a high
index of clinical suspicion or evidence of impaired cellular immunity, an allergy panel
should be performed.

A confident radiological diagnosis is made in less than half of the cases, with the
principal alternative diagnosis being malignant disease. The relative merits of different
imaging procedures like plain radiography, CT and MRI in the diagnosis of spinal TB
have been evaluated. Most of the studies have failed to describe how much information is
provided by each test. Conventional radiographs give a good overview; CT visualizes the
disco-vertebral lesions and paravertebral abscesses, while MRI is useful in determining
the spread of the disease to the soft tissues and spinal canal.18 The plain radiograph
described changes consistent with TB spine in 91−99% of cases.13,14,16 Radiographs may
reveal advanced lesions with vertebral osteolysis and disc space narrowing; these
findings are similar in patients with pyogenic TB. However, absence of relative sclerosis
is suggestive of TB. Paraspinal abscesses responsible for soft tissue swelling can be
visible on plain radiograph. The presence of calcification within the abscess is virtually
diagnostic of spinal TB. Several studies have also reported atypical presentations of
spinal tuberculosis on radiography, including disease confined to only one vertebra or
disease confined to the neural arch with complete sparing of adjacent vertebrae and
intervertebral disc.19 The other unusual site of involvement has been destruction of lateral
aspects of vertebral bodies along with the neural arch. This rare form of disease is
associated with rapid onset of paraplegia and has only been reported in one of 123
patients with spinal TB.20,21 CT scan is of immense value in the diagnosis of spinal TB, as
it demonstrates abnormalities earlier than plain radiography. The pattern of bone
destruction may be fragmentary in 47% of the cases, osteolytic in 34%, localized and
sclerotic in 10%, and subperiosteal in 30%.15 Other suggestive findings include soft tissue
involvement and paraspinal tissue abscess. CT scan is also of great value in the
demonstration of any calcification within the abscess or visualizing epidural lesions
containing bone fragments. It is ideal for guiding a percutaneous diagnostic needle in
potentially hazardous or relatively inaccessible sites.16,22

The best diagnostic modality for spinal TB is MRI.13,18,22,23 MRI is more sensitive than
radiography and more specific than CT in the diagnosis of spinal TB. The anatomical
pattern revealed by MRI, particularly the soft tissue and disc involvement, yields greater
specificity. MRI can also provide the diagnosis of TB of the spine 4−6 months earlier than
conventional methods, offering the benefits of earlier detection and treatment.23 MRI
allows for the rapid determination of the mechanism for neurologic compression and can
distingush between bone and soft tissue lesion (tuberculoma).

As radiological appearances are commonly non-diagnostic and imaging studies are not
fully reliable for differentiating spinal TB from other infections or neoplasm,
bacteriologic and/or histologic confirmation must be obtained.24 Microbiological
diagnosis is virtually impossible without aspiration of pus or some form of tissue
sampling, as few patients have concomitant renal or pulmonary disease yielding
diagnostic urine or sputum. However, collection of a spinal or paraspinal specimen is not
absolutely necessary if pulmonary or lymph node TB is present or if extraskeletal sites
can be sampled. The diagnosis in our first patient was made by histology and AFB smear
of the vertebral body lesion biopsy and culture of bronchial washings growing M.
tuberculosis. Fine needle aspiration of vertebrae for cytologic, histologic and
bacteriologic studies has been recommended. Fine needle aspiration biopsy as a
diagnostic tool is accurate, safe, and cost effective because the procedure does not require
hospitalization. Fine needle aspiration biopsy done under CT-guidance was successful in
diagnosing spinal tuberculosis in 34 out of 38 patients; in the remaining four patients with
a previous history of anti-tubercular treatment, acid-fast bacilli could not be isolated.25
Histologic studies were confirmatory of TB in 59−76% of the cases.5,26

Although TB of the spine is an ancient disease, treatment of this disease has undergone
major changes since 1950. Treatment of spinal TB with anti-tuberculosis medication is
effective in about 90% of the cases. In some cases treatment may be combined with
surgery.26,27 Skeletal TB is treated for 12 months (INH, rifampin and pyrazinamide for 2
months followed by INH and rifampin for 10 more months). There is substantial impact
of patient compliance on treatment success; directly observed therapy (DOT) is
recommended. Surgery, which was once the mainstay treatment for spinal TB, is required
less frequently, even in patients with cord compression. Chemotherapy alone has also
been reported as a successful treatment modality.28

Excellent results with treatment of TB spine can be achieved if early diagnosis is made.
Increasing back pain should suggest plain radiography of the spine, and perhaps followed
by MRI. Our patients present with persistent back pain. Spinal radiographic findings were
misinterpreted as compression fractures. The diagnosis of TB spine was delayed. Though
spinal TB is uncommon in this country, sporadic cases do occur. Differentiating TB of
the spine from osteoporotic compression fractures of the spine, especially in
postmenopausal white women, and from spinal cord involvement in malignancies is
important. Timely treatment of spinal TB can avoid extensive investigations, treatment
delays and adverse long-term outcomes, including compression fractures with
neurological deficits. Treatment of compression fractures in spinal TB with functional
deficits is similar to compression fractures of the spine due to any other cause, requiring
long-term rehabilitation of the patient. In patients with spinal TB pain can be severe.
Various measures to alleviate pain during rehabilitation include appropriate spinal
bracing, miacalcin (may benefit due to its analgesic effect) and narcotic analgesics.

Tuberculosis (TB) of the spine also known as

Potts disease, Pott’s Caries, David's disease, Tuberculosis spondylitis
and
Pott's curvature
, is the most common site of bone infection in TB. The lower thoracic and upper lumbar
vertebrae are the areas of the spine most often affected. The original name was formed
after
Percivall Pott
, a London surgeon, who first studied the disease. When he died,
Patrick David
was the one who continued his work.Pott’s disease results from haematogenous spread of
tuberculosis (mycobacterium tuberculosis) from other sites. The infection then 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 intervertebral disc, which is
avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down
by
caseation
, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage.
A dry soft tissue mass often forms and superinfection is rare. The disease progresses
slowly. Signs and symptoms include: back pain, fever, night sweats, anorexia, weight
loss, and easy fatigability.Diagnosis is based on: blood tests - elevated ESR , skin tests
,radiographs of the spine , bone scan ,CT of the spine , and bone biopsy. Gibbus
formation is the pathognomonic sign of this disease.

A person with Pott's disease often develops kyphosis

, which results in a hunchback. This is often referred to as
Pott’s curvature
. In some cases, a person with Pott's disease may also develop paralysis, referred to as
Pott’s paraplegia
, when the spinal nerves become affected by the curvature. A person who has been
diagnosed with Pott's disease may be treated through a variety of options. He or she may
utilize analgesics or antituberculosis drugs to get the infection under control. It may also
be necessary to immobilize the area of the spine affected by the disease, or the person
may need to undergo surgery in order to drain any abscesses that may have formed or to
stabilize the spine.Since Pott's disease is caused by a bacterial infection, prevention is
possible through proper control. The best method for preventing the disease is reduce or
eliminate the spread of tuberculosis. In addition, testing for tuberculosis is an important
preventative measure, as those who are positive for purified protein derivative (PPD
) can take medication to prevent tuberculosis from forming. A tuberculin skin test is the
most common method used to screen for tuberculosis, though blood tests
, bone scans, bone biopsies, and radiographs may also be used to confirm the disease

THEORETICAL FRAMEWORKFor the theoretical framework, I used the “21 nursing

problems” according to Faye Glenn Abdellah. She defined nursing as broadly grouped
into the 21 nursing problem areas to guide care and promote the use of nursing
judgement. She also said that nursing is a service that is based on the art and science and
aims to help people, sick or well, cope with their health needs.The 21 nursing problems
are as follows:
1)To maintain good hygiene
2)To promote optimal activity: exercise, rest, and sleep3)To promote safety4)To maintain
good body mechanics.5)To facilitate the maintenance of a supply of oxygen6)To
facilitate maintenance of nutrition7)To facilitate maintenance of elimination8)To
facilitate maintenance of fluid and electrolyte imbalance9)To recognize the physiologic
response of the body to disease conditions10)To facilitate the maintenance of regulatory
mechanisms and functions11)To facilitate the maintenance of sensory function12)To
identify and accept positive and negative expressions, feelings and reactions13)To
identify and accept the interrelatedness of emotions and illness14)To facilitate the
maintenance of effective verbal and non-verbal communication15)To promote the
development of productive interpersonal relationships16)To facilitate progress towards
achievement of personal spiritual goals17)To cerate and maintain a therapeutic
environment18)To facilitate awareness of self as an individual with varying needs19)To
accept the optimum possible goals20)To use community resources as aid in resolving
problems

ASSESSMENTI. Personal Data:Name: B.P.Address: Novaliches Quezon CityAge: 28

years oldSex: FemaleCivil status: MarriedReligion: Roman CatholicBirthday: November
19, 1978Birthplace: ManilaAttending Physician: Dr. Adrian Catbagan Admitting
Diagnosis: Spinal cord compression on T/3 levelChief complaint: weakness of lower
extremities

II. Medical History

A.History of Present Illness:
This is a case of B.P., who was admitted for the first time last September 13,2007 with a
chief complaint of weakness of lower extremities. The history of present illness started
two months prior to admission, when the patient started to experience weakness of both
lower extremities. No other associated signs and symptoms were noted. Few hours prior
to admission, persistence of above symptoms prompted consult.
B. Past Medical History:
( - ) HPN( - ) DM( - ) asthma( - ) allergy
B.Family Medical History:
( - ) HPN ( - ) DM ( - ) CA ( - ) asthma
C.Personal and Social History:
( - ) smoker
(-)
alcoholic beverage drinker

MEDICAL/SURGICAL INTERVENTIONS
Management of Pott’s disease
Drug treatment is generally sufficient for Pott’s disease, with spinal immobilization if
required. Surgery is required if there is spinal deformity or neurological signs of spinal
cord compression.Standard antituberculosis treatment
is required. Duration of antituberculosis treatment: If debridement and fusion with bone
grafting are performed, treatment can be for six months. If debridement and fusion with
bone grafting are NOT performed a minimum of 12 months’ treatment is required. It
may also be necessary to immobilize the area of the spine affected by the disease, or the
person may need to undergo surgery in order to drain any abscesses that may have
formed or to stabilize the spine.Other interventions include application of knight/ taylor
brace, head halter traction. Surgery includes ADSF ( Anterior decompression Spinal
fusion).

PATHOPHYSIOLOGY
Pulmonary tuberculosis
Spread of mycobacterium tuberculosis from other
Extrapulmomary tuberculosis
The infection spreads from two adjacent vertebrae into the adjoining disc space
back pain, fever, night sweats,
One vertebra is affected, the disc is normalTwo are involved, the avascular intervertebral
disc cannot receive nutrients and collapse
Disk tissue dies and broken down by
caseation
Vertebral narrowing
Vertebral collapse
Spinal damage
POTT’S DSE
Kyphosis, paraplegia, bowel and urinary incontinenece
Surgery: evacuation of pus, Anterior decompression spinal fusion