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 intervertebral
disc space. If only one vertebra is affected, the disc is normal, but if two are involved
the 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.

ETIOLOGY

Mycobacterium tuberculosis

RISK FACTORS:

• Poor socio-economic conditions

• Endemic tuberculosis
• HIV Infection

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.

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 tuberculosis 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.
• About two thirds of affected patients in developed countries are
immigrants, as shown from both London1 and Paris2 and spinal tuberculosis
may be quite a common presentation.
• 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.

Presentation

• The onset is gradual.

• Back pain is localised.
• Fever, night sweats, anorexia and weight loss.
• Signs may include kyphosis (common) and/or a paravertebral swelling.
• Affected patients 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:
o A psoas abscess most often originates from a tuberculous
abscess of the lumbar vertebra that tracks from the spine inside the
sheath of the psoas muscle.
o Other causes include extension of renal sepsis and posterior
perforation of the bowel.
o There is a tender swelling below the inguinal ligament and they
are usually apyrexial.
o The condition may be confused with a femoral hernia or
enlarged inguinal lymph nodes.

Laboratory Studies

INVESTIGATION for Tuberculosis of Spine

Blood
• TLC: Leucocytosis.
• ESR: raised during acute stage.

Tuberculin skin test

• Strongly positive.
• Negative test does not exclude diagnosis.

Aspirate from joint space & abscess

• Transparency: turbid.
• Colour: creamy.
• Consistency: cheesy.
• Fibrin clot: large.
• Mucin clot: poor.
• WBC: 25000/cc.mm.

Histology

• Shows granulomatous tubercle.

X-Ray spine

Early:-

• Narrowed joint space.

• Diffuse vertebral osteoporosis adjacent to joint.
• Erosion of bone.
• Fusiform paraspinal shadow of abscess in soft tissue.

Late:-

• Destruction of bone.
• Wedge-shaped deformity (collapse of vertebrae anteriorly).
• Bony ankylosis.

Diagnostic and Imaging Studies

• Spinal X-ray
• Plain X-ray- can show vertebral destruction and narrowed disk space
• MRI- extent of spinal compression
• Needle biopsy

SURGICAL MANAGEMENT

-Surgery confirms the diagnosis, relieves compression if it occurs, permits

evacuation of pus and reduces the degree of deformation and degree of treatment.
GENERAL MANAGEMENT for Pott's Disease

• Bed rest.
• Immobilisation of affected joint by splintage.
• Nutritious, high protein diet.
• Drainage of abscess.
• Surgical decompression.
• Physiotherapy.

Nursing Management:
• Note and report for pain
• Promote comfort
• Encourage frequent change in position
• Apply warm or moist compress