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of the intervertebral joints. It is named after Percivall Pott (1714-1788), a London surgeon who trained at Barts. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. AKA: 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 Incidence United States
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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). 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. 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.
In countries with higher rates of Pott disease. Type/ Stage/ Classification • • Bone/Spinal Disease Non-Communicable Disease . Asian Americans. or muscle weakness of the legs Race • • Data from Los Angeles and New York show that musculoskeletal tuberculosis primarily affects African Americans. Pott disease occurs primarily in adults. tingling. Age • • In the United States and other developed countries. involvement in young adults and older children predominates. Risk/ Predisposing factors • • • • • • Manifestation: back pain fever night sweating anorexia weight loss Spinal mass. Hispanic Americans.• Approximately 10% of Pott disease cases involve the cervical spine. the frequency of Pott Disease is related to socioeconomic factors and historical exposure to the infection. and foreign-born individuals.52:1). the disease is more common in males (male-to-female ratio of 1. As with other forms of tuberculosis. Sex • Although some series have found that Pott disease does not have a sexual predilection. sometimes associated with numbness.
In adults. leading to spinal cord compression and neurologic deficits. disk disease is secondary to the spread of infection from the vertebral body. granulation tissue. The kyphotic deformity is caused by collapse in the anterior spine. because the disk is vascularized. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected. or direct dural invasion. . Progressive bone destruction leads to vertebral collapse and kyphosis. In children. The basic lesion involved in Pott’s disease is a combination of osteomyelitis and arthritis that usually involves more than one vertebra. The spinal canal can be narrowed by abscesses. Tuberculosis may spread from that area to adjacent intervertebral disks.Pathophysiology Pott’s disease is usually secondary to an extraspinal source of infection. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. it can be a primary site.
Anorexia. bowel and urinary incontinenece Surgery: evacuation of pus. paraplegia. and easy One vertebra is affected. Weight loss. 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 DISEASE Kyphosis. Anterior decompression spinal fusion Diagnostic Studies . the disc is normal Two are involved.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.
and organisms are isolated for culture and susceptibility. The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). • Fusiform paravertebral shadows suggest abscess formation. These study findings are positive in only about 50% of the cases. • Intervertebral disks may be shrunk or destroyed. disk collapse. sclerosis. and disruption of bone circumference. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB).Laboratory Studies • • • Tuberculin skin test (purified protein derivative [PPD]) results are positive in 8495% of patients with Pott disease who are not infected with HIV. 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. • Vertebral bodies show variable degrees of destruction. Imaging Studies • • Radiography • Radiographic changes associated with Pott disease present relatively late. In contrast to pyogenic disease. particularly in epidural and paraspinal areas. Low-contrast resolution provides a better assessment of soft tissue. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. Microbiology studies are used to confirm diagnosis. • Bone lesions may occur at more than one level. calcification is common in tuberculous lesions. CT scanning14 ο ο ο ο CT scanning provides much better bony detail of irregular lytic lesions. MRI . CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses.
the Infectious Diseases Society of America. At the time. and streptomycin. Management Medical Care • • • • • • • Before the advent of effective antituberculosis chemotherapy. whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. or major neurologic involvement. a 4-drug regimen should be used empirically to treat Pott disease. Because of these limitations. Additional drugs are administered during the first 2 months of therapy. and inpatient care have since evolved. Thus. and the American Thoracic Society. Opinions differ regarding whether the treatment of choice should be conservative chemotherapy or a combination of chemotherapy and surgery. The duration of treatment. The treatment . and relapse was common (30%). many experts still recommend chemotherapy for 9-12 months. Pott disease carried a mortality rate of 20%. contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis. Pott disease was treated with immobilization using prolonged bed rest or a body cast. The use of second-line drugs is indicated in cases of drug resistance. cervical lesions.ο 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. 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. Isoniazid and rifampin should be administered during the whole course of therapy. According to the most recent recommendations issued in 2003 by the US Centers for Disease Control and Prevention. respectively). Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%. These are generally chosen among the first-line drugs. which include pyrazinamide. Other Tests • • Radionuclide scanning findings are not specific for Pott disease. the British Medical Research Council studies did not include patients with multiple vertebral involvement. 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. MRI is also the most effective imaging study for demonstrating neural compression. surgical indications. Regarding the duration of therapy. ethambutol.
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. The lesion site. Surgical Care • • • • • • • Indications for surgical treatment of Pott disease generally include the following: o Neurologic deficit (acute neurologic deterioration. The most conventional approaches include anterior radical focal debridement and posterior stabilization with instrumentation. Nursing Diagnosis • • • • • Acute pain related to inflammatory process Disturbed body image related to trauma/injury to spinal cord Self – bathing hygiene deficit related to musculoskeletal impairment Impaired physical mobility related to therapeutic restriction of movement Imbalance nutrition related to inadequate food intake Nursing Responsibilities . paraparesis. tuberculous abscess). with appropriate treatment and therapy compliance. Routine surgery does not to seem to be indicated. paraplegia. extent of vertebral destruction. it is less likely to progress to a severe deformity. and presence of cord compression or spinal deformity determine the specific operative approach (kyphosis.decision should be individualized for each patient. In Pott disease that involves the cervical spine. Most common indications for surgical procedures are discussed below. 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. 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.
It may also be necessary to immobilize the area of the spine affected by the disease.co.• • • • • Drug treatment is generally sufficient for Pott’s disease. Chapter 68-Musculoskeletal Medical Surgical Nursing by Joyce Black .medscape. treatment can be for six months.com Book Medical Surgical Nursing by Suzanne Smeltzer and Brenda Bare. with spinal immobilization if required.uk/showdoc/40001278/ http://emedicine. Surgery includes ADSF (Anterior decompression Spinal fusion). If debridement and fusion with bone grafting are NOT performed a minimum of 12 months’ treatment is required. head halter traction. Illustration: Internet http://www.patient. Standard antituberculosis treatment is required. 10th Edition. Other interventions include application of knight/ taylor brace.com/article/226141 http://www. or the person may need to undergo surgery in order to drain any abscesses that may have formed or to stabilize the spine. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression.scribd. Duration of antituberculosis treatment: If debridement and fusion with bone grafting are performed.
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