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Pott Disease (Tuberculous Spondylitis)

Introduction
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 months [7 ]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 series [6,7 ]) 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
Blastomycosis
Brucellosis
Candidiasis
Cryptococcosis
Histoplasmosis
Metastatic Cancer, Unknown Primary Site
Miliary Tuberculosis

Multiple Myeloma
Mycobacterium Avium-Intracellulare
Mycobacterium Kansasii
Nocardiosis
Paracoccidioidomycosis
Septic Arthritis
Spinal Cord Abscess
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
o 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
o 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 scanning[14 ]
o CT scanning provides much better bony detail of irregular lytic lesions, sclerosis,
disk collapse, and disruption of bone circumference.
o Low-contrast resolution provides a better assessment of soft tissue, particularly
in epidural and paraspinal areas.
o CT scanning reveals early lesions and is more effective for defining the shape
and calcification of soft-tissue abscesses.
o In contrast to pyogenic disease, calcification is common in tuberculous lesions.
MRI
o 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 ]
o MRI findings useful to differentiate tuberculous spondylitis from pyogenic
spondylitis include thin and smooth enhancement of the abscess wall and welldefined 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.
Consultations

Orthopedic surgeons
Neurosurgeons
Rehabilitation teams

Complications

Abscess
Spine deformities
Neurologic deficits and paraplegia

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.