POTT’S DISEASE / TUBERCULOSIS OF SPINE

Pott’s disease, a disease named after Percivall Pott

(1714–1788), a London surgeon who trained at St
Bartholomew's Hospital, London, is a presentation of
extrapulmonary tuberculosis that affects the spine, a kind
of tuberculous arthritis of the intervertebral joints.
Scientifically, it is called TUBERCULOUS SPONDYLITIS.
Pott’s disease is the most common site of bone infection in
TB; hips and knees are also often affected. The lower
thoracic and upper lumbar vertebrae are the areas of the
spine most often affected.

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.

II. RISK FACTORS

 economic
 hereditary factor
 bad living condition
 overcrowded dwellings
 family history of tuberculosis

ETIOLOGY of Tuberculosis of Spine

• Causative organism: Mycobacterium tuberculosis.

• Spread: Haematogenous. (by blood)
• Commonly associated with: Debilitating diseases, AIDS, Drug addiction, Alcoholism.

Common sites of Potts Disease

Hips
Knees
lower thoracic
upper lumbar vertebrae

III. TYPES

IV SIGNS AND SYMPTOMS

Symptoms

The onset is gradual.

• Back pain is localised.
• Restricted spinal movements.
• Fever.
• Night sweats.
• Anorexia.
• Weight loss.

Signs

• There may be kyphosis. (spinal curvature)

• Muscle wasting.
• A paravertebral swelling may be seen.
• They tend to assume a protective upright, stiff position; gait is erect

• 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).

 kyphosis
 swelling in retropharyngeal region
 patient dislike sitting

GENERAL MANAGEMENT for Pott's Disease

• Bed rest.
• Immobilisation of affected joint by splintage.
• Nutritious, high protein diet.
• Drainage of abscess.
• Surgical decompression.
• Physiotherapy.
Signs and symptoms of TB (Tuberculosis) of Bones and Joints

 low grade fever (afternoon)

 anorexia
 insomnia
 pain in motion
 diaphoresis (excessive sweating at night)
 irritability
 abscess and sinus formation
 pathological fracture
 loss of weight (muscle wasting)

VI. ANATOMY AND PHYSIOLOGY

Intervertebral discs (or intervertebral fibrocartilage) lie between adjacent vertebrae in

the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae,
and acts as a ligament to hold the vertebrae together.

Discs consist of an outer annulus fibrosus, which surrounds the inner nucleus pulposus. The
annulus fibrosus consists of several layers of fibrocartilage. The strong annular fibers
contain the nucleus pulposus and distribute pressure evenly across the disc. The nucleus
pulposus contains loose fibers suspended in a mucoprotein gel with the consistency of jelly.
The nucleus of the disc acts as a shock absorber, absorbing the impact of the body's daily
activities and keeping the two vertebrae separated. The disc can be likened to a doughnut:
whereby the annulus fibrosis is similar to the dough and the nucleus pulposis is the jelly. If
one presses down on the front of the doughnut the jelly moves posteriorly or to the back.
When one develops a prolapsed disc the jelly/ nucleus pulposus is forced out of the
doughnut/ disc and may put pressure on the nerve located near the disc. This can give one
the symptoms of sciatica.

Cervical vertebra with intervertebral disc

There is one disc between each pair of vertebrae, except for the first cervical segment, the
atlas. The atlas is a ring around the roughly cone-shaped extension of the axis (second
cervical segment). The axis acts as a post around which the atlas can rotate, allowing the
neck to swivel. There are a total of twenty four discs in the human spine, which are most
commonly identified by specifying the particular vertebrae they separate. For example, the
disc between the fifth and sixth cervical vertabrae is designated "C5-6".

Medical conditions related to the intervertebral disc

VII. PATHOPHYSIOLOGY

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.

In Pott’s disease, the vertebrae become soft and collapse as the result of caries or osteitis
that is caused by mycobacterium tuberculosis, the same causative agent as the pulmonary
TB. 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.

VIII. DIAGNOSTIC EXAMS AND LABORATORY TESTS:

Blood
• TLC: Leucocytosis.
• ESR: elevated/increased during acute stage.

Tuberculin skin test

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

Bone Biopsy: 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, bone scan, CT of the spine, MRI, radiographs of the 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.

Purified Protein Derivative

 (+) PPD

IX. MANAGEMENT

 rest in bed
 exposure to fresh air and sunlight
 high protein diet
  increase fluid intake
 Jewet and Taylor brace
 Head halter traction
 tuberculosis drugs:

Treatment:

In the Philippine settings, the DOH manage the drug regimen depends upon the Category of
the disease. Here are the 3 categories of TB according to DOH.

1. Category I - new cases with positive sputum test, extrapulmonary TB

2. category II - relapse in drug regimen and disease remissions
3. Category III- new cases with 3 consecutive negative sputum test

Drugs for TB

 Rifamficin - orange urine

 Izoniazid - peripheral neuritis - take Vit. B6
 Pyrazinamide - gout - increase fluid intake
 Ethambutol - visual impairment - no to 6y/o and below
 Streptomycin - tinnitus or hearing impairment - no to pregnant women

X. COMPLICATIONS

• Vertebral collapse resulting in kyphosis.

• Spinal cord compression.
• Sinus formation.
• Paraplegia (so called Pott's paraplegia).