INTRODUCTION

POTT’S SPIN
This entity was first described by PercivalPot. He noted this as a painful kyphosis deformity
of the spine associated with paraplegia.

•Tuberculosis of the spine is one of the oldest diseases afflicting humans.

• 1/5th of TB population is in India.

• 3% are suffering from skeletal TB, 50% of these suffer from spinal lesion and almost 50%
are from pediatric group. An estimated 2 million or more patients have active spinal
tuberculosis.

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Regional Distribution

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 Pathology

 The spinal tuberculosis is a result of haematogenous dissemination from a primary

focus in the lungs or the lymph nodes.
 The central type of vertebral tuberculosis spreads along with Batson’s plexus of veins,
while paradisiac infection spreads through the arteries.
 The anterior type of vertebral body tuberculosis results from the extension of the
abscess beneath the anterior longitudinal ligament and periosteum.
 Lower thoracic and lumbar vertebrae are the most common sites of spinal
tuberculosis followed by middle thoracic and cervical vertebrae.
 Two distinct patterns of spinal tuberculosis can be identified, the classic form, called
spondylodiscitis, and an increasingly common atypical form characterized by
spondylitis without disk involvement.
 The basic lesion is a combination of osteomyelitis and arthritis. The number of the
vertebrae involved varies from a single vertebra to 14 vertebral segments, average
being 3.8 vertebral segments4.
 Typically, more than one vertebra is involved. The area usually affected is the
anterior aspect of the vertebral body adjacent to the subchondral plate. In adults, disc
disease is secondary to the spread of infection from the vertebral body.
 In children, because the disc isvascularized, it can be a primary site. Abscess
formation is more common in children granulation formation is more in adults5.
 Progressive bone destruction leads to vertebral collapse and kyphosis which is
commonest in the thoracic spine.

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 Types of Lesions
Classically, four types of involvement of the spinal column have been described
in spinal tuberculosis:
 Para-discal lesion which arises from arterial spread of the infection.
 Central type of vertebral body involvement of one or more distant or adjacent
 vertebrae (this is o en associated with tuberculosis meningitis as the spread of the
infection is via the Batson’s plexus of veins)
 Anterior type with cortical bone destruction
 appendicle type

PARADISCAL LESION
 The paradiscal lesion begins in the vertebral metaphysis, erodes the cartilage plate and
destroys the disc.
 The cartilaginous end plate acts as a barrier, but once invaded, destruction of the disc
progresses rapidly due to its relative a vascularity, and the infection goes on to
involve the adjacent vertebrae.
 The early resorption of the disc leads to narrowing of the disc space, although with
progressive involvement of the body and accumulation of debris, the space may
sometimes be widened.

CENTRAL TYPE
 In the central type of lesion the infection begins in the midsection of the body instead
of the metaphysis.
 It extends centrifugally to involve the whole body.
 Following the infection, marked hyperaemia and osteoporosis occur.
 The body, which is thus softened, easily yields under gravity and muscle action,
leading to compression, collapse and bony deformation.

ANTERIOR LESIONS
 Anterior lesions lead to cortical bone destruction beneath the anterior longitudinal
ligament.
 * Spread of the infection in the subperiosteal and subligamentous planes, allows
extension of the infection to adjacent bodies without involvement of the intervening
disc space.
 Stripping of the periosteum results in loss of the periosteal blood supply to the body.
 This, along with thromboembolic phenomena, periarteritis and endarteritis can lead to
ischemic reactions of the bone contributing to the vertebral collapse.

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APPENDICEAL TYPE

 In the appendiceal type the pedicle, the lamina, the articular process or the spinous
process is affected primarily.

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 Clinical features

 Presentation depends upon the stage of the disease, site of the disease, and presence of
complications such as neurologic deficit, abscesses, or sinus tracts.
 Constitutional symptoms such as weakness, loss of appetite and weight, evening rise
of temperature, and night sweats generally occur before the symptoms related to the
spine manifest.
 There may be evidences of associated extra-skeletal tuberculosis like cough,
expectoration, lymphadenopathy, diarrhea, and abdominal distension.
 Although both the thoracic and lumbar spinal segments are nearly equally affected,
the thoracic spine is frequently reported as the most common site of involvement.
 Together, these comprise 80% - 90% of spinal tuberculosis sites.
 The remaining cases correspond to the cervical spine. Spine deformity (kyphosis) of
some degree occurs in almost every patient.
 Back pain (spinal or radicular) is the earliest and most common symptom This pain
may worsenwith activity. Relaxation of muscles during sleep permits movements
which are very painful and wake-up the patient. As the infection progresses, pain
increases, and Para spinal muscle spasm occurs.
 Muscle spasm obliterates the normal spinal curves, and all spinal movements become
restricted and painful.
 Physical examination of the spine reveals localized. tenderness and paravertebral
muscle spasm.
 A kyphotic deformity due to prominence of spinouts process may be evident due to
collapse and anterior wedging of vertebral bodies.

 Tuberculosis necrotic material from the dorso-lumbar spine may lead to cold abscess
in the rectus sheath and lower abdominal wall along the intercostal, ilioinguinal, and
iliohypogastric nerves; in the thigh along the psoas sheath; in the back along the
posterior spinal nerves.

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 In the buttock along the superior gluteal nerve; in the Petit’s triangle along the flat
muscles of abdominal wall, or, in the ischiorectal fossa along the internal pudendal
nerve.
 Disease involving the upper cervical spine though less common, can cause dangerous
and rapidly progressive symptoms.

 Clumsiness in walking, and spontaneous twitching of muscles are early signs of

neurological involvement which can progress to a single nervepalsy, to hemiplegia, or
paraplegia with spasticity, sensory impairment, bladder/bowel involvement.

Coldabscesses

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 NEUROLOGICAL COMPLICATIONS (POTT'S
PARAPLEGI A)
It is a most serious complication of spinal TB , incidence is approx 20%. MC in dorsal spine
because it is the narrowest region ,abscess remains confined under tension.

ETIOLOGY
 Inflammatory

Inflammatory edema ,tuberculosis abscess.

Mechanical: Tubercular debris, sequestrate, cord constriction due to vertebral canal stenosis,
localized pressure.

Intrinsic: Infective thrombosis

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SEDDON’S CLASSIFICATION

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TULI & KUMAR’S GRADING OF PARAPLEGIA

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 Differential diagnosis

 Actinomycosis
 Blastomycosis
 Brucellosis
 Candidiasis
 Cryptococcosis
 Histoplasmosis
 Metastatic cancer, unknown primary site
 Multiple Myeloma
 Nocardiosis
 Paracoccidioidomycosis
 Septic arthritis
 Spinal cord abscess, spinal tumours
 Hemivertebra, Calves disease, Scheuermann’s disease, Syphilis, Hydatid
disease – Diagnostic Workup

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 Examination of the patient

AIM
 To pick up the findings suggestion TB of the spin
 To localize the site of lesion
 To find skin lesion
 To detect any associated complication

Gait
 A patient with TB of spine walks with short steps in order to avoid jerking the spin.

Attitude and deformity

 A patient with TB of cervical spine has a stiff , straight neck.
 In dorsal spine TB , part of the spin become prominent ( gibbus or Kyphus)
 Significant deformity is generally absent in lumber spine tuberculosis , there may just
loss of lumber lordosis.

Para-vertebral swelling
 A superficial cold abscess may present as fillness or swelling on the back along the
chest wall or anteriorly.
 Sometimes as abscess may be tense and it may not be possible to elictfluctuation , a
needle aspiration may be performed in such cases to confirm the diagnosis.

Movement
 Spinal movement is limited in case of TB of spine and can be tested wherever
considered suitable.

Neurological examination
 A through neurological examination of the limbs , upper or lower , depending on the
site of tuberculosis should be performed.
 An assessment should be made of motor , sensory reflexes along with the urinary and
bowel functions

The aim of neurological examination is to find out

 Whether or not these is any neurological compression
 The level of neurological compression
 The severity of neurological compression

General examination:-A general examination is preforming to detect any active or

primary lesion .

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 Investigations

Skin test and haematological investigations

 These are in the form of CBC with ESR. Erythrocyte sedimentation rate may be
markedly elevated.
 Mantoux demonstrates a positive finding in 84 - 95% of patients who are non-HIV-
positive 1 to 3 months after infection.
 Co-existent infection by human immunodeficiency virus and other immune
deficiency conditions can give a false negative skin test.
 The enzyme-linked immunosorbent assay (ELISA) has a reported sensitivity of 60 to
80 per cent. PCR though very sensitive is not readily available in different
clinicalsettings.

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 Imaging studies
Plain radiographs:
 Plain radiographs are the first line of investigations in our country. Earliest
radiological features are narrowing of the joint space and indistinct paradiscal margin
of vertebral bodies.
 Gradually, the disc space narrows due to either atrophy or prolapse into the vertebral
body of the disc tissue.
 The collection of tuberculous granulation tissue and necrotic material leads to
formation of paravertebral abscess. In the region of thoracic spine it is visible on
plain radiographs as a fusiform or globular radiodense shadow called the bird nest
appearance.
 Long standing abscesses may produce concave erosions around the anterior margins
of the vertebral bodies producing a scalloped appearance called the aneurysmal
phenomenon.
 Wedging of vertebral bodies leads to a kyphotic deformity. Less commoner
radiological presentations of spinal tuberculosis are central type, anterior type, and
appendiceal type.
 Central disease presents as destruction, ballooning of vertebral bodies, and
concentric collapse.
 Anterior type is more common in the paediatric dorsal spine and appears as erosion
of anterior margin of vertebral bodies.
 Appendiceal disease is involvement of the posterior arches.

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 CT scanning and MRI

For a radiolucent lesion to be seen on a plain radiograph, 30% of mineral loss

must be there.
 CT and MRI detect lesions at an earlier stage. CT scanning provides much better bony
detail of irregular lytic lesions, sclerosis, disc collapse, and disruption of bone
circumference. Low-contrast resolution provides a better soft tissue assessment,
particularly in epidural and paraspinal areas.
 CT is more effective for defining the shape and calcification of soft tissue abscesses.
 CT is useful in assessing bone destruction, but is less accurate in defining the epidural
extension of the disease, and therefore, its effect on neural structures.
 MRI is the gold standard for evaluating disc 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.

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 MRI is most effective for demonstrating neural compression. MRI with contrast is
helpful in differentiating from non-infectious causes and delineating the extent of
disease.
 Serial MRI can be used to assess the response to treatment and regression of the
disease. Bone scan with Tc-99m is considered to be highly sensitive, but nonspecific.
 It may only aid to localise the site of active disease and to detect multilevel
involvement. Patients with active disease have an increased uptake, whereas in
avascular segments and abscesses it may show decreased uptake

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 Histopathology and microbiology

Because of high prevalence, microbiological diagnosis is not mandatory to start

chemotherapy in our country. However, a biopsy/aspiration may be needed in cases of
doubtful clinicoradiological findings, lack of proper response to drug therapy, and suspicion
of drug-resistant strains. Biopsy: Bone tissue or abscess samples are obtained to stain for
acid-fast bacilli (AFB), and isolate organisms for culture and sensitivity. These study findings
may be positive in only about 50% of the cases. The method most widely used is CT-guided
needle biopsy and/or aspiration. Percutaneous needle aspiration and/or biopsy is a newer
method with comparable Bacteriologic and histologic yields as for surgical biopsy. The tissue
should be sent for culture, antibiotic sensitivity and histopathology.

Treatmentof pott’s spine

Principle of treatment:
Aim:
1 To achieve healing of the diseases

2 To prevent detected early and treat promptly any compaction like paraplegia etc.

Anti-tubercular chemotherapy treatment

Name of the drugs Daily dose

Rifampicin(Rf) 10 mg/Kg(600 mg)

Isoniazide(INH) 5-10 mg/Kg (300mg)

Streptomycin (SM) 30 mg/Kg (1mg)

Pyrazinamide 25 mg/kg (1.5mg)

Ethambutol(ETH) 25 mg/kg

Care of the spine:

 This consists of providing rest to the spine during the actuephase , followed by
guarded mobilization.

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Rest:
 A short period of bed rest for pain relief may be sufficient during early stage of
treatment .
 In children , body caste is sometimes given,basically to force them to rest .
 Minerva jacket or collar may be givien for immobilizing the cervical spine

Mobilization
 As the patient improves,he is allowed to sit and walk while the spine is supported in a
collar for the cervical spine,or an ASH brace for the dorsolumber spine.
 The patient is weaned off the brace one bony fusion occurs.

Complications
Cold Abscess

paraplegia

Cold abscess
 This is a collection of pus tubercular debris from a diseased vertebra
 It is called a cold abscess because it is not associated with the usual signs
of inflammation: heat ,rednessetc found in pyogenic abscess.
 The tubercular pus can track in any direction from the affected vertebra.
 If it travels backwards,it may press upon the important neural structures in
the spinal canal.
 This pus may come out interiorly(pre-vertebral abscess) or on the sides of
the vertbral body (pre-vertebral abscess).


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 Treatment
A small cold abscess may subside with anti-tuberculartreatment. Abscesses presenting
superficially need treatment as discussed below

 Aspiration

A thick needle is required because often there is thick caseous material. It should be an anti-
gravity insertion with the needle entering through a zigzag tract.

 Evacuation

In this procedure, the cold abscess is drained, its walls curetted and the wound closed without
a drain

 Paraplegia

Aim of treatment
 To promt recovery of the affected nureal tissues by reversing the cause of
compression,either by drugs or by compression.
 To achive healing of the vertebral lesion.
 To support the spine till the diseased segment becames stable.

Conservative treatment

Anti-tubercular chemotherapy treatment

Name of the drugs Daily dose

Rifampicin(Rf) 10 mg/Kg(600 mg)

Isoniazide(INH) 5-10 mg/Kg (300mg)

Streptomycin (SM) 30 mg/Kg (1mg)

Pyrazinamide 25 mg/kg (1.5mg)

Ethambutol(ETH) 25 mg/kg

 These are the regimens of 6-9months duration which have been found to be highly
effective.
 The spine is put to absolute rest by a sling traction for the cervical spine, and bed
rest for the dorso-lumbar spine.
 The paralytic limbs are taken care of.

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  Repeated neurology examination of the limbs is carried out to detect any
deterioration or improvement in the neurological status.
 If the paraplegia improves ,the conservation treatment is continued. The patient is
allowed to sit in the bed with the help of braces as soon as the spin gains sufficient
strength. Bracing is continued for about 6 to 12 months.

Operative treatment
Anterio-lateral decompression
 Anterior-lateral decompression (MC)-spine is opened up from its lateral side &
access in made to the front and side of the cord. The cord is laid free from
granulation tissue caseousmaterial, bony spur or sequestrum.

Costo-transversectomy
 Costo-transversectomy-removal of 2 inches of rib &transverse process pus drained.

Costo-transversectomy

Radical debridement and arthrodesis (Hongkong operation)

Laminectomy:-Laminectomy & Posterior stabilization-Indicate in spinal tumor syndrome

and paraplegia resulted from post Spinal disease.

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 Physiotherapy Assesment

Name of the patient

Age/Gender

Address

Occupation

Chief complaint

History:-

 Past
 Present
 Medical
 Surgical
 Family
 Social
 Personal

ON OBSERVATION
Vital signs

 Respiratory rate
 Heart rate
 Spo2
 Blood pressure

Body built

 Ectomorphic / Mesomorphic /Endomorphic

Mode of Ambulation

 Independent / wheelchair / stretcher

Posture

 General postore
 Attitude of upper & lower limb

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Gait

 Gait pattern
 use of assistive devices
 Ryle’s tube
 Tracheostomy
 Foley’s catheter
 Swelling

ON EXAMINATION
 Respiratory examination
 Respiratory muscles function
1. Muscles tone
2. Muscles. Atrophy
3. Use of accessory respiratory muscles
 Breathing pattern
 Cough and expectoration
 Bilateral air entry
 Vital capacity
 Chest deformity

 Motor Examination
 Myotomes
1. Hip flexion:L1,L2,L3,extension,L4,L5
2. Knee flexion:L5,S1,S2,extension,L2,L3,L4
3. Ankle flexion L5,S1,dosifer,L4,L5
 Girth of muscle
 Tone of muscle
 Range of motion
1. Active available Rom at specific joint
2. P Rom all joint
 Manual muscle testing
1. Bilateral for all upper & lower limb muscles
 Reflex
1. Bicep jerk (C6)
2. Tricep jerk (C7)
3. Knee jerk (L3,L4)
4. Ankle jerk (S1)

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Sensory examination

 Superficial sensation
1. Curde touch
2. Fine touch
3. point seneat
 Deep sanitation
1. Pressure
2. Proprioception
3. Kinesthetic sensation
4. Vibration sensation
 Pain
1. Intensity (VAS)
2. Location
3. Natux of pain
4. Aggravation factor
5. Reveling fall
 Balance and co-ordination

 Functional status
 Functional molality skills
1. Bed molality
2. Moment transition
3. Transfer
4. Location

 Basic ADL
1. Feeding
2. Hygiene
3. Dressing

INVESTATIONG
 Total blood count
 Sputum cultux
 ESR
 Hemoglobin
 Radiological examination

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 PHYSIOTHERAPY TREATMENT

During Resting Phase

AIM:-

1. To provide good psychological support to the patient

2. To give proper positioning
3. To prevent pressure sores.
4. To maintain normal range of motion
5. To strength spared muscular
6. Bladder and bowel care

TREAMENT :-

For respiratory tract

 Breathing exercises
1. Segmental breathing.
Emphasis is given over lateral costal expansion.
2. Glossopharyngeal breathing
The patient to inspire in small amounts by repeated small glops of air utilizing
the muscles of face and neck.
3. Diaphragmatic breathing
Therapist places his hand just blow the sternum and apprised lite pressure
during deep inhalation and exhalation


 Mobilization sputum
1. Postural drainage accompanied with shaking and vibration.
2. The secretion mobilized to central air way are removed with the help of suction

Bedsore Management

 Preventing bedsore
 Nursing goals: Education of the patient and relatives only sure method of
preventing pressure ulcer is strict nursing care and gradual shifting of responsibility
of the skin care of the patient’s family.
 Spinal bed ,mattresses and pads are not reliable to prevent pressure sore.

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  Sleeping in prone position with a pillow bridging the bony prominence is the most
reliable method of preventing bed sore.
 Managing Bedsores

While prevention is the mantra the following measure are recommended once a bedsore
develop

 Keep the back dry.

 Apply a dry powder to the back.
 Turn the patient every 2 hours.
 Use water or air beds .
 Do periodic dressing taking all aspect precautions

Passive movemnts

 To stimulate circulation and preserve full Rom.

 Movement should be in normal pattern and should be performed slowly in their
full range.
 Each joint from proximal to distal are moved several time through the full Rom.
 SLR beyond 60 and help flexion beyond 90 are avoided.
 Passive movements in both supine and prone position

Strengthening

 To the upper limb muscle mainly shoulder depressor , triceps and lattismusdorsi.
 Bilateral manually resisted movements.
 Proprioceptive neuro muscular facilitation .
 Progression resisted exercises by dumbbells and weights.
 Functional activities like self-feeding, self-care benefit as progressive
strengthens exercise

Bladder and Bowel care

Patient is taught to

 Tappingto tap abdominal wall above pubic symphysis with his fingers.
 Pelvic, floor muscles isometric exercises.
 Isometric contraction of muscles

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 Treatment During Weight Bearing Phase
AIM

 To give postural training

 To reduce spasticity.
 To teach self-careactivities.
 To give proper exercises.
 To provide proper gait training.

Postural Training

 Deep breathing exercises.

 Timing exercises in bed.
 Exercises are performed in front of mirror.
 Patient is shifting to tilting table with assistance and care.
 Patient is probably tied to table and then table is shifting gradually.

To reduce spasticity

Positioning

 If spasticity is more in flexor group of muscles of lower limb then crook lying
position or position with knees as high on chest are more appropriate.
 Ice therapy .
 Deep rhythmical massage with pressure of insertion of muscles.
 Passive movement and passive stretching.
 Weight bearing

Self care activities

Eating and drinking

 Adapted crockery and splints used according to level of lesion.

 Light weight partly filled cup of mug.

Dressing

 Moving the garments over the body.

 Moving the body inside garments

Exercises and activates

Strengthening exercises

 Are giving by providing resistance either manually or by weight and pulley.

 Strenghting of upper limb muscles is done.

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  Progression resisted exercises are given

Functional re-education (mat exercises)

 Rolling
 Prone on hands
 Suspine on elbow
 Pull ups
 Shifting
 Kneeling

Balance activities

Balance in sitting

 To transferring weight over the hips one by one.

Balance in standing

 Weight transference backward.

 Weight transference forward.
 Weight transference laterally .

Transferactivities

 Chair to bed
 Chair to car
 Chair to toilet
 Chair to bath
 Chair ton floor

Ambulation

Preparation for ambulation

Initial parallel bar activities

 Standing
 Weight transference laterally backward forward.
 Arm raising forward , sideward

Strengthening exercises in parallel bar

 Pushups
 Stepping forward and backward

Co-ordination exercises

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  Hip hiking
 Leg swinging

Forward progression

 Drag to gait
 Swing to gait
 Swing through gait
 Four point gait

Gait pattern

 Selection and measurement of appropriate device

(Walker, crutches etc.)

 Selection of gait

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 Prognosis

Prognosis of paraplegia depends on the following factors

 Age children responds to treatment better than adult

 Onset: acute onset paraplegia has better prognosis
 Duration: long standing paraplegia has a worse prognosis
 Severity : motor paralysis alone has a good prognosis .sphincter
involvement i.e urinary or bowel incontinence and bed prognosis
indication
 Progress: sudder progress of the paraplegia has a bad prognosis

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 Case study

Name – Anasuddin

Age – 58 yr / M

Father’s name- Mr. Salimuddin

Chief complaint- L/L paralysed

Provisional diagnoses- Potts spine

Final diagnosis- Potts spine

History
 Medical history- no h/p of D.m, HTN
 Surgical history- K|l|l|d-pott’s spine X 5 months
 Physiotherapy history 6-7 months back

On Observation
 MOA- stretcher (dependent)
 Body built- ectomorph
 Deformity- absent
 Gait- Antalgic
 Swelling- present at both foot
 Skin texture- normal
 Limb attitude- Bilateral ankle planter flexed
 Atrophy- No

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SOn Examination
 MMT- 0 at each muscles of lower limb
 Sensation- No sensation (lower limb)
 Rom- full(Passive rom)
 Tenderness- Absent
 Spasticity- TA tight b/l
 Muscle tone- flaccid
 DTR- knee jerk b/l

VAS for spinal region

X-ray finding
 Not available
 Treatment
 AIM
 To reduce pain
 To restore function
 To maintain range of motion
 To regain muscles strength
 Means
 Passive ROM bilateral lower limb
 Hamstring bilateral stretching
 TA bilateral stretching
 Preformed bilateral stretching
 NMS(IG stimulation for L/L) to be prescribed

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 Conclusion
T.B is still a common infection disease in developing countries. Primary TB affects lung,
lymph node and secondary TB affects the bones and joints TB.

The comments causative organism in mycobacterium Tuberculosis

Clinical features depend upon the site affected patient of all ages and both sexes are affected

 The usual priesting complaints are pain , swelling and deformity of the back

If the patient with presetting complaints responds to the chemotherapy treatment then the
prognosis is better

If does not respond to the treatment then surgical removals of abscesses is the treatment of
choice

If neurological complication occurs when the physiotherapy treatment is better prognosis of

the patient.

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