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Potts Disease / Tuberculosis of Spine

Potts disease 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. Potts 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 Potts 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. Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Potts curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Potts paraplegia, when the spinal nerves become affected by the curvature.

ETIOLOGY of Tuberculosis of Spine


Causative organism: Mycobacterium tuberculosis. Spread: Haematogenous. (by blood) Commonly associated with: Debilitating diseases, AIDS, Drug

addiction, Alcoholism.

Symptoms of Tuberculosis of Spine


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. 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). Differential diagnosis Pyogenic osteitis of the spine. Spinal tumours. 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/MRI 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. Complications Vertebral collapse resulting in kyphosis. Spinal cord compression. Sinus formation. Paraplegia (so called Pott's paraplegia).

GENERAL MANAGEMENT for Pott's Disease


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

Pathophysiology

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Spread of mycobacterium tuberculosis from other site Extrapulmomary tuberculosis The infection spreads from two adjacent vertebrae into the adjoining disc space

back pain, fever, night sweats, anorexia, weight loss, and easy fatigability.
One vertebra is affected, the disc is normal Two are involved, the avascular intervertebral disc cannot receive nutrients and collapse Disk tissue dies and broken down by caseation

Vertebral narrowing

Vertebral collapse

Spinal damage

POTTS DISEASE Kyphosis, paraplegia, bowel and urinary incontinenece Surgery: evacuation of pus, Anterior decompression spinal fusion

Therapy

non-operative antituberculous drugs Chiropractic treatments analgesics immobilization of the spine region by rod (Hull) Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine Richards intramedullary hip screw facilitating for bone healing Kuntcher Nail intramedullary rod Austin Moore intrameduallary rod (for Hemiarthroplasty) Thoracic spinal fusion as a last resort

Pott's disease is treated with multiple antibiotics. Because of the recent increase in antibiotic-resistant organisms, the recommended treatment includes the use of a four-drug regimen(RIPE). Treatment must be maintained for at least 6 to 9 months, and some doctors advise individuals to take medication for as long as 9 to 12 months. Immunodeficient individuals may require lifelong drug therapy to keep the infection from recurring. In the past, immobilizing the patient with a cast or a splint may have been recommended, but now external bracing only is the intervention of choice, allowing the individual to participate in rehabilitation and self care. Surgery (spinal fusion, rod placement) may ultimately be needed to relive spinal cord pressure, correct abnormal curvature of the spine, or resolve spinal instability secondary to loss of bone mass. Although brief bed rest may be indicated, rehabilitation to promote independent transfers and ambulation should be attempted as soon as tolerated.
Mgt Medical Care

Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization using prolonged bed rest or a body cast. At the time, Pott disease carried a mortality rate of 20%, and relapse was common (30%). The duration of treatment, surgical indications, and inpatient care have since evolved. 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.[4] According to the most recent recommendations issued in 2003 by the US Centers for Disease Control and Prevention, the Infectious Diseases Society of America, and the American Thoracic Society, a 4-drug regimen should be used empirically to treat Pott disease.[1] Isoniazid and rifampin should be administered during the whole course of therapy. Additional drugs are administered during the first 2 months of therapy. These are generally chosen among the first-line drugs, which include pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is indicated in cases of drug resistance.[21] Regarding the duration of therapy, the British Medical Research Council studies did not include patients with multiple vertebral involvement, cervical lesions, or major neurologic involvement. Because of these limitations, many experts still recommend chemotherapy for 9-12 months. Opinions differ regarding whether the treatment of choice should be conservative chemotherapy or a combination of chemotherapy and surgery. The treatment decision should be individualized for each patient. Routine surgery does not to seem to be indicated. Most common indications for surgical procedures are discussed below.

Surgical Care

Indications for surgical treatment of Pott disease generally include the following:[22, 23] o Neurologic deficit (acute neurologic deterioration, paraparesis, 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. The lesion site, extent of vertebral destruction, and presence of cord compression or spinal deformity determine the specific operative approach (kyphosis, paraplegia, tuberculous abscess). 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. The most conventional approaches include anterior radical focal debridement and posterior stabilization with instrumentation.[24, 10] In Pott disease that involves the cervical spine, 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, with appropriate treatment and therapy compliance, it is less likely to progress to a severe deformity. Pott's disease, which is also known as Potts 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. Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Potts curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Potts paraplegia, when the spinal nerves become affected by the curvature. ETIOLOGY of Tuberculosis of Spine Causative organism: Mycobacterium tuberculosis. Spread: Haematogenous. (by blood) Commonly associated with: Debilitating diseases, AIDS, Drug addiction, Alcoholism. Symptoms of Tuberculosis of Spine 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. 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). Differential diagnosis Pyogenic osteitis of the spine. Spinal tumours. 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. Complications Vertebral collapse resulting in kyphosis. Spinal cord compression. Sinus formation. Paraplegia (so called Pott's paraplegia). GENERAL MANAGEMENT for Pott's Disease Bed rest. Immobilisation of affected joint by splintage. Nutritious, high protein diet. Drainage of abscess. Surgical decompression. Physiotherapy.

Synonyms: 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 Pott's disease is named after Percival Pott (1714-1788), who was a surgeon in London. Pott's disease is tuberculosis of the spinal column (must not be confused with Pott's fracture of the ankle).

The usual sites to be involved are the lower thoracic and upper lumbar vertebrae. The source of infection is usually outside the spine. It is most often spread from the lungs via the blood. There is a combination of osteomyelitis and infective arthritis. Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral discs.

In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it can be a primary site, as the disc is vascular in children. It is the commonest place for tuberculosis to affect the skeletal system although it can affect the hips and knees too. The infection spreads from two adjacent vertebrae into the adjoining disc space. If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as it is avascular and cannot receive nutrients. Caseation occurs, with vertebral narrowing and eventually vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare.

Risk factors

Endemic tuberculosis. Poor socio-economic conditions. HIV infection.

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.

Differential diagnosis

Pyogenic osteitis of the spine. Spinal tumours.

Investigations

Elevated ESR. Strongly positive Mantoux skin test. Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space.

MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans and nuclear bone scans can also be used but MRI is best to assess risk to the spinal cord. A needle biopsy of bone or synovial tissue is usual. If it shows tubercle bacilli this is diagnostic but usually culture is required. Culture should include mycology.

Management

Immobilisation of the spine is usually for 2 or 3 months. Drug treatment: this is covered in the article on the Management of Tuberculosis. Therapy may need to exceed 6 months.

Surgical

Surgery plays an important part in the management. It confirms the diagnosis, relieves compression if it occurs, permits evacuation of pus, and reduces the degree of deformation and the duration of treatment.3 However, a Cochrane review found that routine surgery in addition to chemotherapy had not been shown to improve outcome but the problem was that the evidence was poor.4 A study from India suggested that surgery is not mandatory.5

Complications

Progressive bone destruction leads to vertebral collapse and kyphosis: o The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurological signs (Pott's paralysis). o Kyphosis occurs because of collapse in the anterior spine and can be severe. o Lesions in the thoracic spine have a greater risk of kyphosis than those in the lumbar spine. o Neurological problems can be prevented by early diagnosis and prompt treatment. It can reverse paralysis and minimise disability. o A combination of conservative management and surgical decompression gives success in most patients. o Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. o Patients with tuberculosis of the spine who are likely to have severe kyphosis should have surgery in the active stage of disease.6 o The degree of kyphosis, the area of affected vertebrae and the lack of sphincter control all correlate with the chance of recovery from paraplegia.7 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 and form sinuses.

Prognosis

The progress is slow and lasts for months or even years. Prognosis is better if caught early and modern regimes of chemotherapy are more effective. A study from London showed that diagnosis can be difficult and is often late.1

Prevention

As for all tuberculosis, BCG vaccination. Improvement of socio-economic conditions. Prevention of HIV and AIDS.

Potts diseaseDefinition Potts disease is a presentation of extrapulmonarytuberculosisthat affects thespine, a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott(1714-1788), a London surgeon who trained at Barts. Scientifically, it iscalled tuberculousspondylitisand it is most commonly localized in the thoracic portionof 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'sdisease Risk/ Predisposing factors Manifestation:back pain fever nightsweating anorexia weight loss Spinal mass, sometimes associated withnumbness, tingling, or muscle weaknessof the legsRace Data from Los Angeles and New York show that musculoskeletal tuberculosisprimarily affects African Americans, Hispanic Americans, Asian Americans, andforeign-born individuals. As with other forms of tuberculosis, the frequency of Pott Disease is related tosocioeconomic factors and historical exposure to the infection.Sex Although some series have found that Pott disease does not have a sexualpredilection, 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 primarilyin adults.

In countries with higher rates of Pott disease, involvement in young adults andolder children predominates

Pathophysiology Potts disease is usually secondary to an extraspinal source of infection. Thebasic lesion involved in Potts disease is a combination of osteomyelitis andarthritisthatusually involves more than one vertebra. The anterior aspect of the vertebral bodyadjacent to the subchondral plate is area usually affected.Tuberculosismay spreadfrom that area to adjacent intervertebral disks. In adults, disk disease is secondary tothe spread of infection from the vertebral body. In children, because the disk isvascularized, it can be a primary site.Progressive bone destruction leads to vertebral collapse andkyphosis.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 iscaused by collapse in the anterior spine. Lesions in the thoracic spine are more likely tolead to kyphosis than those in the lumbar spine. A cold abscess can occur if theinfection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar regionmay descend down the sheath of the psoas to the femoral trigone region and eventuallyerode into the skin.

MRI is the criterion standard for evaluating disk -space infection a n d osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debrisunder the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression. MRI findings useful to differentiate tuberculous spondylitis from pyogenicspondylitis include thin and smooth enhancement of the abscess wall andwell-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signalsuggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to beimportant in the differentiation of these two types of spondylitis.OtherTests 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). Management Medical Care

Before the advent of effective antituberculosis chemotherapy, Pott disease wastreated with immobilization using prolonged bed rest or a body cast. At the time,Pott disease carried a mortality rate of 20%, and relapse was common (30%). The duration of treatment, surgical indications, and inpatient care have since evolved. Studies performed by the British Medical Research Council indicate t h a t t u b e r c u l o u s s p o n d yl i t i s o f t h e t h o r a c o l u m b a r s p i n e s h o u l d b e t r e a t e d w i t h combination chemotherapy for 6-9 months. According to the most recent recommendations issued in 2003 by the U S Centers for Disease Control and Prevention, the Infectious Diseases Society of America, and the American Thoracic Society, a 4-drug regimen should be usedempirically to treat Pott disease. Isoniazid and rifampin should be administered during the whole course o f therapy. Additional drugs are administered during the first 2 months of therapy.T h e s e a r e generally chosen among the first-line drugs, which i n c l u d e pyrazinamide, ethambutol, and streptomycin. The use of second -line drugs isindicated in cases of drug resistance. Regarding the duration of therapy, the British Medical Research Council studiesdid not include patients with multiple vertebral involvement, cervical lesions, or major neurologic involvement. Because of these limitations, many experts stillrecommend chemotherapy for 9-12 months. Opinions differ regarding whether the treatment of choice should be conservativechemotherapy or a combination of chemotherapy and surgery. The treatment

decision should be individualized for each patient. Routine surgery does not toseem to be indicated. Most common indications for surgical procedures are discussed below. Surgical Care Indications for surgical treatment of Pott disease generally include the following: o Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia) o Spinal deformity with instability or pain o No response to medical therapy (continuing prog ression 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.

The lesion site, extent of vertebral destruction, and p r e s e n c e o f c o r d compression or spinal deformity determine the specific operative approach(kyphosis, paraplegia, tuberculous abscess). Vertebral damage is considered significant if more than 50% of the vertebralbody is collapsed or destroyed or a spinal deformity of more than 5 exists. The most conventional approaches include anterior radical focal debridement and posterior stabilization with instrumentation. In Pott disease that involves the cervical spine, the following factors justify earlysurgical 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 ani n d i c a t i o n for surgery because, with appropriate treatment and t h e r a p y compliance, it is less likely to progress to a severe deformity. 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 Drug treatment is generally sufficient for Potts disease, with spinal immobilizationif required. Surgery is required if there is spinal deformity or neurological signs of spinal cordcompression. Standard antituberculosis treatmentis required. Duration of antituberculosistreatment: If debridement and fusion with bone grafting are performed, treatmentcan be for six months. If debridement and fusion with bone grafting are NOTperformed a minimum of 12 months treatment is required. It may also be necessary to immobilize the area of the spine affected by thedisease, or the person may need to undergo surgery in order to drain anyabscesses that may have formed or to stabilize the spine.

Other interventions include application of knight/ taylor brace, head halter traction. Surgery includes ADSF (Anterior decompression Spinal fusion)