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Tuberculosis Spondylitis (TB Spine/pott's Diseasis) : by DR Phillipo Leo Chalya
Tuberculosis Spondylitis (TB Spine/pott's Diseasis) : by DR Phillipo Leo Chalya
By
Dr Phillipo Leo Chalya
1. Introduction
Tuberculous spondylitis has been
documented in ancient mummies from
Egypt and Peru
It is one of the oldest demonstrated
diseases of humankind.
Percival Pott presented the classic
description of TB spine in 1779.
Introduction (cont.)
Since the advent of antiTB drugs and
improved public health measures, TB
spine has become rare in industrialized
countries.
However it is still a common diseasis in
developing countries.
Introduction (cont.)
TB spine causes serious morbidity,
including permanent neurologic deficits
and severe deformity.
Medical treatment or combined medical
and surgical strategies can control the
disease in most patients
2. Epidemiology
TB spine is common in developing
countries> developed countries
Internationally approx. 1-2% of total TB
cases are attributable to Pott disease.
As with other forms of TB, the
frequency is related to socioeconomic
factors and historical exposure to the
infection.
Epidemiology (cont.)
Sex: Males are more often affected
(1.5-2:1).
Age: In developed countries Pott dx
primarily occurs in adults.
In countries with higher rates of
infection, it mainly occurs in children
Epidemiology (cont.)
Mortality/Morbidity : Pott disease is
the most dangerous form of
musculoskeletal TB.
It can cause bone destruction,
deformity, and paraplegia
It commonly involves the thoracic and
lumbosacral spine.
4. Pathophysiology
Pott disease is usually secondary to an
extraspinal source of infection.
The basic lesion is a combination of
osteomyelitis and arthritis.
Typically, more than one vertebra is
involved.
Pathophysiology (cont.)
The area usually affected is the anterior
aspect of the vertebral body adjacent to
the subchondral plate
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.
Pathophysiology (cont.)
In children, because the disk is
vascularized, it can be a primary site.
Progressive bone destruction leads to
vertebral collapse and kyphosis.
The spinal canal can be narrowed by
abscesses, granulation tissue, or direct
dural invasion
Pathophysiology (cont.)
This leads to spinal cord compression
and neurologic deficits.
Kyphotic deformity occurs as a
consequence of collapse in the anterior
spine.
Lesions in the thoracic spine have a
greater tendency for kyphosis than
those in the lumbar spine.
Pathophysiology (cont.)
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.
5. Clinical presentation
Presentation depends on the following:
Stage of disease
Site
Presence of complications such as neurologic
deficits, abscesses, or sinus tracts.
mm/h).
Workup (cont.)
Microbiology studies to confirm
diagnosis: Obtain bone tissue or
abscess samples to stain for acid-fast
bacilli (AFB), and isolate organisms for
culture and susceptibility.
These study findings may be positive in
only about 50% of the cases.
Workup (cont.)
6:2 Imaging studies
Plain radiography demonstrates the
following characteristic changes of
spinal tuberculosis:
Lytic destruction of anterior portion of
vertebral body
Increased anterior wedging
Workup (cont.)
Collapse of vertebral body
Reactive sclerosis on a progressive lytic
process
Enlarged psoas shadow with or without
calcification
Additional findings
Vertebral end plates are osteoporotic.
Intervertebral disks may be shrunk or
destroyed.
Workup (cont.)
Fusiform paravertebral shadows suggest
abscess formation.
Bone lesions may occur at more than one
level.
Workup (cont.)
Intervertebral disks may be shrunk or
destroyed.
Vertebral bodies show variable
degrees of destruction
Workup (cont.)
CT scanning
CT scanning provides much better bony
detail of irregular lytic lesions, sclerosis,
disk collapse, and disruption of bone
circumference.
Low-contrast resolution provides a better
soft tissue assessment, particularly in
epidural and paraspinal areas.
Workup (cont.)
It detects early lesions and is more
effective for defining the shape and
calcification of soft tissue abscesses.
In contrast to pyogenic disease,
calcification is common in tuberculous
lesions
Workup (cont.)
MRI
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
Workup (cont.)
MRI is most effective for demonstrating
neural compression.
In developed countries, MRI has nearly
replaced CT myelography.
Procedures:
Some patients are diagnosed following an
open drainage procedure (eg, following
presentation with acute neurologic
deterioration).
Workup (cont.)
Histologic Findings:
Since microbiologic studies may be
nondiagnostic, anatomic pathology can be
very significant.
Gross pathologic findings include exudative
granulation tissue with interspersed
abscesses.
Coalescence of abscesses results in areas of
caseating necrosis.
7. Treatment
7:1 Medical treatment
Medical therapy requires combination
regimens with at least 3 antituberculous
drugs.
A 3-drug regimen usually includes INH,
rifampin, and pyrazinamide.
The duration of treatment ranges from
9-12 months
Treatment (cont.)
7:2 Surgical treatment
Indications
Neurologic deficit (acute neurologic
deterioration, paraparesis, paraplegia)
Spinal deformity with instability
No response to medical therapy
Treatment (cont.)
Resources and experience are key
factors in the decision to use a surgical
approach
The most appropriate method of
reconstruction depends on the level of
vertebral spine involved and the extent
of bony destruction.
Treatment (cont.)
The lesion site, extent of vertebral
destruction, and presence of cord
compression or spinal deformity
determine the specific operative
approach.
Treatment (cont.)
In disease involving the cervical spine,
the following factors justify early
surgical intervention:
High incidence and severity of neurologic
deficits
Severe abscess compression that may
induce dysphagia or asphyxia
Instability of the cervical spine
Treatment (cont.)
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 severe deformity.
Vertebral damage is considered significant
if more than 50% of the vertebral body is
collapsed or destroyed or if there is spinal
deformity of more than 5°.