http://emedicine.medscape.

com/article/226141-overview
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 in Europe and in ancient mummies from Egypt
and the Pacific coast of South America.[1, 2] In 1779, Percivall Pott, for whom the disease is named, presented
the classic description of spinal tuberculosis. (See the image below.)[3]

MRI of a 31-year-old man with tuberculosis of

the spine. Images show the thoracic spine before and after an infusion of intravenous gadolinium contrast. The abscess and
subsequent destruction of the T11-T12 disc interspace is marked with arrowheads. Vertebral body alignment is normal.
Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich.

Since the advent of antituberculous drugs and improved public health measures, spinal tuberculosis has
become rare in industrialized countries, although it is still a significant cause of disease in developing nations.
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.

Patient education
Patients with Pott disease should be instructed on the importance of therapy compliance. For patient education
information, see the Infections Center, as well as Tuberculosis.

Pathophysiology
Pott disease is usually secondary to an extraspinal source of infection. Pott disease manifests as a combination
of osteomyelitis and arthritis that usually involves more than 1 vertebra. The anterior aspect of the vertebral
body adjacent to the subchondral plate is 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, the disk, because it is vascularized, can be the primary site. [4]
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.

Epidemiology
Occurrence in the 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 10-15% 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. These figures are roughly similar
for North American and international series.[5, 6]

International occurrence
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). [7]

Race-, sex-, and age-related demographics

Data from Los Angeles and New York show that musculoskeletal tuberculosis affects primarily 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.
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).
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. [8, 9]

Prognosis
Current treatment modalities are highly effective against Pott disease if the disorder is not complicated by
severe deformity or established neurologic deficit.
Deformity and motor deficit are the most serious consequences of Pott disease and continue to be a serious
problem when diagnosis is delayed or presentation of the patient is in advanced stages of the disease. [10]
Therapy compliance and drug resistance are additional factors that significantly affect individual outcomes.
Paraplegia resulting from cord compression caused by the active disease usually responds well to
chemotherapy. However, paraplegia can manifest or persist during healing because of permanent spinal cord
damage.
Operative decompression can greatly increase the recovery rate, offering a means of treatment when medical
therapy does not bring rapid improvement.
Careful long-term follow up is also recommended, since late-onset complications can still occur (disease
reactivation, late instability or deformity).[11]

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
shown some variation.[12, 13, 14, 15] The lower thoracic vertebrae make up 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.[16] Approximately 10% of Pott disease cases involve the cervical spine.

History
The presentation of Pott disease depends on the following [17] :

Stage of disease
Affected site
Presence of complications such as neurologic deficits, abscesses, or sinus tracts
Potential constitutional symptoms of Pott disease include fever and weight loss. The reported average duration
of symptoms at diagnosis is 4 months[13] but can be considerably longer.[15, 18] This is due to the nonspecific
presentation of chronic back pain.
Back pain is the earliest and most common symptom of Pott disease, with patients usually experiencing this
problem for weeks before seeking treatment. The pain caused by Pott disease can be spinal or radicular.
Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia,
paresis, impaired sensation, nerve root pain, and/orcauda equina syndrome.
Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe
neurologic complications are more likely. This condition is characterized by pain and stiffness. Patients with
lower cervical spine disease can present with dysphagia or stridor. 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.[19]

Physical Examination
The physical examination in Pott disease should include the following:

Careful assessment of spinal alignment

Inspection of skin, with attention to detection of sinuses
Abdominal evaluation for subcutaneous flank mass
Meticulous neurologic examination
Although 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, these segments make
up 80-90% of spinal tuberculosis sites, with the remaining cases of Pott disease occurring in the cervical spine.
Almost all patients with Pott disease have some degree of spine deformity (kyphosis).
Examination should reveal local pain related to the affected area or radicular pain. Muscle spasm and rigidity
can also be associated.

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. Retropharyngeal
abscesses occur in almost all cases affecting this part of the spine. Neurologic manifestations occur early and
range from a single nerve palsy to hemiparesis or quadriplegia.
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.

Diagnostic Considerations
Many persons with Pott disease (62-90% of patients in reported series [12, 13] ) have no evidence of extraspinal
tuberculosis. Information from imaging studies, microbiology, and anatomic pathology should help to establish
the diagnosis. Etiological diagnosis with microbiologic recovery of organisms is difficult in limited-resources
settings and requires invasive procedures.
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:

Positive tuberculin skin test (purified protein derivative [PPD]) result

Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
Presence of risk factors for tuberculosis
Spinal tuberculosis should always be suspected when radiographs demonstrate a destructive spinal process.
Conditions to consider in the differential diagnosis of Pott disease include the following:

Spinal tumors
Mycobacterium kansasii
Nocardiosis
Paracoccidioidomycosis
Septic arthritis
Spinal cord abscess
Tuberculosis

Differential Diagnoses

Actinomycosis

Blastomycosis

Brucellosis

Candidiasis

Cryptococcosis

Histoplasmosis

Metastatic Cancer With Unknown Primary Site

Miliary Tuberculosis

Multiple Myeloma

Mycobacterium Avium-Intracellulare

Approach Considerations
Lab studies used in the diagnosis of Pott disease include the following:

Tuberculin skin test (PPD) - Results are positive in 84-95% of patients with Pott disease who are not
infected with HIV

Erythrocyte sedimentation rate (ESR) - May be markedly elevated (>100 mm/h)

Microbiologic studies - Used to confirm the diagnosis

With regard to the above-mentioned microbiologic studies, bone tissue or abscess samples are obtained to
stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. Procedures guided by
computed tomography (CT) scanning can be used to guide percutaneous sampling of affected bone or softtissue structures. These study findings are positive in only about 50% of the cases.

Biopsy
Percutaneous, CT scan guided needle biopsy of bone lesions is a safe procedure that also allows therapeutic
drainage of large paraspinal abscesses. Obtain a tissue sample for microbiologic and pathologic studies to
confirm diagnosis and to isolate organisms for culture and susceptibility. Positive culture yield of percutaneous
is 50-83% and appears to be influenced by technical details, such as decontamination of specimens prior to
culture.[20]

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.

Drainage
Some cases of Pott disease are diagnosed following an open drainage procedure (eg, following presentation
with acute neurologic deterioration).

Scintigraphy
Radionuclide scanning findings are not specific for Pott disease. Gallium and technetium bone scans yield high
false-negative rates (70% and up to 35%, respectively).[21]

Radiography
Radiographic changes associated with Pott disease present relatively late. The following are radiographic
changes characteristic of spinal tuberculosis on plain radiography[22] :

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
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 1 level.

CT Scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption
of bone circumference.[23]
Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal
areas.
CT scanning reveals 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.

MRI
Magnetic resonance imaging (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. [6] MRI is also the most
effective imaging study for demonstrating neural compression. [24, 25]
Contrast-enhanced MRI findings are useful in differentiating tuberculous spondylitis from pyogenic spondylitis.
MRI findings in Pott disease include thin and smooth enhancement of the abscess wall and a well-defined
paraspinal abnormal signal. Thick and irregular enhancement of the abscess wall and an ill-defined paraspinal
abnormal signal suggest pyogenic spondylitis.[26] The images below are studies of a man aged 31 years with
spinal tuberculosis.

MRI of a 31-year-old man with tuberculosis of

the spine. Images show the thoracic spine before and after an infusion of intravenous gadolinium contrast. The abscess and
subsequent destruction of the T11-T12 disc interspace is marked with arrowheads. Vertebral body alignment is normal.
Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich.

MRI of the T11 in a 31-year-old man with tuberculosis

of the spine. Extensive bone destruction consistent with tuberculous osteomyelitis is evident. The spinal cord has normal
caliber and signal. No evidence of spinal cord compression or significant spinal stenosis is distinguishable. Courtesy of Mark
C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich

Approach Considerations
Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization
using prolonged bed rest or a body cast. At the time, the disease carried a mortality rate of 20%, and relapse
was common (30%).
The duration of treatment, surgical indications, and inpatient care for Pott disease have since evolved. 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, although routine
surgery does not seem to be indicated.[27]

Devices
Despite questionable efficacy, prolonged recumbence and the use of frames, plaster beds, plaster jackets, and
braces are still used.
Cast or brace immobilization was a traditional form of treatment but has generally been discarded. Patients with
Pott disease should be treated with external bracing.

Inpatient care
Once the diagnosis of Pott disease is established and treatment is started, the duration of hospitalization
depends on the need for surgery and the clinical stability of the patient.

Follow-up
Patients with Pott disease should be closely monitored to assess their response to therapy and compliance
with medication. Directly observed therapy may be required.

The development or progression of neurologic deficits, spinal deformity, or intractable pain should be
considered evidence of poor therapeutic response. This raises the possibility of antimicrobial drug resistance,
as well as the necessity for surgery.
Because of the risk of deformity exacerbations, children with Pott disease should undergo long-term follow-up
until their entire growth potential is completed.[28]Older patients can also present with late-onset complications
such as reactivation, instability, or deformity. Observation is warranted in all groups of patients.

Consultations
Consultations in Pott disease can include the following:

Orthopedic surgeons
Neurosurgeons
Rehabilitation teams

Pharmacologic Therapy
According to recommendations issued in 2003 by the US Centers for Disease Control and Prevention (CDC),
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 from among the first-line drugs,
which include pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is indicated in cases
of drug resistance.[29]

Treatment duration
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. [5]
However, the research councils 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.
For selected cases with surgical indication that allows complete debridement of the lesion, a combination of
surgery and ultra-shortened course of therapy (4.5 mo), appears to show comparable outcomes of a
combination of surgery and 9 months of drug therapy.[30]

Surgical Indications and Contraindications

Indications
While most patients should respond to medical treatment, a surgical approach needs to be evaluated and
considered. Indications for surgical treatment of Pott disease generally include the following [31, 32] :

Neurologic deficit - Acute neurologic deterioration, paraparesis, and paraplegia

Spinal deformity with instability or pain
No response to medical therapy - Continuing progression of kyphosis or instability
Large paraspinal abscess
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). [33]
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. The specific advantages and limitations of surgical techniques are unclear. Individualization of

the case is of greatest importance.[16, 34, 35, 36, 37] Newer modalities and techniques are being reported, such as
thoracoscopic decompression.[38]
In Pott disease that involves the cervical spine, the following factors justify early surgical intervention:

High frequency and severity of neurologic deficits

Severe abscess compression that may induce dysphagia or asphyxia
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.

Medication Summary
A 4-drug regimen should be used empirically to treat Pott disease. Treatment can be adjusted when
susceptibility information becomes available.
Isoniazid and rifampin should be administered during the whole course of therapy. Additional drugs are
administered during the first 2 months of therapy and are generally chosen from among the first-line drugs,
such as pyrazinamide, ethambutol, and streptomycin. (A 3-drug regimen usually includes isoniazid, rifampin,
and pyrazinamide.) In cases of drug resistance, the use of second-line medications is indicated.
The duration of treatment is somewhat controversial. Although some studies favor a 6- to 9-month course,
traditional courses range from 9 months to longer than 1 year. The duration of therapy should be individualized
and based on the resolution of active symptoms and the clinical stability of the patient.

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