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== Definition/Description  ==
== Introduction ==
[[File:Pott vertebra Museum (1910) (14576501749).jpeg|thumb|Vertebrae - Tuberculosis. 1910 museum.|alt=|382x382px]]
Tuberculous spondylitis, also known as Pott disease, refers to vertebral body [[osteomyelitis]] and [[Spondylodiscitis|intervertebral discitis]] from [[Tuberculosis|tuberculosis (TB)]]. The [[Spinal cord anatomy|spine]] is the most frequent location of musculoskeletal tuberculosis, and commonly related symptoms are back pain, [[Kyphosis|kyphotic]] deformity of the spine, lower limb weakness, and [[paraplegia]].&nbsp;<ref name=":0">Radiopedia Tuberculous spondylitis Available: https://radiopaedia.org/articles/tuberculous-spondylitis-2?lang=us<nowiki/>(accessed 14.5.2022)</ref> <ref name="Benzagmout et al.">Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.</ref>


Pott’s Disease, also known as tuberculosis spondylitis, is a rare infectious disease of the spine which is typically caused by an extraspinal infection. Pott’s Disease is a combination of osteomyelitis and arthritis which involves multiple vertebrae.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>&nbsp; The typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. A possible effect of this disease is vertebral collapse and when this occurs&nbsp;anteriorly, anterior wedging results, leading to kyphotic deformity of the spine.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><ref name="Cherian and Thomas">Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011 (1): 116-127.</ref><ref name="Benzagmout et al.">Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.</ref>&nbsp; Other possible effects can include compression fractures, spinal deformities and neurological insults, including paraplegia. <ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><ref name="Goodman and Snyder">Goodman CC, Snyder TES. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, MO: Saunders Elsevier; 2007:345.</ref>
Lately the disease has shown a significant increase in developed nations, particularly among the [[Immunocompromised Client|immunosuppressed population]] secondary to global migration and travel. There has been an ominous, increasing trend in the occurrence of [[Antimicrobial Resistance|multidrug-resistant bacterial strains]] of tuberculosis in the developing nations over the past decades, a tough challenge to the global community. Accordingly, the disease continues to exist as a major, global public health menace to date.<ref name=":1">Viswanathan VK, Subramanian S. Pott Disease.Available: https://www.statpearls.com/articlelibrary/viewarticle/27579/ (accessed 14.5.2022)</ref>  


== Prevalence  ==
== Epidemiolgy ==
[[File:Community health workers specialising in treating TB prepare to make their rounds on the motorbikes. Kiribati 2009. Photo- AusAID (10687431295).jpg|thumb|Community health workers treating TB ]]
Tuberculous spondylitis is one of the more common infections of spine in countries where TB is prevalent. Unfortunately, the incidence of Pott Disease, as with other forms of TB, is on the rise, due to new multiple drug resistant strains<ref name=":0" />.


'''Incidence<br>'''In 2005, there were 8.8 million new patients with tuberculosis (TB) all over the world, and of these, 7.4 million were in Asia and sub-Saharan Africa.<ref name="Nagashima et al.">Nagashima H, Yamane K, Nishi T, Nanjo Y, Teshima R. Recent trends in spinal infections: retrospective analysis of patients treated during the past 50 years. International Orthopaedics. 2010; 34(3): 395-399.</ref>&nbsp;&nbsp;Involvement of the spine reportedly occurs in less than 1-2% of patients who contract TB. Although the incidence of tuberculosis increased in the late 1980’s to early 1990’s, the total number of cases has decreased in recent years. In the United States, bone and soft tissue tuberculosis accounts for approximately 10% of extrapulmonary TB cases and between 1% and 2% of total cases. Of these cases, Pott’s disease is the most common manifestation of musculoskeletal TB, accounting for approximately 40-50%.&nbsp; Internationally, approximately 1-2% of total tuberculosis cases are attributable to Pott’s disease. <ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>  
* Discitis and/or osteomyelitis comprise approximately 50% of all musculoskeletal tuberculosis, and usually affects the lower thoracic and upper lumbar levels of the spine.<ref name=":0" />
* The World Health Organisation (WHO) reported an incidence of 10.4 million new cases of tuberculosis in 2016, among which 46.5% of cases were reported from the South East Asian Region alone. India contributed to 23% of the global TB burden<ref name=":1" />.'''<br>'''


'''Ethnicity<br>'''Data from the United States show that musculoskeletal tuberculosis primarily affects African Americans, Hispanic Americans, Asian Americans, and foreign-born individuals.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>&nbsp; The number of patients with TB spondylitis in Japan also declined to 233 in 2005 from 734 in 1978 and 276 in 2001.<ref name="Nagashima et al.">Nagashima H, Yamane K, Nishi T, Nanjo Y, Teshima R. Recent trends in spinal infections: retrospective analysis of patients treated during the past 50 years. International Orthopaedics. 2010; 34(3): 395-399.</ref>  
== Etiology ==
Pott's disease can develop when air that contains the tuberculosis-causing bacteria Mycobacterium tuberculosis is inhaled into the lungs. From the lungs, an infection can spread to the spine. The spread is hematogenous  ie transmitted through the blood. Bacteria reach the spine via the hematogenous route, from the lungs or lymph nodes. It spreads via the paravertebral plexus of veins i.e Batson's plexus. Someone with active TB infects the air with aerosol droplets by spitting, sneezing, coughing, speaking etc. Each sneeze can release up to 40,000 aerosol droplets, and it only takes one infected droplet to spread TB<ref>Study.com Pott Disease Available: https://study.com/learn/lesson/potts-disease-symptoms-treatments.html<nowiki/>(accessed 14.5.2022)</ref>.


'''Gender<br>'''Although some studies have found that Pott’s disease does not have sexual predilection, the disease is more common in males. The male to female ratio is reportedly 1.5-2:1.
Some known risk factors for TB include prolonged exposure to infected patients, immunodeficiencies (HIV, alcohol, drug abuse), overcrowding, malnutrition, poverty, and lower socio-economic situation.<ref name=":1" />


'''Age<br>'''In the United States and other developed countries, Pott’s disease occurs primarily in adults. In underdeveloped countries which have higher rates of Pott’s disease, involvement in young adults and older children predominates.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
== Types of Vertebral Tuberculosis ==
Lesions in the vertebrae may be of the following types-


== Characteristics/Clinical Presentation  ==
'''''Paradiscal:'''''


'''Spinal Involvement'''
* This is the commonest type.
* The contiguous areas of two adjacent vertebrae along with the intervening disc are affected.


*Lower thoracic vertebrae is the most common area of involvement (40-50%), followed by the Lumbar spine (35-45%)
'''''Central:'''''
*Approximately 10% of Pott's disease cases involve the cervical spine.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
*The thoracic spine is involved in about 65% of cases, and the lumbar, cervical and thoracolumbar spine in about 20%, 10% and 5%, respectively
*The atlanto-axial region may also be involved in less than 1% of cases<ref name="Cherian and Thomas">Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011 (1): 116-127.</ref>


'''Physical Findings'''
* The body of a single vertebra is affected.
* This leads to early collapse of the weakened vertebra.
* The nearby disc may be normal.


*Localized Tenderness
'''''Anterior:'''''
*Muscle Spasms
*Restricted Spinal Motion
*Spinal Deformity
*Neurological Deficits


'''Back Pain'''
* The infection is localized to the anterior part of the vertebral body.
* The infection spreads up and down under the anterior longitudinal ligament.


Back pain is the earliest and most common symptom. Patients with Pott’s disease usually experience back pain for weeks before seeking treatment and the pain caused by spinal TB can present as spinal or radicular. 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, thoracic&nbsp;and lumbar involvement&nbsp;comprise of 80-90% of spinal TB sites.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
'''''Posterior:'''''


'''Neurological Signs'''
* The posterior complex of the vertebra i.e., the pedicle, lamina, spinous process and transverse process are affected <ref>Garg RK, Somvanshi DS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184481/ Spinal tuberculosis: a review.] The journal of spinal cord medicine. 2011 Sep 1;34(5):440-54.</ref>


Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with the following:&nbsp;
== Characteristics/Clinical Presentation ==
[[File:Tuberculosis kyphosis.jpeg|thumb|TB, kyphosis spine]]
The clinical presentation of spinal tuberculosis is variable. The manifestations depend upon the duration of illness, severity of the disease, site of the lesion, and presence of associated complications including deformity and neurological deficit.


*Paraplegia
# In uncomplicated disease, the patient typically presents with back pain. Back pain in tuberculosis can be related to the active disease itself (secondary to inflammation), bone destruction and instability. Rest pain is pathognomonic, and rarely, radicular pain can be the main presenting symptom.
*Paresis
# In complicated tubercular spine disease patient may present with deformity, instability, and neuro deficit.  
*Impaired sensation
[[File:Pott's_Disease_Abscess.jpg|alt=|thumb|364x364px|Pott's Disease Cold Abscess]]Constitutional symptoms including weight or appetite loss, fever, and malaise/ fatigue are less commonly associated with extrapulmonary tuberculosis than pulmonary disease.<ref name=":1" />
*Nerve root pain  
*Cauda equina syndrome<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>


'''Spinal Deformities'''
* Cold Abscess: These abscesses typically lack all the inflammatory signs obvious in abscesses; and hence the name.  
 
* Deformity: Owing to the greater involvement of the anterior spinal column in TB, the spinal column progressively develops a kyphosis, especially in the thoracic and thoracolumbar spine.
Almost all patients with Pott’s disease have some degree of spine deformity with thoracic kyphosis being the most common.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
* Neurological Deficit: Can occur either at the active stage of the disease (secondary to compression from an abscess, inflammatory tissue, sequestrum or spinal instability) or during the healed stage (usually secondary to mechanical traction spinal defect.
 
* Pediatric Spinal TB: Due to the immaturity and increased flexibility of the spine in children, they are prone to developing severe deformity progression. Such worsening of deformity in children can also occur after the disease has completely healed, and follow-up is needed until skeletal maturity<ref name=":1" />.
'''Constitutional Symptoms'''
 
*Fever
*Night sweats
*Weight loss&nbsp;
*Malaise<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref><ref name="Tidy">Tidy C. Patient.co.uk. [Internet]. Updated 2009 Nov 23. Accessed 2012 Mar 28. Available from: http://www.patient.co.uk/doctor/Potts-Disease-(Spine).htm</ref><ref name="Benzagmout et al.">Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.</ref><ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
 
'''Cervical Spinal TB'''
 
Cervical spine TB is a less common presentation occurring in approximately 10% of cases, but is potentially more serious because severe neurological complications are more likely. This condition is characterized by cervical pain and stiffness and symptoms can also include torticollis, hoarseness, and neurological deficits. Upper cervical spine involvement can cause rapidly progressive symptoms and neurologic manifestations occur early and range from a single nerve palsy to hemiparesis or quadriplegia. Retropharyngeal abscesses occur in almost all cases. In lower cervical spine insults, the patient can present with dysphagia or stridor.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
'''Presentation in People Infected with HIV'''
 
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 TB seems to be more common in persons infected with HIV.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>  
 
'''Asymptomatic Presentation'''
 
Many persons with Pott’s disease (62-90%) of patients reported series have no evidence of extraspinal tuberculosis, further complicating a timely diagnosis.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><br>


== Associated Co-morbidities  ==
== Associated Co-morbidities  ==
[[File:Screen Shot 2022-05-14 at 2.55.25 pm.png|thumb|''Estimated TB-related deaths among people living with HIV'']]
Include: Immunosuppressive Disorders; HIV/AIDS; TB; Gastrectomy; Peptic Ulcer; Drug Addiction; Alcoholism; Malnourishment; Low Socioeconomic Status


*Immunosuppressive Disorders
== Diagnosis ==
*HIV/AIDS
For the detection of Tuberculosis, the following diagnostic tests are preferable-
*TB
*Gastrectomy
*Peptic Ulcer
*Drug Addiction
*Alcoholism
*Malnourishment
*Low Socioeconomic Status
 
== Medications  ==
 
The duration of treatment is somewhat controversial. Although some studies favor 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.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
<br>The main drug class consists of agents that inhibit growth and proliferation of the causative bacteria. Isoniazid and rifampin should be administered during the whole course of therapy. Additional drugs are administered during the first two months of therapy and 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.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
<br>'''Isoniazid (Laniazid, Nydrazid)<br>'''View full drug information: http://reference.medscape.com/drug/isoniazid-342564 <br>Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates well into all body fluids and cavities.
 
<br>'''Rifampin (Rifadin, Rimactane)<br>'''View full drug information: http://reference.medscape.com/drug/rifadin-rimactane-rifampin-342570 <br>For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur.
 
<br>'''Pyrazinamide<br>'''View full drug information: http://reference.medscape.com/drug/pyrazinamide-342678 <br>Bactericidal against M tuberculosis in an acid environment (macrophages). Has good absorption from the GI tract and penetrates well into most tissues, including CSF.
 
<br>'''Ethambutol (Myambutol)<br>'''View full drug information: http://reference.medscape.com/drug/myambutol-ethambutol-342677 <br>Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations remain low, even in the presence of meningeal inflammation.
 
<br>'''Streptomycin<br>'''View full drug information: http://reference.medscape.com/drug/streptomycin-342682 <br>Bactericidal in an alkaline environment. Because it is not absorbed from the GI tract, must be administered parenterally. Exerts action mainly on extracellular tubercle bacilli. Only about 10% of the drug penetrates cells that harbor organisms. Enters the CSF only in the presence of meningeal inflammation. Excretion is almost entirely renal. (3)<br>
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
'''The Mantoux Test (Tuberculin Skin Test)<br>'''Injection of a purified protein derivative (PPD). Results are positive in 84-95% of patients with Pott’s disease who are not infected with HIV.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
 
'''Erythrocyte Sedimentation Rate (ESR)''' <br>ESR may be markedly elevated (&gt;100 mm/h)
 
'''Microbiology Studies''' <br>Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft tissue structures; however, these study findings are positive in only about 50% of the cases.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
'''Radiography<br>'''Radiographic changes associated with Pott’s disease present relatively late. The following are radiographic changes characteristics of spinal tuberculosis on plain radiography:
 
*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
*Vertebral end plates may be 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 one level<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
'''CT Scanning<br>'''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 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 which is common in TB lesions.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
'''MRI''' <br>MRI is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also called the most effective imaging study for demonstrating neural compression. MRI findings useful to differentiate tuberculosis spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Pott's Disease Abscess.jpg|302x364px|Pott's Disease Abscess]]
 
''&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;MRI of the thoracic spine (T2-weighted, sagittal reconstruction). The dorsal fluid collection suggests a&nbsp;''
 
''&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; paravertebral abscess (large arrow) just above the fractured and operated third thoracic vertebra (small arrow)<ref name="Ringshausen et al.">Ringshausen FC, Tannapfel A, Nicolas V, Weber A, Duchna H, Schultze-Werninghaus G, et al. A fatal case of spinal tuberculosis mistaken for metastatic lung cancer: recalling ancient Pott's disease. Annals of Clinical Microbiology and Antimicrobials. 2009; 8: 32.</ref>''
 
<br>'''Biopsy<br>'''Use of a percutaneous CT-guided needle biopsy of bone lesions to can be used to obtain tissue samples. This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
'''Polymerase Chain Reaction (PCR)'''<br>PCR techniques amplify species-specific DNA sequences which is able to rapidly detect and diagnose several strains&nbsp;of mycobacterium without the need for prolonged culture.&nbsp;&nbsp;They&nbsp;have also been used to identify discrete&nbsp;genetic mutations in DNA sequences associated with drug resistance.<ref name="Khoo et al">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>&nbsp;
 
== Etiology/Causes  ==
 
The four primary patterns of involvment in adults are as follows:
 
1. Paradiscal
 
*Most common, comprising 50% of all cases
*Primary focus of infection in the vertebral metaphysis
*The granuloma erodes the cartilaginous endplate and narrows the disc space
 
2. Anterior Granuloma
 
*Granulomas develop underneath the anterior longitudinal ligament
*Less bony destruction but increased bone devascularization
*Further development of abscess, necrosis and deformity
 
3. Central Lesions
 
*Involves entire&nbsp;vertebral body
*2-3 vertebrae are often affected
*Results in significant deformities and pathological fractures
 
4. Appendiceal Type Lesions
 
*Lamina, pedicles, articular facets and spinous processes
*Initial expansion followed by rupture and failure<ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
 
The organism that has been identified as causing Pott’s disease is mycobacterium tuberculosis. The primary mode of transmission the bacteria travels to the spine is hematogenously from an extraspinal site of infection. It is common to travel from the lungs in adults but the primary site of infection is often unknown in children.<ref name="Tidy">Tidy C Patient.co.uk. [Internet]. . Updated 2009 Nov 23. Accessed 2012 Mar 28. Available from: http://www.patient.co.uk/doctor/Potts-Disease-(Spine).htm</ref><ref name="Hpathy.com">Hpathy.com [Internet]. Update unknown. Accessed 2012 Mar 28. http://health.hpathy.com/potts-disease-symptoms-treatment-cure.asp.</ref>&nbsp; The infection has also been found to spread through the lymphatic system.<ref name="Schirmer et al.">Schirmer P, Renault CA, Holodniy M. Is spinal tuberculosis contagious? International Journal of Infectious Diseases. Aug 2010; 14(8): 649-666.</ref>&nbsp; Once being spread, the infection can target vertebrae, intervertebral discs, the epidural or intradural space within the spinal canal and adjacent soft tissue.<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>&nbsp; When the infection is developing, it can spread up and down the vertebral column, stripping the anterior and posterior longitudinal ligaments and the periosteum from the front and sides of the vertebral bodies. This results in loss of the periosteal blood supply and distraction of the anterolateral surface of the vertebrae.<ref name="Benzagmout et al.">Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.</ref>
 
If a single vertebra is affected, the surrounding intervertebral discs will remain normal. However, if two adjacent vertebrae are affected, the intervertebral disc between them will also collapse and become avascular.<ref name="Tidy">Tidy C Patient.co.uk. [Internet]. . Updated 2009 Nov 23. Accessed 2012 Mar 28. Available from: http://www.patient.co.uk/doctor/Potts-Disease-(Spine).htm</ref>&nbsp; Due to the vascularity of intervertebral discs in children, the discs can become a primary site of infection rather than spreading from the vertebrae.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
Spinal cord compression in Pott’s disease is usually caused by paravertebral abscesses which can also develop calcifications or sequestra within them.<ref name="Cherian and Thomas">Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011 (1): 116-127.</ref>&nbsp; If the infection reaches adjacent ligaments and soft tissues, a cold abscess can also&nbsp;form. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>&nbsp; Other causes of neurological involvement include dural invasion from granulation tissue, sequestrated bone, intervertebral disc collapse or a dislocated vertebra.<ref name="Cherian and Thomas">Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011 (1): 116-127.</ref><ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><ref name="Tidy">Tidy C Patient.co.uk. [Internet]. . Updated 2009 Nov 23. Accessed 2012 Mar 28. Available from: http://www.patient.co.uk/doctor/Potts-Disease-(Spine).htm</ref>&nbsp; Neurological symptoms can occur at any point, including years later as a result of stretching of the spinal cord within the vertebral foramen of the deformed spine.<ref name="Cherian and Thomas">Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011 (1): 116-127.</ref>
 
== Systemic Involvement  ==
 
The severity of Pott’s disease varies from one person to another, resulting in different clinical presentations. Possible signs and symptoms that may present are depicted in Table 1 by system.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref><ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
 
<br>
 
{| border="1" cellspacing="1" summary="The severity of Pott’s disease varies from one person to another, resulting in different clinical presentations. Possible signs and symptoms that may present are depicted in Table 1 below by system." cellpadding="1" width="200" align="center"
|+ '''Table 1. Systemic Signs and Symptoms of Pott's Disease'''
|-
| '''Musculoskeletal'''
| '''Neurological'''
| '''Cardiovascular'''
| '''Integumentary'''
| '''Urogenital'''
| '''Constitutional Symptoms'''
|-
| Vertebral&nbsp;Fractures
| Paresthesia
| Spinal Artery Infarction
| Pressure Ulcers&nbsp;(Secondary)
| Bowel Dysfunction
| Fever
|-
| Vertebral Collapse
| Paralysis
| Avascularity of Intervertebral Discs
| Sinus (Secondary to Abscess Rupture)
| Bladder Dysfunction
| Night Sweats
|-
| Spinal Ligament Destruction
| Paresis
| Thrombosis
| Cutaneous Fungal Infections
|
| Malaise
|-
| Intervertebral&nbsp;Disc Destruction
| Abnormal Muscle Tone
|
|
|
| Weight Loss
|-
| Paravertebral Abscess
| Abnormal Reflexes
|
|
|
|
|-
| Osteopenia/Osteoporosis
| Cauda Equina Syndrome
|
|
|
|
|-
| Bone Sequestrations
| Myelomalacia
|
|
|
|
|-
| Dislocated Vertebrae
| Gliosis
|
|
|
|
|-
| Kyphotic Deformity
| Syringomyelia
|
|
|
|
|-
| Muscle Atrophy
|
|
|
|
|
|-
| Torticollis
|
|
|
|
|
|}
 
&nbsp;<br>
 
== Medical Management (current best evidence)  ==
 
'''Treatment goals'''
 
*Confirm Diagnosis
*Eradicate Infection
*Identify and Remove Causative Pathogen
*Recover/Maintain Neurological Function
*Recover/Maintain Mechanical Spine Stability
*Correct or Prevent Spinal Deformity and&nbsp;Possible Sequelae&nbsp;
*Functional Return to&nbsp;Activities of Daily&nbsp;Living<ref name="Benzagmout et al.">Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.</ref><ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
 
'''Treatment Techniques'''
 
*Anti-Tuberculosis Chemotherapy
*Surgical Drainage of Abscess
*Surgical Spinal Cord Decompression
*Surgical Spinal Fusion
*Spinal Immobilization
 
'''Predictors of Good Prognosis'''


*Partial Cord Compression
* Chest X-ray
*Short Duration of Neural Complications
* Sputum cultures (to look for the presence of bacteria)
*Early Onset Cord Involvement with Delayed Neural Complications
* Blood culture
*Young Age
* Tissue biopsy (to check for the possibilities of cancer)
*Good General Condition<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>
* Mantoux Tuberculin skin tests ( results are positive in 84-95% of the patients having Pott’s disease)
* [[CT Scans|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 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 which is common in TB lesions.<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
* [[MRI Scans|MRI]] is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments.MRI is also called the most effective imaging study for demonstrating neural compression. MRI findings useful to differentiate tuberculosis spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.<ref name="Hidalgo and Cunha" />
* Biopsy: Use of a percutaneous CT-guided needle biopsy of bone lesions can be used to obtain tissue samples. This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.<ref name="Hidalgo and Cunha" />
* Polymerase Chain Reaction (PCR)''':''' PCR techniques amplify species-specific DNA sequences which is able to rapidly detect and diagnose several strains of mycobacterium without the need for prolonged culture. They have also been used to identify discrete&nbsp;genetic mutations in DNA sequences associated with drug resistance.<ref name="Khoo et al">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>&nbsp;
== Medical Management ==
[[File:Treatment of Tuberculosis (TB) for Drug-Sensitive TB (5102889450).jpeg|thumb|TB usually be cured with a combination of first-line drugs.]]
The mainstay of treatment in spinal TB is [[Chemotherapy Side Effects and Syndromes|chemotherapy]] (antitubercular treatment). Tubercle bacilli may exist as intracellular or extracellular forms or as dormant or rapidly multiplying forms. Multi-drug treatment is essential to attack the bacilli in various stages or forms and reduce the instance of drug resistance.


Effective chemotherapy for Pott’s disease is the gold standard and must be started at the early stages of the disease.<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>&nbsp;Radical ventral debridement, fusion and reconstruction of the vertebral column remains the gold standard of surgical treatment for tuberculosis spondylitis.<ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
It is essential to classify spinal TB disease into a complicated and uncomplicated disease, based on their presentation.  


Multiple surgical approaches have been conducted to correct the spinal deformity seen in Pott's disease&nbsp;with varying results.&nbsp; Laminectomy failed to address the anterior component of the disease process and spinal instability.&nbsp; Posterior fusion has been successful at reducing kyphosis but preoperative infection and high levels of kyphosis have resulted in many fusion failures.&nbsp; An anterior approach, used by Hodgson and Stock,&nbsp;has also been used with&nbsp;great success.<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>
# Uncomplicated spinal TB is essentially a medical disease.
# Complicated TB spine patients need surgical intervention in addition to chemotherapy.<ref name=":1" />
#* The first line of treatment for Pott’s disease is the surgical removal of the tubercular infection. Administration of anti-tubercular medications is done before and after the surgery. This procedure is followed by the surgical reconstruction of the spine.
#* The treatment protocol is formulated based on the presence or absence of neurological involvement. In case of neurological involvement usually, pharmacotherapy is preferred over surgery. The anti-tubercular medications employed in the pharmacotherapy are Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide<ref>Fact Dr Potts Disease Available: https://factdr.com/health-conditions/potts-disease/<nowiki/>(accessed 14.5.2022)</ref>.
#* Surgery done during the active course of the disease is much safer&nbsp;with&nbsp;a faster and better&nbsp;response.<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>


Various surgical techniques are utilized&nbsp;based on which area of the spine is affected.&nbsp; In the upper cervical spine,&nbsp;a transoral or extreme lateral approach is taken which typically requires concurrent occipito-cervical&nbsp;fusion to prevent&nbsp;collapse, instability&nbsp;and delayed deformity.&nbsp; Midcervical lesions are often treated with standard anterior cervical approaches and achieve excellent results.&nbsp; Transsternal, transmanubrial,&nbsp;or lateral extracavitary approaches are conducted in patients with&nbsp;involvement of the lower cervical/upper thoracic spine.&nbsp;&nbsp;In the thoracic spine surgeons make use of transthoracic, extraplural anterolateral or extended posterolateral approaches.&nbsp; The posterolateral method is&nbsp;more often utilized in severe cases of&nbsp;kyphosis due to the nature&nbsp;of the spinal deformity and ease of access to the spine.&nbsp; However, surgical correction of a&nbsp;severe kyphotic deformity (&gt;30 degrees) will often require a posterior technique that is complex and technically demanding.&nbsp; Surgical&nbsp;morbidity and mortality can be significant for these technically demanding procedures with&nbsp;an 8-10% incidence post correction&nbsp;neurological complications.&nbsp;Surgical procedures in the lumbar spine are typically performed through a lateral retroperitoneal approach which is the preferred method compared to an anterior or retroperitoneal procedure.<ref name="Khoo et al.">Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.</ref>
== Education ==
Patient education is of extremly importance in the management of TB at the level of an individual, as well as the whole community.


Surgery done during the active course of the disease is much safer&nbsp;with&nbsp;a faster and better&nbsp;response.&nbsp; Moreover, the importance of early diagnosis, start of appropriate treatment and its continuation for adequate duration along with the proper counseling of the patient and family members with the timely surgical intervention is the key for the success in achieving a good outcome.<ref name="Kumar et al.">Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.</ref>
* The need for isolation of patients who can potentially transmit the disease is paramount. 
* Strict compliance to long term chemotherapy is essential  for complete cure from the infection.  
* In pediatric disease, the chances of progression of deformity even years after healing of the infection and the need for regular follow-up until skeletal maturity need to be clearly communicated to the parents<ref name=":1" />.  


== Physical Therapy Management (current best evidence) ==
== Physical Therapy Management  ==


Patients with Pott's disease often undergo spinal fusion or spinal decompression&nbsp;surgeries to correct their structural deformity and prevent further neurological complications.&nbsp; There are no established guidelines&nbsp;which dictate&nbsp;treatments that will yield positive outcomes in such patients.&nbsp;&nbsp;However, treatment regimens should address each patient individually, focusing on any impairments, functional limitations&nbsp;and/or disabilities with which they present.&nbsp;
Patients with Pott's disease often undergo spinal fusion or spinal decompression surgeries to correct their structural deformity and prevent further neurological complications. There are no established guidelines which dictate treatments that will yield positive outcomes in such patients. However, treatment regimens should address each patient individually, focusing on any impairments, functional limitations and/or disabilities with which they present.


PT&nbsp;Managment Post-Spinal Decompression Surgery  
PT Managment Post-Spinal Decompression Surgery  


*Spinal Stabilization Exercises  
*[[Spinal Stabilization]] Exercises
*Maitland  
*[[Maitland's Mobilisations|Maitland]]
*Back School  
*[[Back School]]
*Exercise and Strengthening
*Exercise and Strengthening


When compared with other physical therapy treatments and self-managment, spinal stabilization exercises were found to produce significantly more positive ratings in global outcomes.&nbsp; Pain and disability, however, did not show significant improvement when compared to the other two treatment options.<ref name="Mannion et al.">Mannion AF, Denzler R, Dvorak J, Muntener M, Grob D. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J (2007) 16:1101–1117.</ref>  
When compared with other physical therapy treatments and self-managment, spinal stabilization exercises were found to produce significantly more positive ratings in global outcomes. Pain and disability, however, did not show significant improvement when compared to the other two treatment options.<ref name="Mannion et al.">Mannion AF, Denzler R, Dvorak J, Muntener M, Grob D. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J (2007) 16:1101–1117.</ref>  


PT Managment Post-Spinal Fusion Surgery  
PT Managment Post-Spinal Fusion Surgery  
Line 319: Line 112:
*Overground Training (Walking Program)  
*Overground Training (Walking Program)  
*Aerobic Exercise  
*Aerobic Exercise  
*Trunk&nbsp;Strengthening
*Trunk Strengthening
 
Studies examining the use of TENS have shown higher frequencies are more effective in decreasing neuropathic pain.&nbsp; Aerobic exercise, PT, and trunk strengthening interventions have all attained significant decreases in pain, psychological distress and disability.<ref name="Pons and Shipton">Pons T, Shipton EA. Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy Theory and Practice. 2011; 27(3):238-245.</ref>


== Alternative/Holistic Management (current best evidence)  ==
Studies examining the use of TENS have shown higher frequencies are more effective in decreasing neuropathic pain. Aerobic exercise, PT, and trunk strengthening interventions have all attained significant decreases in pain, psychological distress and disability.<ref name="Pons and Shipton">Pons T, Shipton EA. Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy Theory and Practice. 2011; 27(3):238-245.</ref><br>
 
== Case Reports  ==
Currently there are no alternative managements of Pott's disease from evidence based sources.
'''Adegboye OA.'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237173/?tool=pmcentrez '''Non-Hodgkin's lymphoma “masquerading” as Pott's disease in a 13-year old boy''']'''.&nbsp;''Indian Journal of Medical and Paediatric Oncology''. 2011 Apr-Jun; 32(2): 101–104.'''  
 
== Differential Diagnosis  ==
 
*Actinomycosis
*Blastomycosis
*Brucellosis
*Candidiasis
*Cryptococcosis
*Histoplasmosis
*Metastatic Cancer, Unknown Primary Site
*Miliary Tuberculosis
*Multiple Myeloma
*Mycobacterium Avium-Intracellulare
*Mycobacterium Kansasii
*Nocardiosis
*Paracoccidioidomycosis
*Sarcoidosis
*Septic Arthritis
*Spinal Cord Abscess
*Spinal Stenosis
*Spondylolisthesis
*Tuberculosis
*Vertebral Osteomyelitis<ref name="Hidalgo and Cunha">Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.</ref>
 
== Case Reports&nbsp; ==
 
'''Sarangapani A, Fallah A, Provias J, Jha NK.'''''<b>&nbsp;</b>''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2592567/ '''Atypical presentation of spinal tuberculosis''']'''.&nbsp;''Canadian Journal of&nbsp;Surgery''. 2008 December; 51(6): E121.'''
 
A 26 y/o male presented with a 4 month history of pain in the right shoulder and ribs, thoracic and lower extremities numbness and weakness. All characteristics were consistent with a neoplasm but was ultimately identified as spinal TB.
 
'''Ringshausen FC, Tannapfel A, Nicolas V, Weber A, Duchna H, Schultze-Werninghaus G, et al.&nbsp;'''[http://ck8zf4yc8t.search.serialssolutions.com/?genre=article&isbn=&issn=14760711&title=Annals+Of+Clinical+Microbiology+And+Antimicrobials&volume=8&issue=&date=20091120&atitle=A+fatal+case+of+spinal+tuberculosis+mistaken+for+metastatic+lung+cancer%3a+recalling+ancient+Pott%27s+disease.&aulast=Ringshausen+FC&spage=32&sid=EBSCO:MEDLINE&pid= '''A fatal case of spinal tuberculosis mistaken for metastatic lung cancer: recalling ancient Pott's disease''']'''''. Annals of Clinical Microbiology and Antimicrobials''. 2009; 8: 32.'''
 
A 67 y/o male of Germanic descent presented to ER with complaints of severe mid back pain and no prior history of TB. He was originally treated for metastatic lung cancer based on a single lung nodule, but the diagnosis was incorrect. Shortly after the diagnosis was correctly identified, the patient passed away.
 
'''Jeon DW, Chang B, Jeung UO, Lee SJ, Lee C, Kim M, et al.&nbsp;'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766690/?tool=pmcentrez '''A Case of Postoperative Tuberculous Spondylitis with a Bizarre Course''']'''. ''Clinics in Orthopedic Surgery''. 2009 March; 1(1): 58–62.'''
 
A 44-year-old man, who had a history of complete recovery from pulmonary tuberculosis 20 years previously, underwent posterior interbody fusion with instrumentation for a herniated intervertebral disc at the L4-L5 level. He developed a fever and low back pain at three weeks postoperative. No labs were taken and after 3 months of antibiotics, he was diagnosed with spinal tuberculosis.
 
'''Adegboye OA.&nbsp;'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237173/?tool=pmcentrez '''Non-Hodgkin's lymphoma “masquerading” as Pott's disease in a 13-year old boy''']'''.&nbsp;''Indian Journal of Medical and Paediatric Oncology''. 2011 Apr-Jun; 32(2): 101–104.'''  


A 13 year old boy presenting with back inflammation, lower extremity paralysis, bowel and bladder incontinence, progressive weight loss, numbness below T10 and&nbsp;low grade fever.&nbsp; Radiographs taken indicative of Pott's disease.  
A 13 year old boy presenting with back inflammation, lower extremity paralysis, bowel and bladder incontinence, progressive weight loss, numbness below T10 and&nbsp;low grade fever.&nbsp; Radiographs taken indicative of Pott's disease.  


'''Wong NM, Sun LK, Lau P.&nbsp;'''[http://www.josonline.org/pdf/v16i3p359.pdf '''Spinal infection caused by Mycobacterium avium complex in a patient with no acquired immune deficiency syndrome: a case report''']'''.&nbsp;''Journal of Orthopaedic Surgery. ''2008; 16(3): 359-63.'''
'''Lotfinia I, Vahedi P.'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899618/?tool=pmcentrez '''Late-onset post-diskectomy tuberculosis at the same operated lumbar level: case report and review of literature''']'''. ''European Spine Journal.'' 2010 July; 19(Suppl 2): 226–232.'''  
 
60 y/o male presents with 6 months of back pain with no reported trauma. He has hypertension and gout, but is not diabetic, immunocompromised or using steroids. Diffuse tenderness over mid lumbar region and no signs of neurological involvement and is afebrile. Common lab values and imaging confirmed diagnosis of spinal TB.
 
'''Lotfinia I, Vahedi P.&nbsp;'''[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899618/?tool=pmcentrez '''Late-onset post-diskectomy tuberculosis at the same operated lumbar level: case report and review of literature''']'''. ''European Spine Journal.'' 2010 July; 19(Suppl 2): 226–232.'''  
 
A 43 y/o male presents with chronic low back pain for 4 months with intermittent pus drainage from his scar status post lumbar discectomy 8 years previously. Patient reported no history of TB but he had worked as a secretary at a hospital for years.
 
== Resources  ==
 
'''General Tuberculosis Information'''
 
*'''Mayo Clinic:''' [http://search2.mayoclinic.com/search?q=tuberculosis&site=mayoclinic-org%7Cmayoclinic-com%7Cmayo-edu%7Cinternet-research%7Cclinical-trials&client=unified&proxystylesheet=unified&output=xml_no_dtd http://search2.mayoclinic.com/search?q=tuberculosis&amp;site=mayoclinic-org%7Cmayoclinic-com%7Cmayo-edu%7Cinternet-research%7Cclinical-trials&amp;client=unified&amp;proxystylesheet=unified&amp;output=xml_no_dtd]&nbsp;&nbsp;
 
*'''Medscape:''' [http://emedicine.medscape.com/article/226141-overview#a0104 http://emedicine.medscape.com/article/226141-overview#a0104]&nbsp;&nbsp;
 
'''Tuberculosis Drug Information<br>'''
 
*'''Drugs.com:'''&lt;span id="fck_dom_range_temp_1333664366649_227" /&gt; [http://www.drugs.com/search.php?searchterm=tuberculosis+drugs http://www.drugs.com/search.php?searchterm=tuberculosis+drugs]&nbsp;&nbsp;
 
*'''U.S. Food and Drug Administration:''' [http://google2.fda.gov/search?q=tuberculosis&client=FDAgov&site=FDAgov&lr=&proxystylesheet=FDAgov&output=xml_no_dtd&getfields http://google2.fda.gov/search?q=tuberculosis&amp;client=FDAgov&amp;site=FDAgov&amp;lr=&amp;proxystylesheet=FDAgov&amp;output=xml_no_dtd&amp;getfields]=* <br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1TmjO1ifNeww3ZATdP4HTD3nBE9UDeXe0-HS4mUbf1NfznBMt_|charset=UTF-8|short|max=10</rss></div>


A 43 y/o male presents with chronic low back pain for 4 months with intermittent pus drainage from his scar status post lumbar discectomy 8 years previously. Patient reported no history of TB but he had worked as a secretary at a hospital for years.
== References  ==
== References  ==


&nbsp;<references />
<references />
 
[[Category:Medical]] [[Category:Bellarmine_Student_Project]]
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Latest revision as of 06:45, 27 July 2023

Original Editors - David Pieschel & Craig Satterley from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Craig Satterley, Lucinda hampton, Admin, Elaine Lonnemann, Joao Costa, Sai Kripa, David Pieschel, WikiSysop, Kim Jackson, Nupur Smit Shah, 127.0.0.1, Wendy Walker and Evan Thomas

Introduction[edit | edit source]

Vertebrae - Tuberculosis. 1910 museum.

Tuberculous spondylitis, also known as Pott disease, refers to vertebral body osteomyelitis and intervertebral discitis from tuberculosis (TB). The spine is the most frequent location of musculoskeletal tuberculosis, and commonly related symptoms are back pain, kyphotic deformity of the spine, lower limb weakness, and paraplegia. [1] [2]

Lately the disease has shown a significant increase in developed nations, particularly among the immunosuppressed population secondary to global migration and travel. There has been an ominous, increasing trend in the occurrence of multidrug-resistant bacterial strains of tuberculosis in the developing nations over the past decades, a tough challenge to the global community. Accordingly, the disease continues to exist as a major, global public health menace to date.[3]

Epidemiolgy[edit | edit source]

Community health workers treating TB

Tuberculous spondylitis is one of the more common infections of spine in countries where TB is prevalent. Unfortunately, the incidence of Pott Disease, as with other forms of TB, is on the rise, due to new multiple drug resistant strains[1].

  • Discitis and/or osteomyelitis comprise approximately 50% of all musculoskeletal tuberculosis, and usually affects the lower thoracic and upper lumbar levels of the spine.[1]
  • The World Health Organisation (WHO) reported an incidence of 10.4 million new cases of tuberculosis in 2016, among which 46.5% of cases were reported from the South East Asian Region alone. India contributed to 23% of the global TB burden[3].

Etiology[edit | edit source]

Pott's disease can develop when air that contains the tuberculosis-causing bacteria Mycobacterium tuberculosis is inhaled into the lungs. From the lungs, an infection can spread to the spine. The spread is hematogenous ie transmitted through the blood. Bacteria reach the spine via the hematogenous route, from the lungs or lymph nodes. It spreads via the paravertebral plexus of veins i.e Batson's plexus. Someone with active TB infects the air with aerosol droplets by spitting, sneezing, coughing, speaking etc. Each sneeze can release up to 40,000 aerosol droplets, and it only takes one infected droplet to spread TB[4].

Some known risk factors for TB include prolonged exposure to infected patients, immunodeficiencies (HIV, alcohol, drug abuse), overcrowding, malnutrition, poverty, and lower socio-economic situation.[3]

Types of Vertebral Tuberculosis[edit | edit source]

Lesions in the vertebrae may be of the following types-

Paradiscal:

  • This is the commonest type.
  • The contiguous areas of two adjacent vertebrae along with the intervening disc are affected.

Central:

  • The body of a single vertebra is affected.
  • This leads to early collapse of the weakened vertebra.
  • The nearby disc may be normal.

Anterior:

  • The infection is localized to the anterior part of the vertebral body.
  • The infection spreads up and down under the anterior longitudinal ligament.

Posterior:

  • The posterior complex of the vertebra i.e., the pedicle, lamina, spinous process and transverse process are affected [5]

Characteristics/Clinical Presentation[edit | edit source]

TB, kyphosis spine

The clinical presentation of spinal tuberculosis is variable. The manifestations depend upon the duration of illness, severity of the disease, site of the lesion, and presence of associated complications including deformity and neurological deficit.

  1. In uncomplicated disease, the patient typically presents with back pain. Back pain in tuberculosis can be related to the active disease itself (secondary to inflammation), bone destruction and instability. Rest pain is pathognomonic, and rarely, radicular pain can be the main presenting symptom.
  2. In complicated tubercular spine disease patient may present with deformity, instability, and neuro deficit.
Pott's Disease Cold Abscess

Constitutional symptoms including weight or appetite loss, fever, and malaise/ fatigue are less commonly associated with extrapulmonary tuberculosis than pulmonary disease.[3]

  • Cold Abscess: These abscesses typically lack all the inflammatory signs obvious in abscesses; and hence the name.
  • Deformity: Owing to the greater involvement of the anterior spinal column in TB, the spinal column progressively develops a kyphosis, especially in the thoracic and thoracolumbar spine.
  • Neurological Deficit: Can occur either at the active stage of the disease (secondary to compression from an abscess, inflammatory tissue, sequestrum or spinal instability) or during the healed stage (usually secondary to mechanical traction spinal defect.
  • Pediatric Spinal TB: Due to the immaturity and increased flexibility of the spine in children, they are prone to developing severe deformity progression. Such worsening of deformity in children can also occur after the disease has completely healed, and follow-up is needed until skeletal maturity[3].

Associated Co-morbidities[edit | edit source]

Estimated TB-related deaths among people living with HIV

Include: Immunosuppressive Disorders; HIV/AIDS; TB; Gastrectomy; Peptic Ulcer; Drug Addiction; Alcoholism; Malnourishment; Low Socioeconomic Status

Diagnosis[edit | edit source]

For the detection of Tuberculosis, the following diagnostic tests are preferable-

  • Chest X-ray
  • Sputum cultures (to look for the presence of bacteria)
  • Blood culture
  • Tissue biopsy (to check for the possibilities of cancer)
  • Mantoux Tuberculin skin tests ( results are positive in 84-95% of the patients having Pott’s disease)
  • 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 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 which is common in TB lesions.[6]
  • MRI is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments.MRI is also called the most effective imaging study for demonstrating neural compression. MRI findings useful to differentiate tuberculosis spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.[6]
  • Biopsy: Use of a percutaneous CT-guided needle biopsy of bone lesions can be used to obtain tissue samples. This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.[6]
  • Polymerase Chain Reaction (PCR): PCR techniques amplify species-specific DNA sequences which is able to rapidly detect and diagnose several strains of mycobacterium without the need for prolonged culture. They have also been used to identify discrete genetic mutations in DNA sequences associated with drug resistance.[7] 

Medical Management[edit | edit source]

TB usually be cured with a combination of first-line drugs.

The mainstay of treatment in spinal TB is chemotherapy (antitubercular treatment). Tubercle bacilli may exist as intracellular or extracellular forms or as dormant or rapidly multiplying forms. Multi-drug treatment is essential to attack the bacilli in various stages or forms and reduce the instance of drug resistance.

It is essential to classify spinal TB disease into a complicated and uncomplicated disease, based on their presentation.

  1. Uncomplicated spinal TB is essentially a medical disease.
  2. Complicated TB spine patients need surgical intervention in addition to chemotherapy.[3]
    • The first line of treatment for Pott’s disease is the surgical removal of the tubercular infection. Administration of anti-tubercular medications is done before and after the surgery. This procedure is followed by the surgical reconstruction of the spine.
    • The treatment protocol is formulated based on the presence or absence of neurological involvement. In case of neurological involvement usually, pharmacotherapy is preferred over surgery. The anti-tubercular medications employed in the pharmacotherapy are Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide[8].
    • Surgery done during the active course of the disease is much safer with a faster and better response.[9]

Education[edit | edit source]

Patient education is of extremly importance in the management of TB at the level of an individual, as well as the whole community.

  • The need for isolation of patients who can potentially transmit the disease is paramount.
  • Strict compliance to long term chemotherapy is essential for complete cure from the infection.
  • In pediatric disease, the chances of progression of deformity even years after healing of the infection and the need for regular follow-up until skeletal maturity need to be clearly communicated to the parents[3].

Physical Therapy Management[edit | edit source]

Patients with Pott's disease often undergo spinal fusion or spinal decompression surgeries to correct their structural deformity and prevent further neurological complications. There are no established guidelines which dictate treatments that will yield positive outcomes in such patients. However, treatment regimens should address each patient individually, focusing on any impairments, functional limitations and/or disabilities with which they present.

PT Managment Post-Spinal Decompression Surgery

When compared with other physical therapy treatments and self-managment, spinal stabilization exercises were found to produce significantly more positive ratings in global outcomes. Pain and disability, however, did not show significant improvement when compared to the other two treatment options.[10]

PT Managment Post-Spinal Fusion Surgery

  • TENS (Transcutaneous Electrical Neuromuscular Stimulation)
  • Aquatic Therapy
  • Overground Training (Walking Program)
  • Aerobic Exercise
  • Trunk Strengthening

Studies examining the use of TENS have shown higher frequencies are more effective in decreasing neuropathic pain. Aerobic exercise, PT, and trunk strengthening interventions have all attained significant decreases in pain, psychological distress and disability.[11]

Case Reports[edit | edit source]

Adegboye OA.Non-Hodgkin's lymphoma “masquerading” as Pott's disease in a 13-year old boy. Indian Journal of Medical and Paediatric Oncology. 2011 Apr-Jun; 32(2): 101–104.

A 13 year old boy presenting with back inflammation, lower extremity paralysis, bowel and bladder incontinence, progressive weight loss, numbness below T10 and low grade fever.  Radiographs taken indicative of Pott's disease.

Lotfinia I, Vahedi P.Late-onset post-diskectomy tuberculosis at the same operated lumbar level: case report and review of literature. European Spine Journal. 2010 July; 19(Suppl 2): 226–232.

A 43 y/o male presents with chronic low back pain for 4 months with intermittent pus drainage from his scar status post lumbar discectomy 8 years previously. Patient reported no history of TB but he had worked as a secretary at a hospital for years.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Radiopedia Tuberculous spondylitis Available: https://radiopaedia.org/articles/tuberculous-spondylitis-2?lang=us(accessed 14.5.2022)
  2. ↑ Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s disease in children. Surgical Neurology International. 2011; 2(1). 1-5.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Viswanathan VK, Subramanian S. Pott Disease.Available: https://www.statpearls.com/articlelibrary/viewarticle/27579/ (accessed 14.5.2022)
  4. ↑ Study.com Pott Disease Available: https://study.com/learn/lesson/potts-disease-symptoms-treatments.html(accessed 14.5.2022)
  5. ↑ Garg RK, Somvanshi DS. Spinal tuberculosis: a review. The journal of spinal cord medicine. 2011 Sep 1;34(5):440-54.
  6. ↑ 6.0 6.1 6.2 Hidalgo JA, Cunha BA. Medscape Reference [Internet]. WebMD. Updated 2011 Dec 5. Accessed 2012 Mar 28. Available from: http://emedicine.medscape.com/article/226141-overview#a0104.
  7. ↑ Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. The Spine Journal. 2003; 130-145.
  8. ↑ Fact Dr Potts Disease Available: https://factdr.com/health-conditions/potts-disease/(accessed 14.5.2022)
  9. ↑ Kumar R, Srivastava K, Tiwari RK. Surgical management of Pott’s disease of the spine in pediatric patients: A single surgeon’s experience of 8 years in a tertiary care center. Journal of Pediatric Neurosciences. 2011; 6: 101-108.
  10. ↑ Mannion AF, Denzler R, Dvorak J, Muntener M, Grob D. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J (2007) 16:1101–1117.
  11. ↑ Pons T, Shipton EA. Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy Theory and Practice. 2011; 27(3):238-245.
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