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Pott's Disease:Tuberculous Spondylitis

Medicine Morning ReportMarch 30, 2009

Michael Craig

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Introduction

HistoryEpidemiologyPathophysiologyClincal Findings

Differential DiagnosisRadiologic and Diagnostic StudiesTreatment

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History

Classic description first in 1779 by Percival Pott, an Englishsurgeon. Other notable achievements:

First to link cancer to environmental carcinogens (scrotal

cancer in chimney sweeps)Pott's fracture - bimalleolar ankle fracturePott's puffy tumor - subperiosteal abcess andosteomyelitis of the frontal bone, serous complication of sinusitis

One of oldest diseases of which we have

evidence4000 BC Egyptian mummies noted withtypical featuresDNA from vertebral lesion in 12-year-oldfrom 1000 AD identified M. tuberculosis

 

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Epidemiology

20% of TB patients in the US have extrapulmonary TBPott's diseease occurs in 5% of those withextrapulmonary tuberculosis45% with spinal involvement have associated

neurological deficits1-2% of overall tuberculosis cases

 Much more common in the undeveloped world

 Endemic areas - tends to occur about 1 year after primaryinfection and more common in children & young adultsDeveloped nations - more often late reactivation diseaseand occurs more in adults

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Pathophysiology

Usually occurs via hematongenous spreadVertebral bodies vulnerable due to high blood flow

 Lumbar and lower thoracic involvement more common,although can involve cervical vertebrae

Usually begins in anterior vertebral body 

Neurological symptoms and cord compression fromabcesses, dural involvement or scarring tissue

 Kyphosis develops from collapse of anterior spine (mainlyamongst thoracic vertebrae)

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Clinical Findings

Usual presents as local pain

Can be indolent in onset with gradually worsening over weeks to monthsAs worsens usually severe muscle spasm and rigidity

 

Systemic symptoms (fever, weight loss, etc.) present <40%of patients 

60-90% with no evidence of extraspinal tuberculosis 

Many (~50% in endemic areas) present with neurologicsymptoms

 Kyphosis may be seen on presentation in advanced disease

 

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Gibbious Deformity

Anterior wedging leads to focal kyphosisthis is the angular gibbious deformity, or "humpbacked"appearance

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Differential Diagnosis

Infection

Staph aureus vertebral osteomyelitisBrucellosisActinomycesCandida

HistoplasmosisBlastomycosisOther mycobacterium

 Cancer 

Metastatic lesionsSpinal tumors

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Radiologic Studies - X-RayLikely normal in early

diseaseFirst changes in anterior part of vertebral body withdemineralization of endplate

Next the oppositevertebral endplate willbecome involvedWith progression, anterior 

wedging develops50% cases spare the diskspaceMay also show evidenceof abcess

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Radiologic Studies - MRI

Show the anterior endplate involvement and relative sparingof the disk and posterior vertebral body in more detailCan better demonstrate abcess formationBest method for demonstrating nerve root and spinal cordcompression

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Diagnostic Studies

PPD - 90% will have positive PPDMay be negative in some immunocompetent and manyimmunosuppressed patientNot helpful in endemic areas

 Biopsy and culture (with AFB smear) essential to confirmdiagnosis and rule-out other causes

If surgical stabilization done may be doneinteroperativelyOtherwise, CT-guided needle biopsy is most common

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Treatment

AntibioticsFour-drug therapy (isoniazid, rifampin, pyrazinamide &ethambutol)May be more complicated if concerns of multi-drugresistant TB or if associated with septicemia

At least six months of therapyUsually responds well (even in severe cases)

 Surgery

May play role in spinal stabilization or abcessdrainage/debridementMore role if advanced neurologic deficits, worseningdeficits on medical therapy or severe kyphosisUsually two-procedure process - first anterior 

decompression and reconstruction then posterior fusion

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Take-Home Points

Pott's disease can be a indolent cause of back pain withoutnecessarily any systemic symptoms of tuberculosis

 Progression can lead to major deformity or neurologic

consequences 

Tuberculosis should be considered in any case of vertebralosteomyelitis or diskitis

 Most patients do well with prolonged 4-drug anti-TB therapy

 

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References

http://www.surgical-tutor.org.uk/default-home.htm?surgeons/pott.htm~right McLain R and Isada C. Spinal tuberculosis deserves a place

on the radar screen. Cleveland Clinic Journal of Medicine2004; 71(7):537-549.http://www.ccjm.org/content/71/7/537.full.pdf  Wikipedia.org Emedicine.com Uptodate.com