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Introduction
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 and in ancient
mummies from Egypt and Peru.[1 ]In 1779, Percivall Pott, for whom Pott disease is named,
presented the classic description of spinal tuberculosis.[2 ]
Since the advent of antituberculous drugs and improved public health measures, spinal
tuberculosis has become rare in developed countries, although it is still a significant cause of
disease in developing countries. 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.
Pathophysiology
Pott disease is usually secondary to an extraspinal source of infection. The basic lesion involved
in Pott disease is a combination of osteomyelitis and arthritis that usually involves more than one
vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area
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,
because the disk is vascularized, it can be a primary site. [3 ]
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.
Frequency
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% 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. [4 ]
International
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).[5 ]
Mortality/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 show some variation.[6,7,8,9 ]Lower thoracic vertebrae is 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. [10 ]
Approximately 10% of Pott disease cases involve the cervical spine.
Race
Data from Los Angeles and New York show that musculoskeletal tuberculosis primarily
affects 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.
Sex
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).
Age
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.
Clinical
History
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.[12 ]
Physical
Differential Diagnoses
Actinomycosis
Blastomycosis
Brucellosis
Candidiasis
Cryptococcosis
Histoplasmosis
Metastatic Cancer, Unknown Primary Site
Miliary Tuberculosis
Multiple Myeloma
Mycobacterium Avium-Intracellulare
Mycobacterium Kansasii
Nocardiosis
Paracoccidioidomycosis
Septic Arthritis
Spinal Cord Abscess
Tuberculosis
Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of
patients with Pott disease who are not infected with HIV.
The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).
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. These study findings are positive in only about
50% of the cases.
Imaging Studies
Radiography
o Radiographic changes associated with Pott disease present relatively late. The
following are radiographic changes characteristic of spinal tuberculosis on plain
radiography:[13 ]
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
o 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 one level.
CT scanning[14 ]
o CT scanning provides much better bony detail of irregular lytic lesions, sclerosis,
disk collapse, and disruption of bone circumference.
o Low-contrast resolution provides a better assessment of soft tissue, particularly
in epidural and paraspinal areas.
o CT scanning reveals early lesions and is more effective for defining the shape
and calcification of soft-tissue abscesses.
o In contrast to pyogenic disease, calcification is common in tuberculous lesions.
MRI
o 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. MRI is also the most effective imaging study for
demonstrating neural compression.[15,16 ]
o MRI findings useful to differentiate tuberculous spondylitis from pyogenic
spondylitis include thin and smooth enhancement of the abscess wall and welldefined 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. [17 ]
Other Tests
Procedures
Use a percutaneous CT-guided needle biopsy of bone lesions to obtain tissue samples.
o This is a safe procedure that also allows therapeutic drainage of large paraspinal
abscesses.
o Obtain a tissue sample for microbiology and pathology studies to confirm
diagnosis and to isolate organisms for culture and susceptibility.
Some cases of Pott disease are diagnosed following an open drainage procedure (eg,
following presentation with acute neurologic deterioration).
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.
Consultations
Orthopedic surgeons
Neurosurgeons
Rehabilitation teams
Complications
Abscess
Spine deformities
Neurologic deficits and paraplegia
Miscellaneous
Medicolegal Pitfalls
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.
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:
o Positive PPD result
o Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
o Presence of risk factors for tuberculosis
Spinal tuberculosis should always be suspected when radiographs demonstrate a
destructive spine process.