TUBERCULOUS SPONDYLITIS

POTTS DISEASE / TUBERCULOSIS OF SPINE

Potts disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Potts disease is the most common site of bone infection in TB; hips and knees are also often affected. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected.

SYMPTOMS
The onset is gradual. Back pain is localised. Restricted spinal movements. Fever. Night sweats. Anorexia. Weight loss.

SIGNS
There may be kyphosis. (spinal curvature) Muscle wasting. A paravertebral swelling may be seen. They tend to assume a protective upright, stiff position. If there is neural involvement there will be neurological signs. A psoas abscess (may present as a lump in the groin and resemble a hernia).

PATHOPHYSIOLOGY
Usually occurs via hematongenous spread o Vertebral 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 from abcesses, dural involvement or scarring tissue Kyphosis develops from collapse of anterior spine (mainly among thoracic vertebrae)

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ANATOMY AND PHYSIOLOGY

The vertebral column provides structural support for the trunk and surrounds and protects the spinal cord. The vertebral column also provides attachment points for the muscles of the back and ribs. The vertebral disks serve as shock absorbers during activities such as walking, running, and jumping. They also allow the spine to flex and extend.

Anatomy of Spinal Involvements - Infection may originate anteriorly in the vertebral body near anterior cortex, in the center of the body, or adjacent to the end plate; - Unlike disc space infection in children, TB affects vertebral bodies and does not destroy the disk until very late in the disease; - originating from metaphysis of vertebral body and spreading under anterior longitudinal ligament, spinal TB can cause destruction of several continguous levels or can result in skip lesions (15%) or abscess formation (50%); - Peridiscal - 33% - disease begins within metaphyseal bone - spread occurs beneath the anterior longitudinal ligament to involve adjacent areas; - disc is spared; - Anterior 2.1% - disease begins and spreads beneath the anterior longitudinal ligament involving several levels; - x-rays show anterior vertebral body scalloping; - Central 11.6% - disease limited to the middle of a single vertebral body; - frequently leads to vetebral collapse w/ result kyphotic deformity

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Figure 1 The Vertebral Column

Figure 2 Normal Spine

Figure 3 Affected Spine

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DIAGNOSTIC STUDIES
SED RATE: sed rate of < 50 mm / hour may indicate uncomplicated TB osteomyelitis rather than pyogenic form;

SKIN TESTING: In the U.S. about 10-15% of the population will have positive test; w/ infection, skin tests are usually, but not always, positive; false negative tests will occur in malnourished patients and AIDS patients; skin testing in a patient w/ an active infection may result in skin slough;

HISTOLOGY: from CT guided needle biopsy, look for granulomatous pattern w/ caseating necrosis & giant cell formation; acid fast bacilli on staining may or may not be seen, and cultures are frequently negative; note, due to the high occurance of false negative results w/ aspiration, attempt to obtain a tissue sample to assist w/ the dx (may not always be possible);

RADIOGRAPHS: Contiguous vertebral involvment w/ diffuse osteopenia, erorsions, kyphosis, and ultimately bony or fibrous briding; it usually involves body of vertebra, sparing the posterior elements; typically appearance involves anterior destruction of two adjacent vertebrae and destruction of the intervening intervertebral disc (in some cases eroded vertebrae will be at different levels); Disc involvement will help shift the diagnosis away from malignancy and toward infection; Note that myeloma and lymphoma may cause disc erosion; Bone scan: unreliable for diagnosis of acitve TB (cold scans in upto 35-40%); CT scan: helps define the extent of soft tissue involvement inaddition to osseous destruction; soft tissue calcification will help distinguish spinal TB from other conditions;

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NON OPERATIVE TREATMENT:

if detected early (before collapse of more than 1-2 vertebral body) treatment consists of antibiotics and immobilization; even w/ mild kyphosis (but no neurologic deficit), antibiotics & bracing are used; o w/ adequate medical treatment, there may be significant resolution of neurologic symptoms, and there will be a halt in the progression of kyphosis; o in young children, there will often be some resolution in the kyphosis, especially if only one or two vertebrae are involved; antibiotics for all patients at the outset, reserving surgery for cold abscesses that are palpable posteriorly, as well as for those cases w/ neurological environment that have failed to improve in response to 2-3 months of antiTB therapy and immobilization; 2 months of pyrazinamide, isoniazid, and rifampin given qd, followed by 4 months of INH and rifampin;

OPERATIVE INDICATIONS TREATMENT:

Surgery is indicated for cold abscesses that are palpable posteriorly; with cord compression surgery is required if neurological status deteriorates in spite of chemotherapy and immobilization; o attempt to give non operative treatment 2-3 months before determining the response; With abscess and kyphosis operative intervention is required especially if kyphosis is progressive; o advantages include less progressive kyphosis, earlier healing, and decrease sinus formation; patients younger than 15 years w/ kyphosis greater than 30 deg are at high risk for progression of kyphosis are also good candidates for surgery; children aged less than 10 yrs with destruction of vertebral bodies who have partial or no fusion even during the adolescent growth spurt; surgery may include; o requires anterior abscess drainage; o anterior spinal arthrodesis w/ iliac strut grating; o anterior arthrodesis allows better correction of the kyphosis, whereas debridement alone may actually have worsening of the kyphosis; o posterior spinal arthrodesis (indications unclear) o adjuvant chemotherapy beginning 10 days before surgery is essential

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