Pott's disease or Pott disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the

intervertebral joints. It is named after Percivall Pott (17141788), a London surgeon who trained at St Bartholomew's Hospital, London. Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Potts curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Potts paraplegia, when the spinal nerves become affected by the curvature. Potts Disease, also known as tuberculosis spondylitis, is a rare infectious disease of the spine which is typical ly caused by an extraspinal infection. Potts Disease is a combination of osteomyelitis and arthritis which involves multiple [1] vertebrae. 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 [1][2][3] occurs anteriorly, anterior wedging results, leading to kyphotic deformity of the spine. Other possible effects can include compression fractures, spinal deformities and neurological insults, including paraplegia. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. Potts disease results from haematogenous spread of tuberculosis fro m other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining intervertebral disc space. If only one vertebra is affected, the disc is normal, but if two are involved, the disc, which is avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down by caseation, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare. Tuberculosis (TB) of the spine (Pott's disease) is both the most common and most dangerous form of TB infection. Delay in establishing diagnosis and management cause spinal cord compression and spinal deformity. This study investigated the data on all cases of Pott's disease reported in Turkey from 1985 to 1996. A total of 694 cases were included. Out of the patients evaluated, 19% were reported in the first half of the period (1985-1990) and 81% in the second half (1991-1996). Tuberculosis affecting the spine was commonly localized in the thoracic region and involved the vertebral body. The presenting symptoms were leg weakness (69%), gibbus (46%), pain (21%), and palpable mass (10%). Decompressive surgery plus anti-TB chemotherapy remains the best mode of therapy for Pott's disease. Follow-up information was available in 414 of the 694 patients and there were ten deaths (2%), one occurring intraoperatively and the other nine postoperatively. This meta-analysis demonstrates that in Turkey Pott's disease remains a serious problem, causing paraplegia. It should be considered when patients present with neurological findings suggesting spinal cord compression and spinal deformity. In the present study, it was concluded that the neurological involvement due to Pott's disease is relatively benign if urgent decompression is performed at the onset of the disease. Pott's disease is named after Percival Pott (1714-1788), who was a surgeon in London. Pott's disease is tuberculosis of the spinal column (must not be confused with Pott's fracture of the ankle). The usual sites to be involved are the lower thoracic and upper lumbar vertebrae. The source of infection is usually outside the spine. It is most often spread from the lungs via the blood. There is a combination of osteomyelitis and infective arthritis. Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral discs. In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it can be a primary site, as the disc is vascular in children. It is the commonest place for tuberculosis to affect the skeletal system although it can affect the hips and knees too. The infection spreads from two adjacent vertebrae into the adjoining disc space. If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as it is avascular and cannot receive nutrients. Caseation occurs, with vertebral narrowing and eventually vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare. Epidemiology

Pott's disease is rare in the UK but in developing countries it represents about 2% of cases of tuberculosis and 40 to 50% of musculoskeletal tuberculosis.

Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting richer ones. India, China, Indonesia, Pakistan and Bangladesh have the largest number of cases but there has been a marked increase in the number of cases in the former Soviet Union and in sub-Saharan Africa in parallel with the spread of HIV. About two thirds of affected patients in developed countries are immigrants, as shown from both London[1] and [ ] Paris 2 and spinal tuberculosis may be quite a common presentation. The disease affects males more than females in a ratio of between 1.5 and 2:1. In the USA it affects mostly adults but in the countries where it is commonest it affects mostly children. Presentation The onset is gradual. Back pain is localised. Fever, night sweats, anorexia and weight loss. Signs may include kyphosis (common) and/or a paravertebral swelling. Affected patients 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: A psoas abscess most often originates from a tuberculous abscess of the lumbar vertebra that tracks from the spine inside the sheath of the psoas muscle. Other causes include extension of renal sepsis and posterior perforation of the bowel. There is a tender swelling below the inguinal ligament and they are usually apyrexial. The condition may be confused with a femoral hernia or enlarged inguinal lymph nodes. Differential diagnosis Pyogenic osteitis of the spine. Spinal tumours. Investigations Elevated ESR. Strongly positive Mantoux skin test. Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space. MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans and nuclear bone scans can also be used but MRI is best to assess risk to the spinal cord. A needle biopsy of bone or synovial tissue is usual. If it shows tubercle bacilli this is diagnostic but usually culture is required. Culture should include mycology. Associated diseases Tuberculosis co-infection with HIV has become common. It is up to 11% in some areas of the UK and over 60% in countries such as Zambia, Zimbabwe and South Africa. In the developed world, the disease is more common in certain sections of society such as alcoholics, the undernourished, ethnic minority communities and the elderly. The disease is also more common in patients after gastrectomy for peptic ulcer. Distribution The commonest area affected is T10 to L1. The lower thoracic region is the most common area of involvement at 40 to 50%, with the lumbar spine in a close second place at 35 to 45%. The cervical spine accounts for about 10%. Management

Immobilisation of the spine is usually for 2 or 3 months.

Drug treatment: this is covered in the article on the Management of Tuberculosis. Therapy may need to exceed 6 months. Surgical Surgery plays an important part in the management. It confirms the diagnosis, relieves compression if it occurs, permits [ ] evacuation of pus, and reduces the degree of deformation and the duration of treatment. 3 However, a Cochrane review found that routine surgery in addition to chemotherapy had not been shown to improve [ ] outcome but the problem was that the evidence was poor. 4 A study from India suggested that surgery is not mandatory.[5] Complications Progressive bone destruction leads to vertebral collapse and kyphosis: The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurological signs (Pott's paralysis). Kyphosis occurs because of collapse in the anterior spine and can be severe. Lesions in the thoracic spine have a greater risk of kyphosis than those in the lumbar spine. Neurological problems can be prevented by early diagnosis and prompt treatment. It can reverse paralysis and minimise disability. A combination of conservative management and surgical decompression gives success in most patients. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis should have surgery in the active [ ] stage of disease. 6 The degree of kyphosis, the area of affected vertebrae and the lack of sphincter control all correlate with the [ ] chance of recovery from paraplegia. 7 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 and form sinuses. Prognosis The progress is slow and lasts for months or even years. Prognosis is better if caught early and modern regimes of chemotherapy are more effective. [ ] A study from London showed that diagnosis can be difficult and is often late. 1 Prevention

As for all tuberculosis, BCG vaccination. Improvement of socio-economic conditions. Prevention of HIV and AIDS.

Pott's disease, which is also known as Potts caries, David's disease, and Pott's curvature, is a medical c ondition of the spine. Individuals suffering from Pott's disease typically experience back pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, which results in tingling, numbness, or a general feeling of weakness in the leg muscles. Often, the pain associated with Pott's disease causes the sufferer to walk in an upright and stiff position. Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Potts curvature. In some cases, a person with Pott's disease may also develop paralysis, referr ed to as Potts paraplegia, when the spinal nerves become affected by the curvature. ETIOLOGY of Tuberculosis of Spine

 Causative organism: Mycobacterium tuberculosis. Spread: Haematogenous. (by blood) Commonly associated with: Debilitating diseases, AIDS, Drug addiction, Alcoholism.

Symptoms of Tuberculosis of Spine 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). Differential diagnosis Pyogenic osteitis of the spine. Spinal tumours. INVESTIGATION for Tuberculosis of Spine Blood TLC: Leucocytosis. ESR: raised during acute stage. Tuberculin skin test Strongly positive. Negative test does not exclude diagnosis. Aspirate from joint space & abscess Transparency: turbid. Colour: creamy. Consistency: cheesy. Fibrin clot: large.

 Mucin clot: poor. WBC: 25000/cc.mm. Histology Shows granulomatous tubercle. X-Ray spine Early: Narrowed joint space. Diffuse vertebral osteoporosis adjacent to joint. Erosion of bone. Fusiform paraspinal shadow of abscess in soft tissue. Late: Destruction of bone. Wedge-shaped deformity (collapse of vertebrae anteriorly). Bony ankylosis. Complications Vertebral collapse resulting in kyphosis. Spinal cord compression. Sinus formation. Paraplegia (so called Pott's paraplegia). GENERAL MANAGEMENT for Pott's Disease Bed rest. Immobilisation of affected joint by splintage. Nutritious, high protein diet. Drainage of abscess. Surgical decompression. Physiotherapy. Diagnosis

blood tests

- CBC : leukocytisis elevated erythrocyte sedimentation rate >100 mm/h

tuberculin skin test

- Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of patients with Pott disease who are not infected with HIV.

radiographs of the spine

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

1. 2. 3. 4. 5.

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:

1. 2. 3. 4. 5.

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.

bone scan CT of the spine bone biopsy MRI

[edit]Late complications

Vertebral collapse resulting in kyphosis Spinal cord compression sinus formation paraplegia (so called Pott's paraplegia)

[edit]Prevention Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis. Patients who have a positive PPD test (but not active tuberculosis) may decrease their risk by properly taking medicines to prevent tuberculosis. To effectively treat tuberculosis, it is crucial that patients take their medications exactly as prescribed. [edit]Therapy

non-operative antituberculous drugs Chiropractic treatments analgesics immobilization of the spine region by rod (Hull) Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine

Richards intramedullary hip screw facilitating for bone healing Kuntcher Nail intramedullary rod Austin Moore intrameduallary rod (for Hemiarthroplasty) Thoracic spinal fusion as a last resort

Characteristics/Clinical Presentation Spinal Involvement

Lower thoracic vertebrae is the most common area of involvement (40-50%), followed by the Lumbar spine (35-45%) Approximately 10% of Pott's disease cases involve the cervical spine.
[1]

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
[2]

Physical Findings

Back Pain

Localized Tenderness Muscle Spasms Restricted Spinal Motion Spinal Deformity Neurological Deficits

Back pain is the earliest and most common symptom. Patients with Potts 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 [1] involvement. Together, thoracic and lumbar involvement comprise of 80-90% of spinal TB sites. Neurological Signs Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with the following:

Paraplegia Paresis Impaired sensation Nerve root pain Cauda equina syndrome
[1]

Spinal Deformities Almost all patients with Potts disease have some degree of spine deformity with thoracic kyphosis being the most common. Constitutional Symptoms
[1]

Fever Night sweats

Weight loss Malaise

[6][7][3][8]

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, ranging 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 [1] dysphagia or stridor. Presentation in People Infected with HIV The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to [1] that of patients who are HIV negative; however, spinal TB seems to be more common in persons infected with HIV. Asymptomatic Presentation 62-90% of patients with Pott's disease are reported to have no evidence of extraspinal tuberculosis, further complicating a [1] timely diagnosis. Associated Co-morbidities

Immunosuppressive Disorders HIV/AIDS 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 [1] active symptoms and the clinical stability of the patient.

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. [1] The use of second-line drugs is indicated in cases of drug resistance.

Isoniazid (Laniazid, Nydrazid) View full drug information: http://reference.medscape.com/drug/isoniazid-342564 Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates well into all body fluids and cavities.

Rifampin (Rifadin, Rimactane)

View full drug information: http://reference.medscape.com/drug/rifadin-rimactane-rifampin-342570 For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur.

Pyrazinamide View full drug information: http://reference.medscape.com/drug/pyrazinamide-342678 Bactericidal against M tuberculosis in an acid environment (macrophages). Has good absorption from the GI tract and penetrates well into most tissues, including CSF.

Ethambutol (Myambutol) View full drug information: http://reference.medscape.com/drug/myambutol-ethambutol-342677 Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations remain low, even in the presence of meningeal inflammation.

Streptomycin View full drug information: http://reference.medscape.com/drug/streptomycin-342682 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) Diagnostic Tests/Lab Tests/Lab Values The Mantoux Test (Tuberculin Skin Test) Injection of a purified protein derivative (PPD). Results are positive in 84-95% of patients with Potts disease who are not [1][8] infected with HIV. Erythrocyte Sedimentation Rate (ESR) ESR may be markedly elevated (>100 mm/h) Microbiology Studies 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 [1] sampling of affected bone or soft tissue structures; however, these study findings are positive in only about 50% of the cases. Radiography Radiographic changes associated with Potts 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
[1]

CT Scanning 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 [1] which is common in TB lesions. MRI 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 [1] differentiation of these two types of spondylitis. Biopsy Use of a percutaneous CT-guided needle biopsy of bone lesions can be used to obtain tissue samples. This is a safe procedure [1] that also allows therapeutic drainage of large paraspinal abscesses. 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 [10] DNA sequences associated with drug resistance. 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 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
[8]

The organism that has been identified as causing Potts 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 [7][11] from the lungs in adults but the primary site of infection is often unknown in children. The infection has also been found to [12] spread through the lymphatic system. Once being spread, the infection can target vertebrae, intervertebral discs, the [6] epidural or intradural space within the spinal canal and adjacent soft tissue. 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 [3] surface of the vertebrae. If a single vertebra is affected, the surrounding intervertebral discs will remain normal. However, if two adjacent vertebrae are [7] affected, the intervertebral disc between them will also collapse and become avascular. Due to the vascularity of [1] intervertebral discs in children, the discs can become a primary site of infection rather than spreading from the vertebrae. Spinal cord compression in Potts disease is usually caused by paravertebral abscesses which can also develop calcifications or [2] sequestra within them. If the infection reaches adjacent ligaments and soft tissues, a cold abscess can also form. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the [1] skin. Other causes of neurological involvement include dural invasion from granulation tissue, sequestrated bone, [2][1][7] intervertebral disc collapse or a dislocated vertebra. Neurological symptoms can occur at any point, including years later [2] as a result of stretching of the spinal cord within the vertebral foramen of the deformed spine. Systemic Involvement The severity of Potts disease varies from one person to another, resulting in different clinical presentations. Possible signs and [1][8] symptoms that may present are depicted in Table 1 by system. 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 Possible Sequelae Functional Return to Activities of Daily Living
[3][8]

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 Short Duration of Neural Complications Early Onset Cord Involvement with Delayed Neural Complications

Young Age Good General Condition

[6]

Effective chemotherapy for Potts disease is the gold standard and must be started at the early stages of the disease. Radical ventral debridement, fusion and reconstruction of the vertebral column remains the gold standard of surgical treatment for [8] tuberculosis spondylitis. Multiple surgical approaches have been conducted to correct the spinal deformity seen in Pott's disease with varying results. Laminectomy failed to address the anterior component of the disease process and spinal instability. Posterior fusion has been successful at reducing kyphosis but preoperative infection and high levels of kyphosis have resulted in many fusion failures. An [6] anterior approach, used by Hodgson and Stock, has also been used with great success. Various surgical techniques are utilized based on which area of the spine is affected. In the upper cervical spine, a transoral or extreme lateral approach is taken which typically requires concurrent occipito-cervical fusion to prevent collapse, instability and delayed deformity. Midcervical lesions are often treated with standard anterior cervical approaches and achieve excellent results. Transsternal, transmanubrial, or lateral extracavitary approaches are conducted in patients with involvement of the lower cervical/upper thoracic spine. In the thoracic spine surgeons make use of transthoracic, extraplural anterolateral or extended posterolateral approaches. The posterolateral method is more often utilized in severe cases of kyphosis due to the nature of the spinal deformity and ease of access to the spine. However, surgical correction of a severe kyphotic deformity (>30 degrees) will often require a posterior technique that is complex and technically demanding. Surgical morbidity and mortality can be significant for these technically demanding procedures with an 8-10% incidence post correction neurological complications. Surgical procedures in the lumbar spine are typically performed through a lateral retroperitoneal approach [8] which is the preferred method compared to an anterior or retroperitoneal procedure. Surgery done during the active course of the disease is much safer with a faster and better response. 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 [6] good outcome. Physical Therapy Management (current best evidence) 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

[6]

Spinal Stabilization Exercises Maitland Back School 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. Pain and disability, however, did not show significant [13] improvement when compared to the other two treatment options. 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 [14] disability. Alternative/Holistic Management (current best evidence) Currently there are no alternative managements of Pott's disease from evidence based sources. 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
[1]