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. Pott's disease, which is also known as Potts caries, David's disease, and Pott's curvature, is a medical condition 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, referred 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/MRI 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.

Pathophysiology

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Spread of mycobacterium tuberculosis from other site Extrapulmomary tuberculosis The infection spreads from two adjacent vertebrae into the adjoining disc space

back pain, fever, night sweats, anorexia, weight loss, and easy fatigability.
One vertebra is affected, the disc is normal Two are involved, the avascular intervertebral disc cannot receive nutrients and collapse Disk tissue dies and broken down by caseation

Vertebral narrowing

Vertebral collapse

Spinal damage

POTTS DISEASE Kyphosis, paraplegia, bowel and urinary incontinenece Surgery: evacuation of pus, Anterior decompression spinal fusion

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

Pott's disease is treated with multiple antibiotics. Because of the recent increase in antibiotic-resistant organisms, the recommended treatment includes the use of a four-drug regimen(RIPE). Treatment must be maintained for at least 6 to 9 months, and some doctors advise individuals to take medication for as long as 9 to 12 months. Immunodeficient individuals may require lifelong drug therapy to keep the infection from recurring. In the past, immobilizing the patient with a cast or a splint may have been recommended, but now external bracing only is the intervention of choice, allowing the individual to participate in rehabilitation and self care. Surgery (spinal fusion, rod placement) may ultimately be needed to relive spinal cord pressure, correct abnormal curvature of the spine, or resolve spinal instability secondary to loss of bone mass. Although brief bed rest may be indicated, rehabilitation to promote independent transfers and ambulation should be attempted as soon as tolerated.