Tuberculous Spondylitis

(TB spine/Pott’s disease)

 1. Introduction
• Tuberculous spondylitis has been documented in
ancient mummies from Egypt and Peru
• It is one of the oldest demonstrated diseases of
humankind.
• Percival Pott presented the classic description of
TB spine in 1779.
• Since the advent of antiTB drugs and improved
public health measures, TB spine has become
rare in industrialized countries.
• However it is still a common diseasis in
developing countries.
 Introduction (cont.)
• Since the advent of antiTB drugs and improved
public health measures, TB spine has become
rare in industrialized countries.
• However it is still a common diseasis in
developing countries.
• TB spine causes serious morbidity, including
permanent neurologic deficits and severe
deformity.
• Medical treatment or combined medical and
surgical strategies can control the disease in most
patients
 2. Epidemiology
• TB spine is common in developing countries>
developed countries
• Internationally approx. 1-2% of total TB cases
are attributable to Pott disease.
• As with other forms of TB, the frequency is
related to socioeconomic factors and historical
exposure to the infection.
 Epidemiology (cont.)
• Sex: Males are more often affected
(1.5-2:1).
• Age: In developed countries Pott dx primarily occurs in
adults. In countries with higher rates of infection, it
mainly occurs in children
• Mortality/Morbidity : Pott disease is the most
dangerous form of musculoskeletal TB.
• It can cause bone destruction, deformity, and
paraplegia
• It commonly involves the thoracic and lumbosacral
spine.
 Epidemiology (cont.)
• Mortality/Morbidity : Pott disease is the most
dangerous form of musculoskeletal TB.
• It can cause bone destruction, deformity, and
paraplegia
• It commonly involves the thoracic and
lumbosacral spine.
 4. Pathophysiology
• Pott disease is usually secondary to an extraspinal
source of infection.
• The basic lesion is a combination of osteomyelitis and
arthritis.
• Typically, more than one vertebra is involved.
• The area usually affected is the anterior aspect of the
vertebral body adjacent to the subchondral plate
• 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.
 Pathophysiology (cont.)
• In children, because the disk is vascularized, it can be a
primary site.
• 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 neurologic
deficits.
• Kyphotic deformity occurs as a consequence of
collapse in the anterior spine.
• Lesions in the thoracic spine have a greater tendency
for kyphosis than those in the lumbar spine.
 Pathophysiology (cont.)
• 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.
 5. Clinical presentation
• Presentation depends on the following:
– Stage of disease
– Site
– Presence of complications such as neurologic deficits,
abscesses, or sinus tracts.

 The reported average duration of symptoms at the

time of diagnosis is 3-4 months.
 Clinical presentation (cont.)
• The average duration of symptoms at the time
of diagnosis is 3-4 months
• Back pain is the earliest and most common
symptom.
– Patients have usually had back pain for weeks
prior to presentation.
– Pain can be spinal or radicular.
 Clinical presentation (cont.)
• Constitutional symptoms include fever and
weight loss.
• Neurologic abnormalities occur in 50% of
cases and can include spinal cord compression
with paraplegia, paresis, impaired sensation,
nerve root pain, or cauda equina syndrome.
 Clinical presentation (cont.)
• Physical examination should include the
following:
– Careful assessment of spinal alignment
– Inspection of skin, with attention to detection of
sinuses
– Abdominal evaluation for subcutaneous flank
mass
– Meticulous neurologic examination
 Clinical presentation (cont.)
• The thoracic spine is frequently reported as the most
common site of involvement followed by lumber spine
• The remaining cases correspond to the cervical spine.
• Spine deformity (kyphosis) of some degree occurs in
almost every patient.
• There may be large cold abscesses of paraspinal tissues
or psoas muscle that protrude under the inguinal
ligament.
• They may erode into the perineum or gluteal area.
 Clinical presentation (cont.)
• Disease involving the upper cervical spine can
cause rapidly progressive symptoms.
– Retropharyngeal abscesses occur in almost all
cases.
– Neurologic manifestations occur early and range
from a single nerve palsy to hemiparesis or
quadriplegia
 Clinical presentation (cont.)
• If there is no evidence of extraspinal
tuberculosis, diagnosis can be difficult.
• Information from imaging studies,
microbiology, and anatomic pathology should
help establish the diagnosis
 6.Workup
6:1 Lab studies
• Tuberculin skin test demonstrates a positive finding in
84-95% of patients who are non–HIV-positive.
• ESR (Eritrosit Sedimentation Rate) may be markedly
elevated (>100 mm/h).
 Microbiology studies to confirm diagnosis: Obtain bone
tissue or abscess samples to stain for acid-fast bacilli
(AFB), and isolate organisms for culture and
susceptibility.
 These study findings may be positive in only about
50% of the cases.
 Workup (cont.)
6:2 Imaging studies
• Plain radiography demonstrates the following
characteristic changes of spinal tuberculosis:
– 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
 Workup (cont.)
• Additional findings
– Vertebral end plates are osteoporotic.
– Intervertebral disks may be shrunk or destroyed.
– Fusiform paravertebral shadows suggest abscess
formation.
– Bone lesions may occur at more than one level.
– Intervertebral disks may be shrunk or destroyed.
– Vertebral bodies show variable degrees of
destruction
 Workup (cont.)
• 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 soft tissue
assessment, particularly in epidural and paraspinal
areas.
– It detects early lesions and is more effective for
defining the shape and calcification of soft tissue
abscesses.
– In contrast to pyogenic disease, calcification is
common in tuberculous lesions
 Workup (cont.)
• MRI
– 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
 Workup (cont.)
– MRI is most effective for demonstrating neural
compression.
– In developed countries, MRI has nearly replaced
CT myelography.
• Procedures:
– Some patients are diagnosed following an open
drainage procedure (eg, following presentation
with acute neurologic deterioration).
 Workup (cont.)
Histologic Findings:
• Since microbiologic studies may be nondiagnostic,
anatomic pathology can be very significant.
• Gross pathologic findings include exudative
granulation tissue with interspersed abscesses.
• Coalescence of abscesses results in areas of
caseating necrosis.
 7. Treatment
7:1 Medical treatment
• Medical therapy requires combination
regimens with at least 3 antituberculous
drugs.
• A 3-drug regimen usually includes INH,
rifampin, and pyrazinamide.
• The duration of treatment ranges from 9-12
months
 Treatment (cont.)
7:2 Surgical treatment
• Indications
– Neurologic deficit (acute neurologic deterioration,
paraparesis, paraplegia)
– Spinal deformity with instability
– No response to medical therapy
 Treatment (cont.)
• Resources and experience are key factors in
the decision to use a surgical approach
• The most appropriate method of
reconstruction depends on the level of
vertebral spine involved and the extent of
bony destruction.
 Treatment (cont.)
• The lesion site, extent of vertebral
destruction, and presence of cord
compression or spinal deformity determine
the specific operative approach.
 Treatment (cont.)
• Contraindications
– Vertebral collapse of a lesser magnitude is not
considered an indication for surgery because with
appropriate treatment and therapy compliance, it
is less likely to progress to severe deformity.
– Vertebral damage is considered significant if more
than 50% of the vertebral body is collapsed or
destroyed or if there is spinal deformity of more
than 5°.