SPINAL TUBERCULOSIS (Pott Disease)

Pott’s Disease, also known as tuberculosis spondylitis, is a rare infectious disease of the spine which is typically caused by an extraspinal infection. Pott’s Disease is a combination of osteomyelitis and arthritis which involves multiple 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.

In the developing world, children primarily bear the bur­den of musculoskeletal tuberculosis. In the United States, however, musculoskeletal infection is more often seen in adult immigrants from countries where tuberculosis is prevalent, or it develops in the setting of immunosuppres­sion (eg, HIV infection, therapy with TNF inhibitors). Spinal tuberculosis (Pott disease) accounts for about 50% of musculoskeletal infection due to M tuberculosis. Seeding of the vertebrae may occur through hematogenous spread from the respiratory tract at the time of primary infection, with clinical disease developing years later as a consequence of reactivation, or through lymphat­ics from infected foci in the pleura or kidneys. The thoracic and lumbar vertebrae are the most common sites of spinal involvement; vertebral infection is associated with paraver­tebral cold abscesses in 75% of cases.

Symptoms and Signs

Patients complain of back pain, often present for months and sometimes associated with radicular pain and lower extremity weakness.

Constitutional symptoms are usually absent, and less than 20% have active pulmonary disease.

Destruction of the anterior aspect of the vertebral body can produce the characteristic gibbus deformity.

Diagnosis

Most patients have a positive reaction to purified protein derivative (PPD) or a positive interferon-gamma release assay. Cultures of paravertebral abscesses and biopsies of vertebral lesions are positive in up to 70–90%. Biopsies reveal characteristic caseating granulomas in most cases. Isolation of M tuberculosis from an extraspinal site is sufficient to establish the diagnosis in the proper clinical setting.

Radiographs can reveal lytic and sclerotic lesions and bony destruction of vertebrae but are normal early in the disease course. CT scanning can demonstrate paraspinal soft tissue extensions of the infection; MRI is the imaging technique of choice to detect compression of the spinal cord or cauda equina.

Differential diagnosis

Spinal tuberculosis must be differentiated from subacute and chronic spinal infections due to pyogenic organisms, Brucella, and fungi as well as from malignancy.

Paraplegia due to compression of the spinal cord or cauda equina is the most serious complication of spinal tuberculosis.

Treatment

Antimicrobial therapy should be administered for 6–9 months, usually in the form of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months followed by isoniazid and rifampin for an additional 4–7 months. Medical management alone is often sufficient. Surgical interven­tion, however, may be indicated when there is neurologic compromise or severe spinal instability.