POTT’S DISEASE

Pott’s Disease - also known as tuberculosis spondylitis, is one of the oldest demonstrated diseases of
humankind. It is a rare infectious disease of the spine which is typically caused by an extraspinal
infection.

An old term for tuberculosis of the spine that caused softening and collapse of the vertebrae, often
resulting in kyphosis, a "hunchback" deformity, which was called "Pott's curvature."

CAUSES

Tuberculosis begins in the lungs when you inhale air that contains Mycobacterium tuberculosis
(Mtb), or the bacteria that causes TB. This can develop into Pott's Disease if the infection spreads
from the lungs to the spine.

Mtb infects the joints of the spine, causing a form of spinal arthritis. If two contiguous joints become
infected, the disc of cartilage between them cannot receive the nutrients it needs to live. The disc
dies and collapses, leading to a narrowing of the vertebrae, eventual vertebral collapse and spinal
cord damage. If untreated, spinal TB can lead to severe deformities, nerve damage and even
paralysis.

Pott’s Disease Classification

1. Early onset TB Spine: Â presents with pressure caused by an containing caseous material
and bony sequestrum

2. Late onset TB Spine: in this, there is increasing deformity of the spine with reactivation of
old TB and it causes vascular insufficiency of the spinal cord

Pott’s Disease Risk factors

1. Pulmonary Tuberculosis

2. Untreated Tuberculosis

3. Abdominal Tuberculosis

4. Overcrowding

5. Immune suppression such as in HIV/Aids

6. Consumption of unpasteurized milk

SIGNS AND SYMPTOMS

1. Weight loss and signs of malnutrition such as it occurs

in Kwashiorkor and Marasmus especially in children

2. Drenching Night sweats

3. Paraesthesia

4. Fever especially in the evening

 5. Severe back pain

6. Night cries for children and increased back pain in adults that wakes them up at night due to
relaxation of muscles at night with loss of protection of the inflamed spine following muscle
relaxation.

7. Difficulty standing

8. Numbness or weakness in the legs.

9. Stiffness of the back with localized tenderness is an early sign or symptom.

10. Coin test: in this test, the patient always bends his hips and knees to pick objects from
the floor instead of bending the back because of deformity and pain

*Pott's Disease can lead to severe curvature of the spine and paralysis of the legs.

PATHOPHYSIOLOGY

Pott disease is usually secondary to an extraspinal source of infection. Pott disease manifests
as a combination of osteomyelitis and arthritis that usually involves more than 1 vertebra. The
anterior aspect of the vertebral body adjacent to the subchondral plate is usually affected.
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. In children, the disk, because it is
vascularized, can be the primary site. [6]

Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be
narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord
compression and neurologic deficits.

The kyphotic deformity is caused by collapse in the anterior spine. Lesions in the thoracic spine are
more likely to lead to kyphosis than those in the lumbar spine. 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.

TREATMENT

PHARMACOLOGIC THERAPY

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

Isoniazid (Laniazid, Nydrazid)

Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates well into
all body fluids and cavities.
Rifampin (Rifadin, Rimactane)
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
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)
Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations
remain low, even in the presence of meningeal inflammation.
Streptomycin
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.

Medical Management (current best evidence)

Treatment Techniques

 Anti-Tuberculosis Chemotherapy

 Surgical Drainage of Abscess

 Surgical Spinal Cord Decompression

 Surgical Spinal Fusion

 Spinal Immobilization

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 Pott’s
disease who are not infected with HIV.[1][8]

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 sampling of affected bone or soft tissue structures;
however, these study findings are positive in only about 50% of the cases

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 which is common in TB
lesions.[1]

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 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 that also allows therapeutic drainage of large paraspinal
abscesses.[1]

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 DNA sequences associated with drug resistance.

Pott’s disease Complications

1. Spinal cord damage

2. Chronic back pain

3. Secondary amyloidosis

4. Concomitant involvement of the lung and rarely genito - urinary involvement.

5. Paralysis

6. Deformity (hunchback aka Kyphosis)

Causes of spinal cord damage in TB Spine

1. Spinal cord damage may occur following compression due to the following: Sequestra
formation, Fluid pus accumulation, Prolapsed disc or Granulation tissue formation

2. Spinal cord injury may also occur due to non-compressive causes such as Pachymeningitis or
Thrombosis of spinal arteries

Pott’s disease Prevention

1. Prompt treatment of pulmonary tuberculosis or any form of tuberculosis

 2. Ensure proper and complete treatment of any form of tuberculosis such as completing the
required treatment course

3. Avoid overcrowding

4. Ensure proper ventilation of rooms and workplace

5. Avoid contact with chronically coughing individuals

TB Spine or Tuberculosis of the spine (or Pott’s disease) is a devastating infection to the human spine
which when not treated has a natural history that leads to paralysis, genitourinary sphincter
incontinence and their sequelae and the treatment is best conservative with similar outcome to
operative treatment.

Nursing Diagnosis

1. Impaired physical mobility

2. Acute pain: joints and muscles.

3. Disturbed body image

4. Knowledge deficit: about home care.