POTT SDISEASE:

ARadiologicalReviewof Tuberculous Spondylitis

StellaSafo GillianLieberman,MD April2009
HarvardMedicalSchool BethIsraelDeaconessMedicalCenter

Agenda
1.Explaintheevaluation,diagnosisand treatment of
spinaltuberculosis. 2.Reviewfeaturesofspinaltuberculosisonradiographs,CT andMRI. 3.FocusonthediagnosisofspinalTBusingradiographs,as thisistheprimarymodalityavailableinmanyresource limitedsettingswherespinalTBisendemic.

OurPatient:InitialPresentation
A40yearoldhealthyKenyanwoman,MsB.G,presentedtoherPCP witha1yrhistoryoflowbackpain(LBP) thatbeganafterafall.
Sharp,unremittingpainexacerbatedbymovement,withoutradiculopathy Physicalexamwasunremarkable MinimalreliefwithNSAIDSandphysicaltherapy

Shebecamepregnant threemonthslater.
LBPcontinuedandworsenedthroughoutpregnancy

Postpartum
Developedbilateralanteriorthighparesthesias exacerbatedbysitting Duetofailuretorespondtoconservativetherapy,shewassentfor radiologicalevaluation.

Further exploration of this topic requires a review of the anatomy of the spine and of a differential diagnosis of low back pain

CERVICAL

SpineAnatomy
Vertebral body Transverse process

THORACIC

LUMBAR

Pedicle

http://www.sofamordanek.com

http://www.columbiaspine.org

Intervertebral disc Spinous process

http://www.fla-ortho.com

DifferentialDiagnosisLowBackPain
MECHANICAL
Degenerativediskdisease,compressionfracture,musculoskeletal sprainorstrain

NEUROGENIC
Diskherniation,sciatica,spinalstenosis,infection,malignancy, connectivetissuedisorder(ie.ankylosing spondylitis) Others:

VISCEROGENIC UTI,pyelonephritis,retroperitonealtumororbleed VASCULAR Abdominalaorticaneurysm PSYCHOGENIC

With this differential in mind for patient BG, further imaging revealed infection of the spine.

IntroducingPottDisease
Knownbymanynames:spinaltuberculosis,tuberculous spondylitis,PottdiseaseorPottsdisease Firstdescribedin1782byPercivalPott,aBritish orthopedicsurgeon. DifferentialdiagnosisofPottdisease
Pyogenicorfungalosteomyelitis Eosinophilicgranuloma Multiplemyeloma Multiplecompressionfractures Note:BrucellosisofthespineandPottdiseaseareradiologically indistinct.

OurPatient:Imaging
Ms.BGsdiagnosiswasmadebasedonherimaging

Imaging
Plainfilmofthespinedemonstratedcompression fractureL12withanteriorkyphosis MRIspinerevealed T12 L3vertebralosteomyelitis L12compressionfractureswithforwardangulation Cauda equina impingement Leftpsoas abscess

OurPatient:Radiograph
Lateral radiograph Anterior collapse of L1, L2 vertebrae with loss of disk space. (*). Central lucencies within the L1 vertebrae (*).

PACS, BIDMC

OurPatient:CTTorso

PACS, BIDMC

Noncontrast axial CT Large left psoas abscess with hypoattenuated core region.

OurPatient:MRI Spine
1 2

PACS, BIDMC Sagittal T2W Destruction of L1-L2 disk space and collapse of adjacent vertebral bodies (*) with retropulsion into the spinal canal(*). In image, edema in T12 to L3 vertebral bodies (*), suggestive of spinal osteomyelitis.

OurPatient:ClinicalOutcome
Diagnosis:Pott diseasewasdiagnosedbasedon
Radiologic findings
1)psoas abscess2)continuousanteriorvertebralbodydestruction 3)cordcompression

Emigrationfromanareawithendemictuberculosis Indolentnatureofsymptoms

Treatment:
Patientwasplacedonbedrestandfittedforathoracolumbosacral orthosis (TLSO) Underwentdebridement andspinalstabilization Mycobacteriumtuberculosiswasisolatedfromsurgicalspecimensand sputum PlacedonalongcourseofRifampin,Isoniazid,Pyrazinamide,&Ethambutol

Pott Disease:Epidemiology
Pott diseaseisuncommonintheUnitedStates
U.S.versusKenya(homelandofcasepatient) 4/100,000/yr:384/100,000/yr Spinaltuberculosislooselyreportedas100200casesyearly

Skeletaltuberculosis
Accountsfor10%ofallcasesofextrapulmonary TB Targetsthehips,knees,spine Spinaltuberculosisismostcommon,accountsfor50%allskeletalTBcases

Clinicalpresentationvariesbygeographiclocation
HighTBprevalence Pott diseaseiscommonlyseeninchildren Targetsthoracicvertebrae UnitedStates Seeninimmigrantsfromendemiccountries,immunocompromised, men>women Targetslumbarvertebrae

Pott Disease:Pathophysiology
Tuberculosisinfiltratesthespinevia
Hematogenous spreadthroughthedensevasculatureofcancellous boneoftheanteriorvertebralbodies Lymphaticspreadfromparaaorticlymphnodespossiblebutrare

Upto75%ofinfectedindividualsdevelopasofttissue infection
Commonlyoccursinthepsoas muscle coldabscess
Knownascoldabscessbecauseformsslowlyanddoesnotnormally presentwith heat,inflammationorpain

Paraspinal fistulawhichmayformacommunicationwiththechest wallorpelvicfloor

Leftuntreated,degenerationandinflammationofthe vertebraecauses
Herniation intothecordspace cordcompressionandcauda equina Kyphosis gibbous(severekyphosis) Paraplegia

Pott Disease:Complications
1 Cord Compression Radiograph (1), sagittal CT reconsturction (2) and MRI (3) of a 70 year old man with Pott disease. Note continuous vertebral body destruction of thoracolumbar spine, causing severe kyphosis. Patient developed compression of the conus medullaris, resulting in inability to ambulate.

Oguz et al.- http://www.springerlink.com.ezpprod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf

Gibbous Lateral radiographs and T2W MRI Young male with gibbus deformtity (A) at thoracolumbar junction seen on radiograph (B) and T2W MRI (C).
Pappou et al.- http://ovidsp.tx.ovid.com.ezpprod1.hul.harvard.edu/spb/ovidweb.cgi?WebLinkFrameset

Pott Disease:Diagnosis
PhysicalDiagnosis:
Usuallypresentswith4monthto3yearhistoryoflowbackpain with orwithoutassociatedneurologicaldeficits. Signsofnearbycoldabscessorfistulamaybepresent Only20%presentwithconcomitantTBlunginfection RoutinelabtestsandtheMantoux skintestareoflittlediagnosticaid

KEY POINT: Must maintain high clinical suspicion in order to make the diagnosis of tuberculous spondylitis in a timely fashion.

Pott Disease:Pathology
Definitivediagnosis:
Madeviasputumorbiopsyshowingacidfastbacilli orpathognomonic caseating granulomas intissuesample
Acid fast bacilli

http://library.med.utah.edu/WebPath

http://www.med.nus.edu.sg/path

Caseating granuloma

Pott Disease:Imaging
Menuoftests
Maystartwithplainfilm tovisualizegrossdeformitiesi.e.kyphosis,fracture. CTisgoodforvisualizingdiscovertebrallesionsandparavertebral abscess, particularlyforabscesscalcification. MRI providesthebestvisualizationoftheextentofspinalcanalandsoft tissueinvolvement.Allowsforearlydetection.
Examples of types of imaging modalities > Lateral Radiographshows signs of early disk destruction (*) > Coronal T2W MRI- disk destruction and bone marrow edema (*) > Transaxial CT- large left paravertebral abscess (*)

RADIOGRAPH

MRI

CT

Oguz et al.- http://www.springerlink.com.ezpprod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf

Pott Disease: AdditionalImaging

Lesserusedimagingmodalities include:
Bonescintigraphy Ultrasound usefulinvisualizing paraspinal abscesses

Nigg et al.- http://www.springerlink.com.ezpprod1.hul.harvard.edu/content/74l418224t055432/full text.pdf

46 year old male with spinal TB on bone scintigraphy Increased radionuclide uptake in thoracic and lumbar spine (*) secondary to increased bony metabolism from infection.

Radiographs:GeneralFeatures
FeaturesofPotts onradiographinclude Signsofinfectionwithlytic lucencies inanteriorportionofvertebrae Diskspacenarrowing Erosionsoftheendplate Sclerosisresultingfromchronicinfection Compressionfracture Continuousvertebralbodycollapse Kyphosis;gibbous(severekyphosis) Atypicalfeatures Softtissueswellingfromparaspinal abscesses,+/ calcification Involvementofonlyonevertebralbody Involvementofseveralvertebralbodieswithout intervertebral discitis Bowingofribcagesecondarytocollapseofmultiplevertebralbodies Destructionoflateralorposterioraspectsofvertebralbodies

Radiographs:Erosions
Lucentareainlateralaspectofadjacentvertebralbodies erosions(*) Lossofintervertebral diskspace(*) Centrallucency (*)withsurroundingsclerosissuggestingchronicinfection(*)

Pertuiset et al.- http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?QS2

Radiographs:EndplateDestruction
1 2

Image 1 Lateral radiograph of spinal TB in a 23 yo man showing endplate erosion, loss of disk space(*), and anterior compression fracture of the lumbar spine. Image 2 Lateral radiograph of 56 yo man with Pott disease with additional features of sclerosis at vertebral endplates that have undergone severe compression and erosion(*).

Private Collection of Ferris Hall MD

Private Collection of Ferris Hall MD

Radiographs:Osteosclerosis
1 2

Image 1 Frontal radiograph 45 yo female. Note compression fracture with loss of intervertbral disk space (*).

Image 2 Lateral radiograph of 56 yo male. Similarly, note compression fracture and secondary osteosclerosis (*).

Private Collection of Ferris Hall MD

Private Collection of Ferris Hall MD

Radiographs: AtypicalFeatures
72 yo M with long history of long history of spinal TB.
Private Collection of Ferris Hall MD

72 yo M with long history of long history of spinal TB. Note collapse of multiple thoracic vertebrae (*) with resulting bowing in of ribs (*). Paraspinal abscess seen with circular calcified mass (*).

Collapse of mulitple thoracic vertebrae (*) resulting in severe kyphosis (*).

Private Collection of Ferris Hall MD

CT:Features
FeaturesonCT
Softtissuefindings AbscesswithcalcificationisdiagnosticofspinalTB;CTis excellentmodalitytovisualizesofttissuecalcifications Patternandseverityofbonydestruction
Patternofvertebralbodydestruction framentary,osteolytic, localizedandsclerotic,andsubperiosteal

Usedtoguideneedleinpercutaneous needlebiopsyof paraspinal abscess

CT:Calcification

PACS, BIDMC Noncontrast axial CT Large psoas abscess (*) with central calcification (*); these features are highly diagnostic of spinal TB.

CT:BonyDestruction

PACS, BIDMC Noncontrast axial CT Extensive vertebral body destruction causing bony fragments (*). Destruction of cancellous bone indicated by hypoattenuation of central vertebral body (*).

MRI:Features
HighlysensitiveandspecificforspinalTB Providesearlydetection Besttodistinguishexactextentofspinalcordandsoft tissueinvolvement Features
Edemaofvertebraeanddiskspace Signsofspinalcompromisei.e.cordcompression Note:Poorlyvisualizescalcificationinabscesses

MRI:SpinalCordInvolvement
1 2 3 4

PACS, BIDMC
Sagittal T2W (Images 1-3)and axial T1W (Image 4) High intensity activity in T12 to L3 vertebrae indicative of infection (*) (*). Complete destruction of vertebral bodies with osseous retropulsion into the spinal canal, causing cauda equina (*). On axial view, note destruction of vertebral body with loss of circular shape(*).

Pott Disease:Treatment
Variousimagingmodalitiesareusefulindeterminingextentofdisease. Treatmentoptionsthendependonthedegreeofspinaldestruction.

Mostpracticing clinicianssimply definePotts as EARLY orLATE disease.

GATA Classification
Oguz et al.- http://www.springerlink.com.ezpprod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf

ConservativeTreatment
EarlyDisease:
Treatwithafourdrugregimenforsixtotwelvemonths CommonantibioticsareRifampin,Isoniazid, Pyrazinamide,Ethambutol Mostindividualsexperiencefullresolutionofsymptoms withappropriateantituberculosistreatment

SurgicalInterventions
LateDisease: Looselydefinedbyneurologicdeficits,spinalkyphosis >40%,orfailure ofmedicaltherapy Surgicaldebridement,abscessdrainage,and/orvertebralfusionin Ms. BG post surgery additiontoantibiotics

Oguz et al.- http://www.springerlink.com.ezpprod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf

Young man with gibbous deformity (*) status post instrumentation surgery. Note stabilization of spine and resolution of gibbous (*). PACS, BIDMC

Lateral radiograph Our index patient, Ms. BG after spinal debridement and vertebral fusion.

Summary
Imagingmodalities areplainfilm,CTandMRI;MRIisgoldstandardfor imagingspinalTB. SpinaltuberculosisisnotcommoninU.S.,thereforemustmaintainhigh clinicalsuspicionsoasnottooverlookdiagnosis,especiallyamong immigrantpopulations. DiagnosisandtreatmentofspinalTBinendemicareasisdifficultgiven resourcelimitations;relyonradiographsandclinicalsignstofacilitate earlydiagnosis. ConservativeversussurgicaltreatmentofPott diseasedependson degreeofspinaldestruction, makingearlydiagnosisessentialfora positiveoutcome.

References
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Acknowledgements
Manythankstothefollowingcontributorsfor theirmuchappreciatedassistance.
GillianLieberman,MD FerrisHall,MD Gul Moonis,MD AlexanderCarbo,MD MariaLevantakis MichaelLarson