Pott Disease (Tuberculous [TB] Spondylitis)

Updated: Aug 28, 2018

 Author: Jose A Hidalgo, MD; Chief Editor: John L Brusch, MD, FACP

Background
Pott disease, also known as tuberculous spondylitis, is one of the oldest demonstrated
diseases of humankind, having been documented in spinal remains from the Iron Age in
Europe and in ancient mummies from Egypt and the Pacific coast of South
America. [1, 2] In 1779, Percivall Pott, for whom the disease is named, presented the
classic description of spinal tuberculosis.

Since the advent of antituberculous drugs and improved public health measures, spinal
tuberculosis has become rare in industrialized countries, although it is still a significant
cause of disease in developing nations. Tuberculous involvement of the spine has the
potential to cause serious morbidity, including permanent neurologic deficits and severe
deformities. Medical treatment or combined medical and surgical strategies can control
the disease in most patients

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.
Epidemiology

Occurrence in the United States

Between 2002 and 2011, a total of 75,858 cases of tuberculosis (TB) were reported in
the United States. Of these, 2,789 cases (3.7%) involved the spine. The median age
among affected individuals was 51 years; 61% of cases involved males, and 11% had
diabetes mellitus. Twenty percent required surgery, most commonly of the thoracic-
lumbar segments. [7]
Although the incidence of tuberculosis increased in the late 1980s to early 1990s, the
total number of cases has decreased in recent years. The frequency of extrapulmonary
tuberculosis has remained stable. However, the increased use of biologics to treat
various rheumatic diseases has the potential to adversely affect this trend. [8]
Bone and soft-tissue tuberculosis accounts for approximately 10-15% of extrapulmonary
tuberculosis cases and between 1% and 2% of total cases. Tuberculous spondylitis is
the most common manifestation of musculoskeletal tuberculosis, accounting for
approximately 40-50% of cases. These figures are roughly similar for North American
and international series. [9, 10]
International occurrence

Approximately 1-2% of total tuberculosis cases are attributable to Pott disease. In the
Netherlands, between 1993 and 2001, tuberculosis of the bone and joints accounted for
3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin, and 2.3-6.3% in
patients of non-European origin). [11]
Race-, sex-, and age-related demographics

Data from Los Angeles and New York show that musculoskeletal tuberculosis affects
primarily African Americans, Hispanic Americans, Asian Americans, and foreign-born
individuals.
As with other forms of tuberculosis, the frequency of Pott Disease is related to
socioeconomic factors and historical exposure to the infection.
Although some series have found that Pott disease does not have a sexual predilection,
the disease is more common in males (male-to-female ratio of 1.5-2:1).
In the United States and other developed countries, Pott disease occurs primarily in
adults. In countries with higher rates of Pott disease, involvement in young adults and
older children predominates. [12, 13]
Prognosis
Current treatment modalities are highly effective against Pott disease if the disorder is
not complicated by severe deformity or established neurologic deficit.
Deformity and motor deficit are the most serious consequences of Pott disease and
continue to be a serious problem when diagnosis is delayed or presentation of the
patient is in advanced stages of the disease. [14]
Therapy compliance and drug resistance are additional factors that significantly affect
individual outcomes.
Paraplegia resulting from cord compression caused by the active disease usually
responds well to chemotherapy. However, paraplegia can manifest or persist during
healing because of permanent spinal cord damage.
Operative decompression can greatly increase the recovery rate, offering a means of
treatment when medical therapy does not bring rapid improvement.
Careful long-term follow up is also recommended, since late-onset complications can
still occur (disease reactivation, late instability or deformity). [15]
Morbidity

Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can
cause bone destruction, deformity, and paraplegia.
Pott disease most commonly involves the thoracic and lumbosacral spine. However,
published series have shown some variation. [16, 17, 18, 19] The lower thoracic vertebrae
make up the most common area of involvement (40-50%), followed closely by the
lumbar spine (35-45%). In other series, proportions are similar but favor lumbar spine
involvement. [20] Approximately 10% of Pott disease cases involve the cervical spine.
Patient Education
Patients with Pott disease should be instructed on the importance of therapy
compliance. For patient education information, see the Infections Center, as well
as Tuberculosis.

History
The presentation of Pott disease depends on the following [21] :
 Stage of disease
 Affected site
 Presence of complications such as neurologic deficits, abscesses, or sinus tracts

Potential constitutional symptoms of Pott disease include fever and weight loss. The
reported average duration of symptoms at diagnosis is 4 months [17] but can be
considerably longer. [19, 22] This is due to the nonspecific presentation of chronic back
pain.
Back pain is the earliest and most common symptom of Pott disease, with patients
usually experiencing this problem for weeks before seeking treatment. The pain caused
by Pott disease can be spinal or radicular.
Neurologic abnormalities occur in 50% of cases and can include spinal cord
compression with paraplegia, paresis, impaired sensation, nerve root pain,
and/or cauda equina syndrome.
Cervical spine tuberculosis is a less common presentation but is potentially more
serious because severe neurologic complications are more likely. This condition is
characterized by pain and stiffness. Patients with lower cervical spine disease can
present with dysphagia or stridor. Symptoms can also include torticollis, hoarseness,
and neurologic deficits.
The clinical presentation of spinal tuberculosis in patients infected with the human
immunodeficiency virus (HIV) is similar to that of patients who are HIV negative;
however, spinal tuberculosis seems to be more common in persons infected with
HIV. [23]

Physical Examination
The physical examination in Pott disease 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
Although the thoracic and lumbar spinal segments are nearly equally affected in
persons with Pott disease, the thoracic spine is frequently reported as the most
common site of involvement. Together, these segments make up 80-90% of spinal
tuberculosis sites, with the remaining cases of Pott disease occurring in the cervical
spine. [18, 19, 21] Almost all patients with Pott disease have some degree of spine
deformity (kyphosis).
Examination should reveal local pain related to the affected area or radicular pain.
Muscle spasm and rigidity can also be associated.
Large, cold abscesses of paraspinal tissues or psoas muscle may protrude under the
inguinal ligament and may erode into the perineum or gluteal area.
Neurologic deficits may occur early in the course of Pott disease. Signs of such deficits
depend on the level of spinal cord or nerve root compression.
Pott disease that involves the upper cervical spine can cause rapidly progressive
symptoms. Retropharyngeal abscesses occur in almost all cases affecting this part of
the spine. Neurologic manifestations occur early and range from a single nerve palsy to
hemiparesis or quadriplegia. A large proportion of patients with Pott disease do not
present with extraskeletal disease. In reported series, only 10-38% of cases of Pott
disease are associated with extraskeletal tuberculosis.
Diagnostic Considerations
Many persons with Pott disease (62-90% of patients in reported series [16, 17] ) have no
evidence of extraspinal tuberculosis. Information from imaging studies, microbiology,
and anatomic pathology should help to establish the diagnosis. Etiological diagnosis
with microbiologic recovery of organisms is difficult in limited-resources settings and
requires invasive procedures.
The diagnosis of tuberculous spondylitis should be investigated if strong clinical
suspicion exists, even if suggestive pulmonary radiology findings are absent.
Other features suggestive of tuberculosis include the following:
 Positive tuberculin skin test (purified protein derivative [PPD]) result
 Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
 Presence of risk factors for tuberculosis
Spinal tuberculosis should always be suspected when radiographs demonstrate a
destructive spinal process.
Other granulomatous processes, particularly brucellosis
Conditions to consider in the differential diagnosis of Pott disease include the following:
 Spinal tumors
 Mycobacterium kansasii
  Nocardiosis
 Paracoccidioidomycosis
 Septic arthritis
 Spinal cord abscess
 [24]

Approach Considerations
Lab studies used in the diagnosis of Pott disease include the following:
 Tuberculin skin test (PPD) - Results are positive in 84-95% of patients with Pott
disease who are not infected with HIV
 Erythrocyte sedimentation rate (ESR) - May be markedly elevated (>100 mm/h)
 Microbiologic studies - Used to confirm the diagnosis

With regard to the above-mentioned microbiologic studies, bone tissue or abscess

samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for
culture and susceptibility. Procedures guided by computed tomography (CT) scanning
can be used to guide percutaneous sampling of affected bone or soft-tissue structures.
These study findings are positive in only about 50% of the cases. A 2015 multicentric,
multinational study involving 35 centers and 314 cases reported that the causative
agent was identified in 41% of cases. [25]
It is expected that nonculture methods (DNA amplification) using skeletal tissue
samples will become additional routine diagnostic methodologies. Their main
advantages include high specificity, high sensitivity, and rapid results.

Biopsy
Percutaneous, CT scan ̶ guided needle biopsy of bone lesions is a safe procedure that
also allows therapeutic drainage of large paraspinal abscesses. Obtain a tissue sample
for microbiologic and pathologic studies to confirm diagnosis and to isolate organisms
for culture and susceptibility. Positive culture yield of percutaneous is 50-83% and
appears to be influenced by technical details, such as decontamination of specimens
prior to culture. [30]
Histologic findings
Because microbiologic studies may be nondiagnostic of Pott disease, anatomic
pathology can be significant. Gross pathologic findings include exudative granulation
tissue with interspersed abscesses. Coalescence of abscesses results in areas of
caseating necrosis.
Drainage
Some cases of Pott disease are diagnosed following an open drainage procedure (eg,
following presentation with acute neurologic deterioration).
Scintigraphy
Radionuclide scanning findings are not specific for Pott disease. Gallium and
technetium bone scans yield high false-negative rates (70% and up to 35%,
respectively). [31]
Radiography
Radiographic changes associated with Pott disease present relatively late. The
following are radiographic changes characteristic of spinal tuberculosis on plain
radiography: [32]
 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
Additional radiographic findings may include the following:
 Vertebral end plates are osteoporotic.
 Intervertebral disks may be shrunk or destroyed.
 Vertebral bodies show variable degrees of destruction.
 Fusiform paravertebral shadows suggest abscess formation.
 Bone lesions may occur at more than 1 level.

CT Scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk
collapse, and disruption of bone circumference. [33]
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. In contrast to pyogenic disease, calcification is
common in tuberculous lesions.

MRI
Magnetic resonance imaging (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. [34] MRI is also the most effective imaging
study for demonstrating neural compression. [35,36]
Contrast-enhanced MRI findings are useful in differentiating tuberculous spondylitis
from pyogenic spondylitis. MRI findings in Pott disease include thin and smooth
enhancement of the abscess wall and a well-defined paraspinal abnormal signal. Thick
and irregular enhancement of the abscess wall and an ill-defined paraspinal abnormal
signal suggest pyogenic spondylitis. [37] The images below are studies of a man aged 31
years with spinal tuberculosis.
Involvement of the disk is typically a characteristic of infectious spondylitis; however,
this may not always be the case, and Pott disease can present with atypical features
resembling neoplastic lesions. Findings of an intradural extramedullary mass at the
lower end of the spinal cord associated with holocord T2 hyperintensities of the choroid
has been described in intramedullary tubercular abscesses ”precipitation
sign." [38, 39, 40, 41]

Approach Considerations
Before the advent of effective antituberculosis chemotherapy, Pott disease was treated
with immobilization using prolonged bed rest or a body cast. At the time, the disease
carried a mortality rate of 20%, and relapse was common (30%).
The duration of treatment, surgical indications, and inpatient care for Pott disease have
since evolved. Opinions differ regarding whether the treatment of choice should be
conservative chemotherapy or a combination of chemotherapy and surgery. The
treatment decision should be individualized for each patient, although routine surgery
does not seem to be indicated.

Devices
Despite questionable efficacy, prolonged recumbence and the use of frames, plaster
beds, plaster jackets, and braces are still used.
Cast or brace immobilization was a traditional form of treatment but has generally been
discarded. Patients with Pott disease should be treated with external bracing.
Inpatient care
Once the diagnosis of Pott disease is established and treatment is started, the duration
of hospitalization depends on the need for surgery and the clinical stability of the
patient.
Follow-up
Patients with Pott disease should be closely monitored to assess their response to
therapy and compliance with medication. Directly observed therapy may be required.
The development or progression of neurologic deficits, spinal deformity, or intractable
pain should be considered evidence of poor therapeutic response. This raises the
possibility of antimicrobial drug resistance, as well as the necessity for surgery.
Because of the risk of deformity exacerbations, children with Pott disease should
undergo long-term follow-up until their entire growth potential is completed. [43]Older
patients can also present with late-onset complications such as reactivation, instability,
or deformity. Observation is warranted in all groups of patients.
Consultations
Consultations in Pott disease can include the following:
 Orthopedic surgeons
 Neurosurgeons
 Rehabilitation teams
Pharmacologic Therapy
According to recommendations issued in 2003 by the US Centers for Disease Control
and Prevention (CDC), the Infectious Diseases Society of America, and the American
Thoracic Society, a 4-drug regimen should be used empirically to treat Pott disease. [44]
Isoniazid and rifampin should be administered during the whole course of therapy.
Additional drugs are administered during the first 2 months of therapy. These are
generally chosen from among the first-line drugs, which include pyrazinamide,
ethambutol, and streptomycin. The use of second-line drugs is indicated in cases of
drug resistance.

Treatment duration
Studies performed by the British Medical Research Council indicate that tuberculous
spondylitis of the thoracolumbar spine should be treated with combination
chemotherapy for 6-9 months. [46]
However, the research council’s studies did not include patients with multiple vertebral
involvement, cervical lesions, or major neurologic involvement. Because of these
limitations, many experts still recommend chemotherapy for 9-12 months.
For selected cases with surgical indication that allows complete debridement of the
lesion, a combination of surgery and ultra-shortened course of therapy (4.5 mo),
appears to show comparable outcomes of a combination of surgery and 9 months of
drug therapy. [47]
Surgical Indications and Contraindications

Indications

While most patients should respond to medical treatment, a surgical approach needs to
be evaluated and considered. Indications for surgical treatment of Pott disease
generally include the following: [48, 49]
 Neurologic deficit - Acute neurologic deterioration, paraparesis, and paraplegia
 Spinal deformity with instability or pain
 No response to medical therapy - Continuing progression of kyphosis or instability
 Large paraspinal abscess
 Nondiagnostic percutaneous needle biopsy sample
Resources and experience are key factors in the decision to use a surgical approach.
The lesion site, extent of vertebral destruction, and presence of cord compression or
spinal deformity determine the specific operative approach (kyphosis, paraplegia,
tuberculous abscess). [50]
Vertebral damage is considered significant if more than 50% of the vertebral body is
collapsed or destroyed or a spinal deformity of more than 5° exists.
The most conventional approaches include anterior radical focal debridement and
posterior stabilization with instrumentation. The specific advantages and limitations of
surgical techniques vary. [51] Individualization of the case is of greatest
importance. [20, 52, 53, 54, 55] Newer modalities and techniques are being reported, such as
thoracoscopic decompression. [56]
In Pott disease that involves the cervical spine, the following factors justify early surgical
intervention:
  High frequency and severity of neurologic deficits
 Severe abscess compression that may induce dysphagia or asphyxia
 Instability of the cervical spine
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 a severe deformity.
Complications
Tubercular epidural abscess may produce spinal cord and nerve root compression
leading to significant deficits. The American Spinal Injury Association impairment scale
(ASIA) is useful to document neurological recovery from Pott disease. A designation of
ASIA A indicates the most severe neurological compromise, ASIA E the least. At the
beginning of treatment, most individuals are characterized as ASIA D. Large epidural
abscesses correlated with a poor prognosis in terms of recovery from neurological
deficits. [57]

Medication Summary
A 4-drug regimen should be used empirically to treat Pott disease. Treatment can be
adjusted when susceptibility information becomes available.
Isoniazid and rifampin should be administered during the whole course of therapy.
Additional drugs are administered during the first 2 months of therapy and are generally
chosen from among the first-line drugs, such as pyrazinamide, ethambutol, and
streptomycin. (A 3-drug regimen usually includes isoniazid, rifampin, and pyrazinamide.)
In cases of drug resistance, the use of second-line medications is indicated.
The duration of treatment is somewhat controversial. Although some studies favor a 6-
to 9-month course, traditional courses range from 9 months to longer than 1 year. The
duration of therapy should be individualized and based on the resolution of active
symptoms and the clinical stability of the patient. [58, 59]
Antitubercular Agents
Class Summary
These agents inhibit the growth and proliferation of the causative organism.

Isoniazid

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Isoniazid is highly active against Mycobacterium tuberculosis. It has good
gastrointestinal (GI) absorption and penetrates well into all body fluids and cavities.
Rifampin (Rifadin)

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Rifampin is for use in combination with at least 1 other antituberculous drug. It inhibits
deoxyribonucleic acid (DNA) ̶ dependent bacterial (but not mammalian) ribonucleic acid
(RNA) polymerase. Cross resistance may occur.

Pyrazinamide

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Pyrazinamide is bactericidal against M tuberculosis in an acid environment
(macrophages). It has good absorption from the GI tract and penetrates well into most
tissues, including the cerebrospinal fluid (CSF).

Ethambutol (Myambutol)

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Ethambutol has bacteriostatic activity against M tuberculosis. The drug has good GI
absorption. CSF concentrations remain low, even in the presence of meningeal
inflammation.

Streptomycin

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Streptomycin is bactericidal in an alkaline environment. Because it is not absorbed from
the GI tract, the drug must be administered parenterally. Streptomycin exerts action
mainly on extracellular tubercle bacilli. Only about 10% of the drug penetrates cells that
harbor organisms. Streptomycin enters the CSF only in the presence of meningeal
inflammation. Excretion is almost entirely renal.
MRI of a 31-year-old man with tuberculosis of the spine. Images show the thoracic spine
before and after an infusion of intravenous gadolinium contrast. The abscess and
subsequent destruction of the T11-T12 disc interspace is marked with arrowheads.
Vertebral body alignment is normal.
MRI of the T11 in a 31 year old man with tuberculosis of the spine. Extensive bone destruction
consistent with tuberculous osteomyelitis is evident. The spinal cord has normal caliber and signal. No
evidence of spinal cord compression or significant spinal stenosis is distinguishable.