Pott’s Disease / Tuberculosis of Spine

Pott’s disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically, it is
called tuberculous spondylitis. Pott’s disease is the most common site of bone infection in TB; hips and knees are also often affected. The lower thoracic and
upper lumbar vertebrae are the areas of the spine most often affected.

Pott's disease, which is also known as Pott’s caries, David's disease, and Pott's curvature, is a medical condition of the spine. Individuals suffering from Pott's
disease typically experience back pain, night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, which results in tingling, numbness,
or a general feeling of weakness in the leg muscles. Often, the pain associated with Pott's disease causes the sufferer to walk in an upright and stiff position.

Pott’s disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As
a result, a person with Pott's disease often develops kyphosis, which results in a hunchback. This is often referred to as Pott’s curvature. In some cases, a person
with Pott's disease may also develop paralysis, referred to as Pott’s paraplegia, when the spinal nerves become affected by the curvature.

ETIOLOGY of Tuberculosis of Spine

• Causative organism: Mycobacterium tuberculosis.

• Spread: Haematogenous. (by blood)
• Commonly associated with: Debilitating diseases, AIDS, Drug addiction, Alcoholism.

Symptoms of Tuberculosis of Spine

Symptoms

The onset is gradual.

• Back pain is localised.
• Restricted spinal movements.
• Fever.
• Night sweats.
• Anorexia.
• Weight loss.

Signs

• There may be kyphosis. (spinal curvature)

• Muscle wasting.
• A paravertebral swelling may be seen.
• They tend to assume a protective upright, stiff position.
• If there is neural involvement there will be neurological signs.
• A psoas abscess (may present as a lump in the groin and resemble a hernia).

Differential diagnosis

• Pyogenic osteitis of the spine.

• Spinal tumours.

INVESTIGATION for Tuberculosis of Spine

Blood

• TLC: Leucocytosis.
• ESR: raised during acute stage.

Tuberculin skin test

• Strongly positive.
• Negative test does not exclude diagnosis.

Aspirate from joint space & abscess

• Transparency: turbid.
• Colour: creamy.
• Consistency: cheesy.
• Fibrin clot: large.
• Mucin clot: poor.
• WBC: 25000/cc.mm.

Histology• Shows granulomatous tubercle.

X-Ray spine

Early:-

• Narrowed joint space.

• Diffuse vertebral osteoporosis adjacent to joint.
• Erosion of bone.
• Fusiform paraspinal shadow of abscess in soft tissue.

Late:-• Destruction of bone.

• Wedge-shaped deformity (collapse of vertebrae anteriorly).
• Bony ankylosis.

Complications

• Vertebral collapse resulting in kyphosis.

• Spinal cord compression.
• Sinus formation.
• Paraplegia (so called Pott's paraplegia).

GENERAL MANAGEMENT for Pott's Disease

• Bed rest.
• Immobilisation of affected joint by splintage.
• Nutritious, high protein diet.
• Drainage of abscess.
• Surgical decompression.
• Physiotherapy.

Homeopathy Treatment & Homeopathic Remedies for Spinal Tuberculosis

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The
homeopathic medicines are selected after a full individualizing examination and case-analysis, which includes the medical history of the patient, physical and
mental constitution etc. A miasmatic tendency (predisposition/susceptibility) is also often taken into account for the treatment of chronic conditions. The
medicines given below indicate the therapeutic affinity but this is not a complete and definite guide to the treatment of this condition. The symptoms listed against
each medicine may not be directly related to this disease because in homeopathy general symptoms and constitutional indications are also taken into account for
selecting a remedy. To study any of the following remedies in more detail, please visit our Materia Medica section. None of these medicines should be taken
without professional advice.

Homeopathic Remedies

Calc carb.Pain as if sprained; can scarcely rise; from overlifting. Pain between shoulder-blades, impeding breathing. Rheumatism in lumbar region; weakness in
small of back. Curvature of dorsal vertebrae. Nape of neck stiff and rigid.

Calc carb suits to person with Leucophlegmatic constitution, blond hair, light complexion, blue eyes, fair skin; tendency to obesity in youth. Psoric constitutions;
pale, weak, timid, easily tired when walking. Disposed to grow fat, corpulent, unwieldy. Children with red face, flabby muscles, who sweat easily and take cold
readily in consequence. Large heads and abdomens; fontanelles and sutures open; bones soft, develop very slowly. Curvature of bones, especially spine and long
bones; extremities crooked, deformed; bones irregularly developed. Head sweats profusely while sleeping,

Calc phos.Rheumatic pain and stiffness of neck with dulness of head, from slight drought of air. Cramp-like pain in neck first one side then the other (right to
left). Throbbing or jerking pains below scapula. Violent pain in region of back when making the least effort. Backache and uterine pains. Sharp pains in sacrum
and coccyx. Soreness as if separate in sacro-illiac synchondrosis. Curvature of the spine to the left, lumbar vertebrae bend to the left, spina bifida. Soreness in
sacro-iliac symphysis, as if broken.Calc phos suits to person with anaemic and dark complexion, dark hair and eyes; thin spare subjects, instead of fat.
Phos acid.Tension and cramp-like drawing in muscles of neck, especially on moving head. Miliaria on neck. Boring pain between scapulae. Spondylitis of
cervical vertebrae.
Eruption, painful to touch, on back, shoulder-blades, neck, and chest. Burning pain in a spot above small of back. Itching stitch in coccyx, fine stitches in coccyx
and sternum. Crawling (formication) tingling in back and loins.

Phos acid best suited to persons of originally strong constitutions, who have become debilitated by loss of vital fluids.

Phosphorus.Rigidity of nape of neck. Pressure on shoulders. Swelling of neck. Engorgement of axillary glands and of those of nape of neck and of neck.
Paralysed sensation in upper sacrum and lower lumbar vertebrae. Contusive pain in loins and back (as if back were broken), especially after having been seated a
long time, hindering walking, rising up, or making the least movement. Pain in small of the back when rising from a stooping position. Sensitiveness of spinous
processes of dorsal vertebrae to pressure. Softening of spine. Heat or burning in back, between scapula. Tearings and stitches in and beneath both scapula. Pain in
coccyx impeding easy motion, can find no comfortable position, followed by painful stiffness of nape. Coccyx painful to touch as from an ulcer. Transient pain
from coccyx though spine to vertex that drew head back during the stool. Backache and palpitations prevail.

Phos best adapted to tall slender persons of sanguine temperament, fair skin, eyelashes, fine blond, or red hair, quick perceptions, and very sensitive nature. Young
people who grow too rapidly are inclined to stoop who are chlorotic or anaemic; old people, with morning diarrhea. Nervous, weak; desires to be magnetized
Oversensitiveness of all the senses to external impressions, light, noise, odors, touch. Restless, fidgety; moves continually, cannot sit or stand still a moment
Burning: in spots along the spine; between the scapulae; or intense heat running up the back;of palms of hands in chest and lungs; of every
organ or tissue of the body generally in diseases of nervous system. Haemorrhage diathesis; small wounds bleed profusely.

Silicea.Stiffness of nape, with headache. Swelling of glands of nape, in the neck, and under the axillae (with suppuration), sometimes with induration. Suppuration
of axillary glands. Caries of clavicle.Stitches between the hips.Coccyx painful, as after a long carriage ride.- Stinging in os coccyges on rising, painful to pressure.
-Scabby elevation on coccyx, above fissure of nates.- Pain in the loins, which prevents rising up, and forces patient to remain lying down.- Inflammatory abscess
in lumbar region (on the psoas muscle).- Weakness and paralytic stiffness in back, loins, and nape.- Tearings and shootings in the back.- Shootings in the loins,
when seated or lying down.-Burning in back when walking in open air and becoming warm.- Aching, shooting, burning, and throbbing in lumbo-sacral region.-
Swelling and distortion of spine (curvature of the vertebrae).-Contusive pain between the shoulder-blades.

Silicea best adapted to the nervous, irritable, sanguine temperament; persons of a psoric diathesis. Persons of light complexion; fine dry skin; pale face; weakly,
with lax muscles. Constitutions which suffer from deficient nutrition, not because food is lacking in quality or quantity, but from imperfect assimilation.
Oversensitive, physically and mentally. Scrofulous, rachitic children with large heads; open fontanelles and sutures; much sweating about the head.

Sulphur.Stiffness of neck, in nape, with paralytic, sprained pain. Child cannot hold head up neck muscles so weak. Tetters on nape. Swelling and inflammation of
glands of nape and of neck.Swelling and suppuration of axillary glands. Cracking in vertebrae of neck, especially on bending backwards. Weakness and
wrenching pains, or pain as from a bruise in loins, coccyx, and in back, especially on walking, or rising from a seat. Gnawing pain in small of back. Pain in small
of back not permitting one to stand erect. Finds himself at night lying on back. Cannot lie on back on account of rush of blood to head. Pain in back after manual
labour. Shootings in loins, back, and shoulder-blades, sometimes with obstructed respiration. Sharp and rheumatic pains, drawing, tension, and stiffness in loins,
back,and nape. Pinching and burning sensation between the shoulder-blades. Tension and bruised pain between scapulae and in nape, which on moving head goes
to shoulders. Stitches beneath scapulae which take away the breath. Drawing in right scapula, evening on going to sleep. Tearing in left scapula while sitting.
Needle-shoots at point of left scapula. Sprained pains in back. During whole day aching in small of back, worse when urinating.Distortion (curvature) of spine.
Vertebrae softened. Cracking of vertebrae on bending head backward.Sulphur Adapted to persons of a scrofulous diathesis, subject to venous congestion;
especially of portal system. Persons of nervous temperament, quick motioned, quick tempered, plethoric, skin excessively sensitive to atmospheric changes. For
lean, stoop-shouldered persons who walk and sit stooping like old men. Standing is the worst position for sulphur patients; they cannot stand; every standing
position is uncomfortable. Dirty, filthy people, prone to skin affections. Aversion to being washed; always <. after a bath.

Symphytum.Pain in back from a fall, from sexual excess. Pott's disease after injury. Psoas abscess. Much used among herbalists in caries of spinal and other
bones.
Symphytum facilitates union of fractured bones; lessens peculiar pricking pain; favors production of callous; when trouble is of nervous origin. Irritability at point
of fracture; periosteal pains after wounds have healed.

Mortality/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 show some variation. Lower thoracic vertebrae is
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.

Approximately 10% of Pott disease cases involve the cervical spine.

Risk/ Predisposing factors
•
Manifestation: back pain
•
fever
•
nightsweating
•
anorexia
•
weight loss
•
Spinal mass, sometimes associated withnumb ness,tingling, ormuscle
weakness of the legs
Race
•

Data from Los Angeles and New York show that musculoskeletal tuberculosis primarily affects 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.
Sex•

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).

Age•
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.
Type/ Stage/ Classification
•
Bone/Spinal Disease
•
Non-Communicable Disease

Pathophysiology

Pott’s disease is usually secondary to an extraspinal source of infection. The basic lesion involved in Pott’s disease is a combination of osteomyelitis
andarthritis that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area 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, because the disk is vascularized, it can be a primary site.

Progressive bone destruction leads to vertebral collapse andk yphosis. 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.

Laboratory Studies
•
Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-
95% of patients with Pott disease who are not infected with HIV.
•
The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100
mm/h).
•

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. These study findings are
positive in only about 50% of the cases.

Imaging Studies
•
Radiography
•

Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain
radiography:13

•
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 one level.
•
CT scanning14
ο
CT scanning provides much better bony detail of irregular lytic lesions,
sclerosis, disk collapse, and disruption of bone circumference.
ο
Low-contrast resolution provides a better assessment of soft tissue,
particularly in epidural and paraspinal areas.
ο
CT scanning reveals early lesions and is more effective for defining the
shape and calcification of soft-tissue abscesses.
ο
In contrast to pyogenic disease, calcification is common in tuberculous
lesions.

MRI
ο

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. MRI is also the most effective imaging study for
demonstrating neural compression.

ο
MRI findings useful to differentiate tuberculous 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.

Other Tests
•
Radionuclide scanning findings are not specific for Pott disease.
•
Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%,
respectively).
Management
Medical Care
•

Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization using prolonged bed rest or a body cast. At the time,
Pott disease carried a mortality rate of 20%, and relapse was common (30%)

The duration of treatment, surgical indications, and inpatient care have since

evolved.
•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.
• According to the most recent recommendations issued in 2003 by the US Centers for Disease Control and Prevention, the Infectious Diseases Society of
America, and the American Thoracic Society, a 4-drug regimen should be used empirically to treat Pott disease.
• 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 among the first-line drugs, which include pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is indicated in
cases of drug resistance.
• Regarding the duration of therapy, the British Medical Research Council 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.
•
Opinions differ regarding whether the treatment of choice should be conservative
chemotherapy or a combination of chemotherapy and surgery. The treatmen

decision should be individualized for each patient. Routine surgery does not to seem to be indicated. Most common indications for surgical procedures are
discussed below.

Surgical Care
•
Indications for surgical treatment of Pott disease generally include the following:
o
Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)
o
Spinal deformity with instability or pain
o
No response to medical therapy (continuing progression of kyphosis or
instability)
o
Large paraspinal abscess
o
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).
•
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.
•
In Pott disease that involves the cervical spine, the following factors justify early
surgical intervention:
o
High frequency and severity of neurologic deficits
o
Severe abscess compression that may induce dysphagia or asphyxia
o
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.
Nursing Diagnosis
•
Acute pain related to inflammatory process
•
Disturbed body image related to trauma/injury to spinal cord
•
Self – bathing hygiene deficit related to musculoskeletal impairment
•
Impaired physical mobility related to therapeutic restriction of movement
•
Imbalance nutrition related to inadequate food intake Nursing Responsibilities
• Drug treatment is generally sufficient for Pott’s disease, with spinal immobilization
if required.
•
Surgery is required if there is spinal deformity or neurological signs of spinal cord
compression.
• Standard antituberculosis treatment is required. Duration of antituberculosis
treatment: If debridement and fusion with bone grafting are performed, treatment
can be for six months. If debridement and fusion with bone grafting are NOT
performed a minimum of 12 months’ treatment is required.It may also be necessary to immobilize the area of the spine affected by the
disease, or the person may need to undergo surgery in order to drain any
abscesses that may have formed or to stabilize the spine.Other interventions include application of knight/ taylor brace, head halter traction. Surgery includes
ADSF (Anterior decompression Spinal fusion).