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AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis

secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's


disease

Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more
vertebrae. Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction
with the body's natural bone growth (osteoblastic) processes to fuse the vertebrae. This procedure is used primarily to
eliminate the pain caused by abnormal motion of the vertebrae by immobilizing the vertebrae themselves.

Reasons for spinal fusion

Spinal fusion is done most commonly in the lumbar region of the spine, but it is also used to treat cervical and thoracic
problems. The indications for lumbar spinal fusion are controversial.[1] People rarely have problems with the thoracic
spine because there is little normal motion in the thoracic spine. Patients requiring spinal fusion have either
neurological deficits or severe pain which has not responded to conservative treatment.

Conditions where spinal fusion may be considered:

• degenerative disc disease


• spinal disc herniation
• discogenic pain
• spinal tumor
• vertebral fracture
• scoliosis
• kyphosis (i.e, Scheuermann's disease)
• spondylolisthesis
• spondylosis
• Posterior Rami Syndrome
• other degenerative spinal conditions
• any condition that causes instability of the spine

Types of spinal fusion

There are two main types of lumbar spinal fusion, which may be used in conjunction with each other:

Posterolateral fusion places the bone graft between the transverse processes in the back of the spine. These vertebrae
are then fixed in place with screws and/or wire through the pedicles of each vertebra attaching to a metal rod on each
side of the vertebrae.

Interbody fusion places the bone graft between the vertebra in the area usually occupied by the intervertebral disc. In
preparation for the spinal fusion, the disc is removed entirely, for example in ACDF. A device may be placed between
the vertebra to maintain spine alignment and disc height. The intervertebral device may be made from either plastic or
titanium. The fusion then occurs between the endplates of the vertebrae. Using both types of fusion is known as 360-
degree fusion. Fusion rates are higher with interbody fusion. Three types of interbody fusion are:

• Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision
• Posterior lumbar interbody fusion (PLIF) - the disc is accessed from a posterior incision
• Transforaminal lumbar interbody fusion (TLIF) - the disc is accessed from a posterior incision on one side of
the spine

In most cases, the fusion is augmented by a process called fixation, meaning the placement of metallic screws (pedicle
screws often made from titanium), rods or plates, or cages to stabilize the vertebra to facilitate bone fusion. The fusion
process typically takes 6–12 months after surgery. During this time external bracing (orthotics) may be required.
External factors such as smoking, osteoporosis, certain medications, and heavy activity can prolong or even prevent the
fusion process. If fusion does not occur, patients may require reoperation.

Some newer technologies are being introduced which avoid fusion and preserve spinal motion. Such procedures, such
as artificial disc replacement, are being offered as alternatives to fusion, but have not yet been adopted on a widespread
basis in the US. Their advantage over fusion has not been well established. Minimally invasive techniques have also
been introduced to reduce complications and recovery time for lumbar spinal fusion.

Pott's Disease of the Spine

Synonyms: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis,
tuberculosis of the spine, tuberculous spondylitis and David's disease

Pott's disease is named after Percival Pott (1714-1788), who was a surgeon in London. Pott's disease is tuberculosis of
the spinal column (must not be confused with Pott's fracture of the ankle).

• The usual sites to be involved are the lower thoracic and upper lumbar vertebrae.
• The source of infection is usually outside the spine. It is most often spread from the lungs via the blood.
• There is a combination of osteomyelitis and infective arthritis.
• Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral body
adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral discs.
• In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it can be
a primary site, as the disc is vascular in children.
• It is the commonest place for tuberculosis to affect the skeletal system although it can affect the hips and
knees too.
• The infection spreads from two adjacent vertebrae into the adjoining disc space.
• If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as
it is avascular and cannot receive nutrients.
• Caseation occurs, with vertebral narrowing and eventually vertebral collapse and spinal damage. A dry soft
tissue mass often forms and superinfection is rare.

Epidemiology

• Pott's disease is rare in the UK but in developing countries it represents about 2% of cases of tuberculosis and
40 to 50% of musculoskeletal tuberculosis.
• Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year.
• Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting richer ones.
• India, China, Indonesia, Pakistan and Bangladesh have the largest number of cases but there has been a
marked increase in the number of cases in the former Soviet Union and in sub-Saharan Africa in parallel with
the spread of HIV.
• About two thirds of affected patients in developed countries are immigrants, as shown from both London1
and Paris2 and spinal tuberculosis may be quite a common presentation.
• The disease affects males more than females in a ratio of between 1.5 and 2:1. In the USA it affects mostly
adults but in the countries where it is commonest it affects mostly children.

Risk factors

• Endemic tuberculosis.
• Poor socio-economic conditions.
• HIV infection.

Presentation

• The onset is gradual.


• Back pain is localised.
• Fever, night sweats, anorexia and weight loss.
• Signs may include kyphosis (common) and/or a paravertebral swelling.
• Affected patients 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:
o A psoas abscess most often originates from a tuberculous abscess of the lumbar vertebra that tracks
from the spine inside the sheath of the psoas muscle.
o Other causes include extension of renal sepsis and posterior perforation of the bowel.
o There is a tender swelling below the inguinal ligament and they are usually apyrexial.
o The condition may be confused with a femoral hernia or enlarged inguinal lymph nodes.

Associated diseases

• Tuberculosis co-infection with HIV has become common. It is up to 11% in some areas of the UK and over
60% in countries such as Zambia, Zimbabwe and South Africa.
• In the developed world, the disease is more common in certain sections of society such as alcoholics, the
undernourished, ethnic minority communities and the elderly.
• The disease is also more common in patients after gastrectomy for peptic ulcer.

Distribution

• The commonest area affected is T10 to L1.


• The lower thoracic region is the most common area of involvement at 40 to 50%, with the lumbar spine in a
close second place at 35 to 45%.
• The cervical spine accounts for about 10%.

Management

• Immobilisation of the spine is usually for 2 or 3 months.


• Drug treatment: this is covered in the article on the Management of Tuberculosis. Therapy may need to
exceed 6 months.

Surgical

• Surgery plays an important part in the management. It confirms the diagnosis, relieves compression if it
occurs, permits evacuation of pus, and reduces the degree of deformation and the duration of treatment.3
• However, a Cochrane review found that routine surgery in addition to chemotherapy had not been shown to
improve outcome but the problem was that the evidence was poor.4
• A study from India suggested that surgery is not mandatory.5

Complications

• Progressive bone destruction leads to vertebral collapse and kyphosis:


o The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This
leads to spinal cord compression and neurological signs (Pott's paralysis).
o Kyphosis occurs because of collapse in the anterior spine and can be severe.
o Lesions in the thoracic spine have a greater risk of kyphosis than those in the lumbar spine.
o Neurological problems can be prevented by early diagnosis and prompt treatment. It can reverse
paralysis and minimise disability.
o A combination of conservative management and surgical decompression gives success in most
patients.
o Late onset paraplegia is best avoided by prevention of the development of severe kyphosis.
o Patients with tuberculosis of the spine who are likely to have severe kyphosis should have surgery
in the active stage of disease.6
o The degree of kyphosis, the area of affected vertebrae and the lack of sphincter control all correlate
with the chance of recovery from paraplegia.7
• 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 and form sinuses.

Prognosis

• The progress is slow and lasts for months or even years.


• Prognosis is better if caught early and modern regimes of chemotherapy are more effective.
• A study from London showed that diagnosis can be difficult and is often late.1

Prevention

• As for all tuberculosis, BCG vaccination.


• Improvement of socio-economic conditions.
• Prevention of HIV and AIDS.