Tuberculosis was popularly known as consumption for a long time. Scientists know it as an infection caused by M. tuberculosis. In 1882, the microbiologist Robert Koch discovered the tubercle bacillus, at a time when one of every seven deaths in Europe was caused by TB

1. SPINALSPINAL
TUBERCULOSISTUBERCULOSIS
(POTT(POTT‘S DISEASE‘S DISEASE((
Dr. SAYF ALDEEN HUSSAMDr. SAYF ALDEEN HUSSAM
ORTHOPEDIC DEPARTENTORTHOPEDIC DEPARTENT
AL-WASITY TEACHING HOSPITALAL-WASITY TEACHING HOSPITAL

2. INTRODUCTIONINTRODUCTION
 Tuberculous spondylitis is one ofTuberculous spondylitis is one of
the oldest demonstrated diseasesthe oldest demonstrated diseases
of humankindof humankind
 It has been documented in ancientIt has been documented in ancient
mummies from Egyptmummies from Egypt
According to WHO(2006), about one thirdAccording to WHO(2006), about one third
of the world’s population is infected byof the world’s population is infected by
Mycobacterium TB, and 9 millionMycobacterium TB, and 9 million

3. INTRODUCTIONINTRODUCTION
 Three percent are suffering fromThree percent are suffering from
skeletal TB.skeletal TB.
 Vertebral TB is the most commonVertebral TB is the most common
form of skeletal TB and accounts forform of skeletal TB and accounts for
50% of all cases of skeletal TB.50% of all cases of skeletal TB.
 Almost 50% are from pediatric groupAlmost 50% are from pediatric group
Neurological complications are the mostNeurological complications are the most
cripplingcrippling
complications of spinal TB ( Incidence :complications of spinal TB ( Incidence :
10 to 43%10 to 43%(.(.

5. PATHOANATOMYPATHOANATOMY
 early infection
 begins in the metaphysis of the
vertebral body
 spreads under the anterior longitudinal
ligament and leads to:
- contiguous multilevel involvement
- skip lesion or noncontiguous
segments (15%(
- paraspinal abscess formation (50%(
usually anterior and can be quite large
(much more common in TB than
pyogenic infections(
 initially does not involve the disc space
(distinguishes from pyogenic
osteomyelitis, but can be
misdiagnosed as a neoplastic lesion(

6. PATHOANATOMYPATHOANATOMY (cont(cont.(.(
 chronic infection leads to:
 severe kyphosis :because the
infection is often diagnosed late, there
is often much more severe kyphosis in
granulomatous spinal infections
compared to pyogenic infections
 sinus formation
 Pott's paraplegia

7. Sever kyphosis

8.  Recently, two distinct patternsRecently, two distinct patterns
of spinal TB can be identified,of spinal TB can be identified,
- the classic form, called- the classic form, called
spondylodiscitis (SPD)spondylodiscitis (SPD)
- atypical form characterized by- atypical form characterized by
spondylitis without diskspondylitis without disk
involvement (SPwD). whichinvolvement (SPwD). which
seems to be the most commonseems to be the most common
pattern of spinal TBpattern of spinal TB

9. CLINICAL FEATURESCLINICAL FEATURES
Constitutional symptomsConstitutional symptoms::
1-Malaise1-Malaise
2-Loss of weight2-Loss of weight // appetiteappetite
3-Night sweats3-Night sweats
4-Evening rise of temperature4-Evening rise of temperature

10. CliniCal FeaturesCliniCal Features
Specific SymptomsSpecific Symptoms::
1-Pain1-Pain//Night criesNight cries
2-Stiffness2-Stiffness
3- Deformity3- Deformity
4- Restricted ROM4- Restricted ROM
5-Enlarged lymph nodes5-Enlarged lymph nodes
6-Abscess6-Abscess
7-Neurodeficit7-Neurodeficit

11. POtt’s ParaPleGia
 Paraplegia is the most feared complication
of spinal tuberculosis.
 Divided into:
1-Early-onset paresis: (usually within 2 years
of disease onset) is due to pressure by
inflammatory oedema, an abscess, caseous
material, granulation tissue or sequestra.
The patient presents with lower limb
weakness, upper motor neuron signs,
sensory dysfunction and incontinence. In
these cases the prognosis for neurological
recovery following surgery is good
2-Late onset paresis:may develop two to three
decades after active infection is due to
direct cord compression from increasing

12. PhysiCal examinatiOnPhysiCal examinatiOn
 The physical examination inThe physical examination in
Potts disease should include thePotts disease should include the
followingfollowing::
1-Careful assessment of spinal1-Careful assessment of spinal
alignmentalignment
2-Inspection of skin, with attention2-Inspection of skin, with attention
to detection of sinusesto detection of sinuses
3-Abdominal evaluation for3-Abdominal evaluation for
subcutaneous flank masssubcutaneous flank mass

13. PhysiCalPhysiCal examinatiOnexaminatiOn
(COnt(COnt.(.(
 Large, cold abscesses ofLarge, cold abscesses of
paraspinal tissues or psoasparaspinal tissues or psoas
muscle may protrude under themuscle may protrude under the
inguinal ligament and may erodeinguinal ligament and may erode
into the perineum or glutealinto the perineum or gluteal
areaarea..
 Pott disease that involves thePott disease that involves the
upper cervical spine can causeupper cervical spine can cause
rapidly progressive symptomsrapidly progressive symptoms..
Retropharyngeal abscesses occurRetropharyngeal abscesses occur

14. tyPes OF vertebraltyPes OF vertebral
lesiOnslesiOns
11.. ParadiscalParadiscal(commonest(commonest))
22.. CentralCentral
33.. AnteriorAnterior
44.. AppendicularAppendicular
55.. ArticularArticular

15. DiaGnOstiC stuDiesDiaGnOstiC stuDies
1. Laboratory studies1. Laboratory studies
2. Imaging2. Imaging
3. Cultures3. Cultures

16. labOratOry stuDieslabOratOry stuDies
 The WBC count, ESR, and CRP levelThe WBC count, ESR, and CRP level
may be elevated in these patients.may be elevated in these patients.
These values are generallyThese values are generally
nonspecificnonspecific
 Patients with active tuberculosis orPatients with active tuberculosis or
previous exposure toprevious exposure to MycobacteriumMycobacterium
will normally exhibit a positivewill normally exhibit a positive
tuberculin purified protein derivativetuberculin purified protein derivative
skin test, although false-negativeskin test, although false-negative
results may occur.results may occur.

17. imaGinGimaGinG
 A-Plain radiograph signsA-Plain radiograph signs ::
1- Reduced disc space1- Reduced disc space
2-Blurred paradiscal margins2-Blurred paradiscal margins
3-Destruction of bodies3-Destruction of bodies
4-Loss of trabecular pattern4-Loss of trabecular pattern
5-Increased prevertebral soft tissue5-Increased prevertebral soft tissue
shadowshadow
6-Subluxation6-Subluxation //dislocationdislocation
7-Decreased lordosis7-Decreased lordosis//KyphosisKyphosis

18. Reduced disc spaceReduced disc space

19. Blurred paradiscal marginsBlurred paradiscal margins

20. Increased prevertebral soft tissue shadowIncreased prevertebral soft tissue shadow

21. Destruction of vertebral bodiesDestruction of vertebral bodies

22. KyphosisKyphosis

23. ImagIngImagIng (cont(cont.(.(
 B-Computed tomographyB-Computed tomography ((CTCT))::
CT demonstrates abnormalities earlier thanCT demonstrates abnormalities earlier than
plain radiography .plain radiography .
•• CT is of great value in the demonstration ofCT is of great value in the demonstration of
any calcification within the cold abscessany calcification within the cold abscess
(pathognomic for Tb)(pathognomic for Tb)
•• Regions which are difficult to visualize onRegions which are difficult to visualize on
plain films like :plain films like :
1. Cranio-vertebral junction (CVJ)1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,2. Cervico-dorsal region,
3. Sacrum3. Sacrum
4. Sacro-iliac joints.4. Sacro-iliac joints.
5. Posterior spinal tuberculosis because

25. ImagIngImagIng (cont(cont.(.(
C-MRI:C-MRI:
•• Detect marrowDetect marrow
infiltration ininfiltration in
vertebral bodies,vertebral bodies,
leading to earlyleading to early
diagnosisdiagnosis..
••Detect Changes ofDetect Changes of
diskitisdiskitis
•• Assessment ofAssessment of
extraduralextradural
abscesses /

26. ImagIngImagIng (cont(cont.(.(
d-USGd-USG ::
-to find out primary TB in abdomen-to find out primary TB in abdomen
-Detect cold abscess-Detect cold abscess
-Guided aspiration -Guided aspiration

27. culturescultures
 CT guided biopsy with
cultures and staining
effective at obtaining
diagnosis
 should be tested for acid-
fast bacilli (AFB)
 mycobacteria (acid-fast
bacilli) may take 10 weeks to
grow in culture
 PCR allows for faster
identification (95% sensitivity
and 93% accuracy)

28. TreaTmenTTreaTmenT
Nonsurgical:
1●pharmacotherapy:
isoniazid, rifampin, and pyrazanamide therapy
indications
drugs are the mainstay of treatment in most
cases
technique
treated with isoniazid, rifampin, and
pyrazanamide for 9 to 18 months
ethambutol and streptomycin added for part of
treatment
2● spinal orthosis
indications
may be used for pain control and prevention of
deformity

29. TreaTmenT (conTTreaTmenT (conT.(.(
Operative:
indications:
 neurologic deficit
 spinal instability or progressive kyphosis
 Advanced disease with caseation,
fibrosis, and avascularity that limits
antibiotic penetration
 failure of nonoperative treatment after
3 to 6 months

30. Surgical TreaTmenTSurgical TreaTmenT
SurgerySurgery indicationindication
11 DecompressionDecompression(+/-(+/- fusionfusion(( Too advanced disease, Failure toToo advanced disease, Failure to
respond to conservative therapyrespond to conservative therapy
22 DebridementDebridement +/-+/-
decompressiondecompression +/-+/- fusionfusion
Recurrence of disease or ofRecurrence of disease or of
neural complicationsneural complications
33 Anterior transposition ofAnterior transposition of
cordcord ((ExtrapleuralExtrapleural
anterolateralanterolateral approachapproach((
Sever KyphosisSever Kyphosis ((>60 degree>60 degree) + /) + /
neural deficitneural deficit
44 LaminectomyLaminectomy Extradural granulomaExtradural granuloma// OldOld
healed disease presenting ashealed disease presenting as
secondary canal stenosissecondary canal stenosis //
Posterior spinal diseasePosterior spinal disease

31. complicaTionScomplicaTionS
 ParaplegiaParaplegia
 Cold abscessCold abscess
 Spinal deformitySpinal deformity
 SinusesSinuses
 Secondary infectionSecondary infection
 Amyloid diseaseAmyloid disease
 FatalityFatality

32. Follow upFollow up
Patient evaluated at 3 months interval upto 2 yearsPatient evaluated at 3 months interval upto 2 years
 Clinical EvaluationClinical Evaluation ::
Weight gainWeight gain
Pain reliefPain relief
Free ROMFree ROM
Resolution of abscessesResolution of abscesses
Neurological recoveryNeurological recovery
 RadiologicalRadiological EvaluationEvaluation ::
Decreased soft tissue shadowDecreased soft tissue shadow
Disappearance of erosionsDisappearance of erosions
Return of mineralization GraftReturn of mineralization Graft
incorporationincorporation
Bony ankylosisBony ankylosis