Pott's spine


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Pott's spine

  1. 1. Pottt’s Spine 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. 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. 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: 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. 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). Clinical Signs: The clinical presentation of Pott disease depends on the following:
  2. 2. 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, but can be considerably longer. 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. 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. 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.
  3. 3. 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: Differentiating spinal TB from pyogenic and fungal vertebral osteomyelitis as well as primary and metastatic spinal tumors may be difficult when only clinical and radiographic findings are considered. A history of tuberculosis, a positive skin test (its value declines in endemic areas), and an elevated erythrocyte sedimentation rate (ESR) may be useful in the diagnosis of spinal TB. Biopsy plays a valuable role in the diagnosis of spinal TB infection. The use of DNA amplification techniques (polymerase chain reaction or PCR) may facilitate rapid and accurate diagnosis of the disease. Culturing the organisms is slow and may be inaccurate. Nevertheless, it is still a precious diagnostic method in order to recognize the causative germs. In a small number of cases with imaging and clinical findings suggestive of spinal infection, no organism can be cultured despite multiple attempts. Mycobacterial infection as well as fungal involvement should be considered in these cases. Computed tomography (CT) provides bony detail, while MRI evaluates the involvement of soft tissue and abscess formation. The relative preservation of the disc, rarefaction of the vertebral endplates, anterior wedging, the presence of separate pre- and paravertebral or intra-osseous abscesses with a subligamentous extension and breaching of the epidural space, concentric collapse of vertebral body, ivory vertebra which is seen at conventional radiographs and refers to an increase in opacity of a vertebral body while preserving its size and contours (with no change in the opacity and size of adjacent intervertebral discs), neural arch tuberculosis, circumferential or pan vertebral involvement, extradural tuberculoma, subdural granuloma, intramedullary tuberculoma, and multilevel spinal TB are considered as the diagnostic clues for this disease in various imaging modalities. Significant bone destruction can be detected on plain radiographs or CT scan. However, epidural granulomatous tissue or tuberculoma of the spinal cord may not be detected by these tool. Among the various types of imaging modalities, MRI has the ability to diagnose the disease earlier and more accurately than plain radiographs. Although not specific to spinal TB, there is a decrease in signal intensity of the involved bone and soft tissues on T2-weighted images and the increase in intensity of a uniform thin rim enhancement is a pathogenomic finding suggesting either caseation necrosis or a cold abscess in tuberculosis. In the evaluation of spinal TB with isolated involvement of the posterior elements, MRI is also useful in diagnosis and assessment of the treatment response.
  4. 4. Differential Diagnoses: Actinomycosis Blastomycosis Brucellosis Candidiasis Cryptococcosis Histoplasmosis Metastatic Cancer, Unknown Primary Site Miliary Tuberculosis Multiple Myeloma Mycobacterium Avium-Intracellulare. 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.
  5. 5. 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. Older patients can also present with late-onset complications such as reactivation, instability, or deformity. Observation is warranted in all groups of patients. Surgical Techniques: The following techniques are currently used for the treatment of TB spondylitis: 1) posterior decompression and fusion with bone autografts, 2) anterior debridement/decompression and fusion with bone autografts, 3) anterior debridement/decompression and fusion, followed by simultaneous or sequential posterior fusion with instrumentation, and 4) posterior fusion with instrumentation, followed by simultaneous or sequential anterior debridement/decompression and fusion. The posterolateral or transpedicular approach has been used extensively for the management of spinal TB. This approach is a viable and importantly a safe surgical option for ventral decompression in thoracic spine TB when followed by antitubercolusis treatment for 18 months and immobilization in an alkathene shell for 3 months. Pedicle screw fixation has also been advocated. In the setting of non-equipped medical centers, the anterolateral approach is feasible and safe and provides 360 degree exposure for lesions located in the spine from the second thoracic vertebra down to the fifth lumbar vertebra. Using this approach, anterior debridement, decompression, bone grafting (anterior or posteriorly), posterior implant fixation, and kyphosis correction are all options. Some authors suggested that anterior instrumentation in the presence of active disease can be dangerous and may fail or be associated with additional complications. However, in our experience instrumented stabilization in a tubercular infected bed seems to be safe if meticulous debridment is performed. On the other hand, some authors reported series of patients that underwent one-stage anterior interbody autografting and anterior instrumentation with good results. Regarding the type of bone graft, some authors suggested fresh-frozen allograft and anterior instrumentation which is superior to rib grafts in supporting the anterior spinal column. Although fusion occurs late following the use of allografts, the grafts remain stable. Certainly, reoperation to remove the anteriorly placed implants is complex and is associated with higher risks than the first operation. Supplementary posterior fusion should be considered to prevent postoperative kyphosis when this procedure is performed in children. From a biomechanical view point, neither anterior nor posterior approaches alone can stabilize the spinal column as well as combined approaches in cases of spinal TB. Therefore, several authors have suggested that the combined approach may yield better outcomes and prevent future kyphosis more efficiently. Performing posterior instrumentation and fusion combined with anterior debridement and fusion in order to shorten the external immobilization period and hospital stay, obtains good and long lasting correction of kyphosis, and prevents further collapse and graft failure and has been recommended in many recent studies. However, changes in sagittal alignment have shown that this strategy provides limited kyphosis correction. These combined approaches can be specifically beneficial when doing an anterior correction of a fixed kyphotic deformity with concomitant wedge resection of the posterior elements. Combined
  6. 6. approaches can be performed in two ways: 1) Anterior-posterior, anterior debridement/decompression and fusion is performed first; 2) Posterior-anterior, posterior fusion with instrumentation is the first stage. There were no differences in clinical or radiological parameters between these two groups, indicating that either of these two surgical techniques may be selected depending on the patient's condition. One-stage surgical management in children with spinal TB by anterior decompression and posterior instrumentation has been shown to be both feasible and effective. Recently, minimally invasive spinal techniques are introduced as alternative surgical approaches to address different pathologies in the spine, even if fusion is indicated. Such techniques including posterolateral endoscopic debridement and irrigation have also been used with good results for the management of spinal TB. Combined anterior and posterior fusion is sometimes preferred in young cases without significant co- morbidities with either of the following indications: 1) Both anterior and posterior involvement, 2) More than three segments involved, 3) Significant degree of kyphosis associated with overt destruction of one or two vertebral bodies, 4) Thoracolumbar junction involvement. Certainly, to achieve the best results, the surgical treatment of choice for each patient should be individualized. According to different reports, considering the following factors could be helpful in order to select the approach. 1-Patient's age 2-Presence of medical co-morbidities 3-Location of bony destruction (anterior, posterior or both) 4-Location of the compressive lesion with respect to the dura (anterior, posterior or both) 5-Density of the compressive lesion (pus or solid extradural lesion) 6-Patient's bone stock 7-Number of segments involved 8-Degree of kyphotic deformity 9-Region of involvement(craniovertebral junction, cervical, cervicothoracic junction, thoracic, thoracolumbar junction, upper lumbar, cauda equina).
  7. 7. References: Chandra SP, Singh A, Goyal N, et al; Analysis of changing paradigms of management in 179 patients with spinal tuberculosis over a 12-year period and proposal of a new management algorithm. World Neurosurg. 2013 Jul-Aug;80(1-2):190-203. doi: 10.1016/j.wneu.2012.12.019. Epub 2013 Jan 22. Cormican L, Hammal R, Messenger J, et al; Current difficulties in the diagnosis and management of spinal tuberculosis. Postgrad Med J. 2006 Jan;82(963):46-51. Eisen S, Honywood L, Shingadia D, et al; Spinal tuberculosis in children. Arch Dis Child. 2012 Aug;97(8):724-9. doi: 10.1136/archdischild-2011-301571. Epub 2012 Jun 25. Immunisation against infectious disease - the Green Book; Dept of Health (latest edition) Jutte PC, van Loenhout-Rooyackers JH; Routine surgery in addition to chemotherapy. Percivall Pott; Whonamedit.com Pola E, Rossi B, Nasto LA, et al; Surgical treatment of tuberculous spondylodiscitis. Eur Rev Med Pharmacol Sci. 2012 Apr;16 Suppl 2:79-85. Shikhare SN, Singh DR, Shimpi TR, et al; Tuberculous osteomyelitis and spondylodiscitis. Semin Musculoskelet Radiol. 2011 Nov;15(5):446-58. doi: 10.1055/s-0031-1293491. Epub 2011 Nov 11. Tuberculosis; NICE CKS, January 2009. Tuberculosis; NICE Clinical Guideline (March 2011). Figures are the next attachmenet of power point