This document provides information about Pott's disease (spinal tuberculosis), including its epidemiology, sites of involvement within the spine, routes of infection and spread, clinical features, neurological complications, and classifications of spinal cord involvement. Some key points are: - Spinal tuberculosis most commonly involves the lower thoracic and upper lumbar vertebrae. - It spreads via hematogenous or lymphatic routes from a primary infection, most often in the lungs or abdominal lymph nodes. - Clinical features include chronic back pain, stiffness, deformity and cold abscesses. Advanced cases can cause paraplegia from spinal cord compression. - Paraplegia is most common when the thoracic spine is involved due to the

1. Pott’s Disease
Roll no 0954

2. •The spine is the most common site of skeletal tuberculosis
•50 per cent of all musculoskeletal TB.
•approximately 2 million people with spinal tuberculosis worldwide.

4. Artery of Adamkiewicz
• When damaged or
obstructed, it can result
in anterior spinal artery
syndrome with loss of
urinary and fecal
continence and
impaired motor
function of the legs;
sensory function is
often preserved to a
degree.
•largest anterior segmental medullary artery
•arises from a left posterior intercostal artery, which branches
from the aorta, and supplies the lower two thirds of the spinal
cord via the anterior spinal artery

5. Lower thoracic and lumbar vertebra-
80%
Large amount of spongy tissue within vertebral
body
Degree of weight bearing which is comparatively
more
More vertebral mobility
Proximity of maximum no of abdominal lymph
nodes to this region

6. Cervical 12%
Cervicodorsal 5%
Dorsal 42%
Dorsolumbar 12%
Lumbar 26%
Lumbosacral 3%

7. Sites within vertebra
1. Central (<5%)
• less common
• Infection comes through
nutrient A of vertebra
• Starts as diffuse
osteomyelitis in middle of
body
• Early collapse
• Central or concertina
collapse of vertebra

8. 2. Metaphyseal/intervertebral/paradiscal
space(98%)• Lower half of 1
vertebra and
upper half of
adjacent vertebra
with intervening
disc develop from
one sclerotome
• Bacillaemia
involves this
embryological
section more often
• Starts near
epiphysis

9. 3. Anterior/ periosteal
• Primary focus- in front of
body beneath ALL
• Via- branches of intercostal/
lumbar As
• May give rise to anterior
wedge compression
4. Appendiceal
Transverse process and rarely
vertebral arch
5. True tubercular arthritis
Atlantoaxial and atlanto-
occipital joints

11. Aetiopathogenesis
• Mycobacterium tuberculosis
• Always secondary
• Routes of infection
1. Blood borne- commonest
2. Lymph borne -from abdominal glands and
lymph vessels

12. Pathology
• Blood-borne infection usually settles in a vertebral body adjacent to the intervertebral
disc.
• Bone destruction and caseation follow, with infection spreading to the disc space and
the adjacent vertebrae
• Tuberculous endarteritis which develops results in marrow devitalisation
• Tubercular follicle develops later
Primary foci in lungs, lymph nodes or
abdomen
Bacillaemia
Batson plexus
spine

13. • Lamellae are destroyed due
to hyperemia causing
osteoporosis
• So vertebral body gets
easily compressed
• In thoracic vertebra
because of normal kyphotic
curve- anterior wedge
compression more
common
• cervical and lumbar-
minimal wedging

14. Types of vertebral reactions
Exudative
• Common
• severe
osteoporosis
• Rapid spread
• Abcess is formed
frequently
• Constitutional
symptoms
pronounced
Caseative
•Rarer
•Mechanism of
formation and
spread of
destruction is
similar but
slower

15. Cold abcess
• Non-pyogenic infection
• When body of vertebra collapses-> expresses
a collection of caseous material, granulation
tissue, tubercle bacilli, bone marrow, serum,
wbcs
• Not associated with usual signs of
inflammation
• It penetrates epiphyseal cortex and involves
adjacent disc and vertebra

16. • Beneath Ant
longitudinal ligament-
reaches neighbouring
vertebra
• May penetrate Ant
longitudinal ligament
and migrate along lines
of least
resistance(fascial
planes, blood vessels,
nerves)
• Posterior spread-
pressure on spinal cord(
more in thoracic)
• Post longitudinal
ligament- limits spread
of sequestra and bone
fragments into joints

17. Spread of cold abcess
Cervical region
1. Behind prevertebral
fascia
2. Retropharyngeal space
3. Post edge of SCM –
axilla, arm
4. Mediastinum, from
here it may gravitate to
-trachea
-oesophagus
-pleural cavity

18. Thoracic region
1. May press spinal cord posteriorly causing paraplegia
2. Laterally towards extrapleural space-effusion
3. May penetrate ALL and lie in mediastinum
4. May remain prevertebral and from here it may spread

19. Lateral arcuate
ligament and
quadratus lumborum
Remains behind
kidney/ extends
along nerves related
to bed of kidney
Along 12th, ilioinguinal
and iliohypogastric
nerves
Presents on anterior
abdominal wall
Medial arcuate
ligament
enters psoas
sheath
Reaches lesser
trochanter where
psoas gets inserted
Median
arcuate
ligament
Lumbar
abcess
Branches of
aorta

21. Lumbar region
1. May remain paravertebral
2. Psoas abcess
3. Iliac crest
4. Along femoral vessels to femoral triangle
5. Along gluteal vessels to gluteal region
6. Ischiorectal abcess-internal pudendal A
7. Rarely to iliac crest
8. May present in Petit’s triangle

22. – Psoas sheath
• Fascia covering the
psoas muscle
• Attaches to lumbar
vertebrae and pelvic
brim
• Thickened superiorly
to form the medial
arcuate ligament—a
site of origin of the
muscle of the
diaphragm
• Psoas abcess- mimics
femoral hernia, may
reach iliac fossa ,
lumbar region ,
popliteal fossa

23. • Three layers of fascia run outwards from the vertebrae, and fuse,
enclosing muscles as they do so, to form the lumbar aponeurosis. The
most posterior of these three fasciae, called the vertebral aponeurosis,
extends outwards from the spines of the vertebrae to meet the middle
layer, which arises from the tips of the transverse processes of the lumbar
vertebrae, enclosing the erector spinae between them. The anterior layer
arises from the junctions of transverse processes and bodies, and extends
outwards to meet the middle layer, enclosing the quadratus lumborum,
and separating it anteriorly from the psoas (see Fig. 19).
• The psoas fascia, or sheath, forms a fourth layer, which, rising from the
front of the bodies of the lumbar vertebra (with arches to permit of the
passing of the lumbar arteries), runs outwards and fuses with the anterior
layer, shortly before it fuses with the middle and posterior layers to form
the lumbar aponeurosis. Above, the psoas sheath commences at the
internal arcuate ligament of the diaphragm, being derived from the
diaphragmatic portion of the transversalis fascia, and thus the psoas
muscle only receives its sheath after perforating the diaphragm.
• The lumbar aponeurosis is a narrow ligamentous band, extending from the
last rib to the iliac crest. Besides giving attachments to the internal oblique
and transversalis muscles, it is continuous by its anterior edge with the
transversalis fascia, and hence it connects the outer border of the psoas

24. • The psoas sheath arises from the front of the bodies of the lumbar vertebra runs
outwards and fuses with the anterior, middle and posterior layers of fascia to form
the lumbar aponeurosis.
• commences at the internal arcuate ligament of the diaphragm, being derived from
the diaphragmatic portion of the transversalis fascia
• on reaching the iliac fossa, becomes directly continuous with the iliac fascia,
covering the iliacus muscle
• This iliac fascia, then, is attached along the whole iliac crest and ilio-lumbar
ligament.
• Then it extends over the psoas, on the inner border of which it is attached to the
sacrum and brim of the true pelvis, and ilio-pectineal eminence, and is continuous
with the pelvic fascia. Along Poupart's ligament it fuses with the transversalis
fascia, save where the external iliac vessels emerge to form the femoral vessels,
the transversalis fascia at this point joining in front of, and the iliac fascia behind,
the vessels, to form their sheath (femoral sheath).
• Thus the ilio-psoas muscle and anterior crural nerve enter the thigh through a
compartment composed of fascia and bone, which is closed, save for the
communication with the psoas above, and with the pelvis below and to the inside.

28. • As the vertebral bodies collapse into each other,
a sharp angulation (gibbus or kyphos) develops.
• cord damage →pressure by the abscess,
granulation tissue, sequestra or displaced bone,
or (occasionally) ischaemia from spinal artery
thrombosis.
• With healing → vertebrae recalcify ,bony fusion
may occur
• Spine is usually ‘unsound’, and flares are
common, resulting in further illness and further
vertebral collapse. .

29. Clinical features
Complaints
• There is usually a long history of ill-health and backache; in late
cases a gibbus deformity is the dominant feature.
• Constitutional symptoms antedate local spinal involvement-
weakness, anorexia, night sweats and cries, evening and afternoon
rise of temperature, loss of appetite and weight
Pain
• Back pain commonest- diffuse, later localised
• Referred pain
- arm (cervical)
- Girdle pain (dorsal)
- Abdomen(dorsolumbar)
- Groin (lumbar)

30. • Stiffness-
 very early symptom
 Paravertebral muscles go into spasm to prevent movement
• Cold abcess
 Swelling or problems secondary to compression effects-
dysphagia, dyspnoea
• Deformity –gibbus
under 10 years with thoracic spine TB - pectus carinatum
• Paraplegia-Back stiffness, weakness, parasthesia of lower
extremities- heralds onset of paraplegia
• Concurrent pulmonary TB is a feature in most children
under 10 years with thoracic spine involvement.

31. Examination
GPE
•Any active or healed primary lesion
•Diabetes, hypertension, jaundice
•Malnourished
Gait
•Cautious and careful
•Short steps to avoid jerking the spine
•C spine- may support head with both hands
under chin and twists the whole body to look
sideways

32. Attitude and deformity
• Very protective
attitude
• Muscle spasm
straightens the spine
• Dorsal spine- gibbus
or kyphus
Kyphosis(95%)
Scoliosis (5%)
Lordosis
Paravertebral thickening

33. Typical attitudes
• Upper cervical
• Lower cervical
• Upper thoracic
• Lower thoracic
• Upper lumbar
• Lower lumbar
Wryneck
Military position
Shoulders raised,
arms backwards
Alderman’s gait
Prominent
abdomen
Increased lordosis

34. Para-vertebral swelling
• Cold abscess
• Fullness or swelling on the back, chest wall or
anteriorly
• Fluctuant, may be tense
Tenderness
Spinous process of involved vertebra is tender to
percuss / when attempt is made to rotate the
vertebra

35. Pronounced wasting of back muscles
Sinuses
Movements
• Decreased in all directions especially forward, flexion
• Coin test
Spastic or flaccid paraplegia
LMN features -cauda equina lesion
Neurological examination-
• Upper and lower limbs
• Motor, sensory, reflexes
• Urinary and bowel functions assessed

36. POTT’S PARAPLEGIA
• Most feared complication
• Compression of spinal cord
• 10- 30%
• Most often with tb of dorsal spine
 Spinal cord terminates below L1
 Spinal cord is smallest in this
region(0.63 cm) (C and L-1.27cm)
 Normal curve encourages marked
kyphosis
 ALL in dorsal region loosely
confines the abcess

37. Causes
Inflammatory
• Oedema
• Granulatio
n tissue
• Abcess
• Caseous
tissue
Mechanical
•Tubercular
debris
•Sequestra
•Stenosis of
vertebral canal
•Internal
gibbus
Intrinsic
•Prolonged
stretching
•Infective
•Endocarditis
•Pathological
dislocation
•Tuberculous
meningomyelitis
•syringomyelia
•Infarction
Spinal
tumor
disease
•Extradural
granuloma
Spinal
tumour
syndrome
•Tuberculo
ma
•Peridural
fibrosis

38. Seddon’s classification
Early-onset paresis (usually within 2 years )
• pressure by inflammatory oedema, an abscess,
caseous material, granulation tissue or sequestra.
• CT and MRI may reveal cord compression.
• prognosis for neurological recovery following
surgery is good.
Late-onset paresis
• direct cord compression from increasing
deformity, or (occasionally) vascular insufficiency
of the cord
• recovery following decompression is poor.

39. Clinical features
• Early onset- lower limb weakness, upper
motor neuron signs, sensory dysfunction and
incontinence.
• Late onset- clumsiness, twitching, increased
reflexes, clonus, +ve Babinski sign
• Motor functions usually affected first

40. Paralysis follows these stages in order of severity-
• muscle weakness, spasticity, incoordination-
Pressure on corticospinal tracts whish are placed
anteriorly in the cord, more sensitive to pressure
• paraplegia in extension- tone increased due to
absence of normal corticospinal inhibition
• flexor spasm
• paraplegia in flexion- absence of paraspinal
functions in addition to corticospinal functions
• flaccid paraplegia- all transmission across cord
stops

41. Cotran, Robin and Kumar’s Grading
• Grade I - Negligible, pt is unaware, physician detects ankle
clonus and upgoing plantar
• Grade II- Mild, pt aware, complains of clumsiness,
incoordination or spasticity but walks with support
• Grade III- Moderate, non-ambulatory, paralysis in
extension, sensory deficit<50%
• Grade IV -Severe grade III + paraplegia in flexion with
severe muscle spasm+ sphincter disturbance+sensory
deficit >50%

42. • Clonus if the first most prominent early sign of Pott’s
disease
• Sense of position , vibration last to disappear
Sudden paraplegia:
1. Thromboembolism
2. Pathological dislocation
3. Rapid accumulation of infected material
HIV
•resurgence of TB,
•Spinal TB is AIDS defining.
•prone-opportunistic infections and atypical mycobacterial
infections
•Multiple vertebrae ,severe deformity, primary epidural
abscess