What is the management and outcome of prolonged thoracic nerve compression due to Potts disease (tuberculous spondylitis) presenting with severe myelopathy and significant motor weakness?

Management and Outcome of Prolonged Thoracic Nerve Compression from Pott's Disease with Severe Myelopathy and Motor Weakness 1/5

Immediate surgical decompression combined with anti-tuberculous chemotherapy is mandatory for Pott's disease presenting with severe myelopathy and motor weakness 1/5, as neurological recovery is relatively benign if urgent decompression is performed at disease onset, though prolonged compression significantly worsens prognosis. 1, 2

Immediate Management Algorithm

Surgical intervention must be performed urgently when neurological compromise is present, regardless of hemodynamic stability or sepsis concerns. 1 The IDSA guidelines provide a strong recommendation for immediate surgical intervention in patients with neurologic compromise from vertebral osteomyelitis, which includes Pott's disease. 1

Surgical Approach Selection

• Trans-thoracic corpectomy with anterior decompression is the preferred approach for thoracic Pott's disease with anterior cord compression and abscess formation. 3, 4
• The surgical plan should include: abscess drainage, mass removal, spinal realignment with anterior graft (autologous rib or vertebral body replacement), and posterior stabilization with instrumentation. 3, 5
• Posterior approach decompression may be required first if there is acute paraplegia with posterior compression or mechanical instability, followed by staged anterior reconstruction if needed. 5

Medical Therapy Initiation

• Start RIPE therapy (rifampin, isoniazid, pyrazinamide, ethambutol) immediately upon diagnosis, even before culture confirmation. 1, 3
• Do not delay antimicrobial therapy to obtain biopsy in patients with neurologic compromise. 1
• Continue anti-tuberculous chemotherapy for minimum 12 months postoperatively. 4

Prognostic Factors and Expected Outcomes

Critical Determinants of Recovery

Pretreatment neurological status is the main determinant of recovery, with duration of symptoms before intervention being inversely correlated with neurological improvement. 6, 2

• Timing of intervention: Neurological involvement is relatively benign if urgent decompression is performed at disease onset. 2
• Prolonged compression leads to marked atrophy, neuronal loss in gray matter, and severe white matter degeneration—similar to transient hypoperfusion syndrome. 1
• Pathological progression worsens with duration and degree of anteroposterior compression. 1

Realistic Outcome Expectations

For patients presenting with severe motor weakness (1/5):

• Only 30% of non-ambulatory patients and 2-6% of paraplegic patients regain ability to walk with standard treatment. 6
• However, with aggressive surgical decompression and optimal medical therapy, full neurologic function restoration is possible within 4 months, even in immunocompromised patients. 3
• The presence of prolonged compression significantly worsens this prognosis, as irreversible spinal cord damage may have already occurred. 1, 2

Critical Pitfalls to Avoid

Delayed Diagnosis and Treatment

• Leg weakness (69%), gibbus deformity (46%), pain (21%), and palpable mass (10%) are the presenting symptoms of Pott's disease. 2
• The slippery course often causes diagnostic delay until large abscess, neurological impairment, or vertebral fractures develop. 4
• Medical treatment alone is ineffective once abscess formation occurs, as antibiotics cannot penetrate the abscess capsule to achieve effective concentration. 4

Inadequate Surgical Planning

• The thoracic cord is particularly susceptible to external compression due to kyphotic tethering by dentate ligaments and tenuous blood supply. 7
• Careful preoperative planning with specific attention to location and source of compression is critical to successful decompression and complication avoidance. 7
• Consider multilevel involvement, as non-contiguous tuberculous spondylitis can occur. 5

Postoperative Management

• Implement thromboprophylaxis immediately with combined pharmacologic and mechanical prophylaxis to prevent deep vein thrombosis in paraplegic patients. 6
• Perform MRI with gadolinium at 12 months postoperatively to assess for disease recurrence. 4
• Continue physiotherapy throughout recovery period for optimal neurological restoration. 5

Special Considerations

Immunocompromised Patients

• HIV-positive or otherwise immunocompromised patients have greatly complicated treatment and worsened outcomes. 3
• Despite this, full neurologic recovery remains possible with aggressive surgical and medical management. 3

Culture Confirmation

• Culture positivity may take 40 days of incubation, so do not delay treatment awaiting confirmation. 4
• Obtain mycobacterial cultures on all surgical specimens. 1