What are the full details of Pott's disease (Spinal Tuberculosis)?

From the Guidelines

Pott's disease, a form of tuberculosis affecting the spine, should be treated with a 6- to 9-month antitubercular regimen containing rifampin, as it has been shown to be at least as effective as 18-month regimens without rifampin. The treatment approach for Pott's disease involves a combination of antitubercular therapy and, in some cases, surgical intervention. According to the American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America guidelines, as stated in the study by 1, a 6- to 9-month regimen containing rifampin is recommended.

Key Considerations

• The infection typically begins in the vertebral body and can spread to adjacent intervertebral discs, causing destruction of bone and cartilage.
• Symptoms include back pain, stiffness, fever, night sweats, weight loss, and neurological complications such as weakness or paralysis if the spinal cord becomes compressed.
• Diagnosis involves clinical evaluation, imaging studies (X-rays, MRI, CT scans), and microbiological confirmation through tissue samples.
• Treatment requires a multidisciplinary approach with antitubercular therapy as the cornerstone, typically consisting of a four-drug regimen (isoniazid, rifampin, pyrazinamide, and ethambutol) for 2 months, followed by isoniazid and rifampin for an additional 7-10 months, as supported by the study 1.
• Surgical intervention may be necessary for cases with significant neurological deficits, spinal instability, or deformity, as noted in the study by 1, which demonstrated no additional benefit of surgical debridement or radical operation in combination with chemotherapy compared to chemotherapy alone, but suggested that surgery may be beneficial in certain situations.

Treatment Approach

• A 9-month duration of antitubercular therapy may be favored by some experts due to the difficulties in assessing response, as mentioned in the study by 1.
• Myelopathy with or without functional impairment most often responds to chemotherapy, with studies showing complete resolution of myelopathy or complete functional recovery in a significant proportion of patients, as reported in the study by 1.
• Bracing or immobilization may be recommended to support the spine during healing, and early diagnosis and treatment are crucial to prevent permanent spinal deformity and neurological complications.

From the Research

Definition and Overview

• Pott's disease, also known as tuberculous spondylitis, is a vertebral infection caused by Mycobacterium tuberculosis 2.
• It is an entity that produces a characteristic kyphotic deformity, and was described by Sir Percivall Pott in 1779 and 1782 3.
• The disease is an uncommon extrapulmonary form of tuberculosis, and delay in diagnosis and management may cause serious complications 4.

Clinical Findings and Diagnosis

• Clinical findings include complaints of back pain and symptoms of fever, chills, weight loss, malaise, and fatigue 3.
• Characteristically, a late finding is paraplegia, which is occasionally the initial indicator of spinal involvement 3.
• Plain spinal radiographs are usually the initial diagnostic modality utilized, and computed tomography scanning and magnetic resonance imaging can be used to further define the process 3.
• The differential diagnosis includes neoplasm, pyogenic or disseminated fungal infection, and sarcoid arthritis 3.
• Tc-99m MDP bone and Ga-67 citrate scintigraphy can be used to detect multiple sites of Pott's disease 4.

Treatment and Management

• Antituberculous chemotherapy with isoniazid, rifampicin, pyrazinamide, and ethambutol is commonly used to treat Pott's disease 4, 5.
• Surgical treatment, such as posterior decompression and posterolateral spinal fusion with bone grafts, may be necessary in some cases 4, 2.
• Early diagnosis and treatment are crucial to prevent severe vertebral and neurological sequelae 6.

Epidemiology and Risk Factors

• Pott's disease is still generally a disease of children in developing countries, but in Europe and North America, it more commonly involves older adults 3.
• The incidence of tuberculosis in the industrialized world has declined dramatically, but the number of cases of extrapulmonary disease, including Pott's disease, has remained relatively unchanged 3.
• Diabetes is a risk factor for Pott's disease, as seen in a case report where the disease was incidentally detected on Tc-99m MDP bone and Ga-67 citrate scintigraphy in a patient with diabetes 4.