“destruction of disc space

and adjacent vertebral

bodies, collapse of spinal
elements and progressive
spinal deformities”
Pervical Pott, 1779
• most common and most
dangerous form of
skeletal tuberculosis
• 2-20% of extrapulmonary
TB
• thoracolumbar region
• long history of illness
• constitutional illness
• back pain with restricted
movement
• abscess ( groin or lumbar
region at one side from
midline)
• weakness of lower limb
• paraesthesia of lower limb
• deformity-kyphosis
• Presence of blood-borne infection settles
in a vertebral body.
• Lead to bone destruction and caseation.
• Infection spread to the disc space and the
adjacent vertebrae.
• Also spread to paravertebral soft tissue,
causing abscess, and track along muscle
planes to sacro-iliac or hip joint, or along
the psoas muscle to the thigh.
• As vertebral bodies collapse, a sharp angulation (
kyphos) develops
• As vertebral bodies collapse, a sharp
angulation ( kyphos) develops.
• There is a major risk of cord damage due
to pressure by abscess, granulation tissue,
sequestra or displaced bone.
• With healing, the vertebrae recalcify and
bony fusion may occur between them.
• If there too much angulation, spine is
usually “unsound” and flares are common,
cause further illness and collapse.
• With progressive kyphos, risk of cord
compression.
 Imaging Studies
X-ray
1. Earliest signs :
Local osteoporosis of 2 adjacent vertebrae
Narrowing of the intervertebral disc space
Fuzziness of end plate
2. Progressive disease :
 bone destruction
 Collapse of adjacent vertebral bodies into each other,
forward spine angulation
 Paraspinal shadows(oedema/swelling/paravertebral
abscess)
3. Chest x-ray is essential (because spine x-ray may mimic
those of other infections including fungal infections and
parasitic infections.
4. Healing :
 bone density increase
 The ragged appearance disappears
 Paravertebral abscess may undergo
resolution/fibrosis/calcification
MRI and CT scans are invaluable in the investigation of
hidden lesions, involvement of posterior vertebral
elements, paravertebral abscess, an epidural abscess
and cord compression.
Myelography is appropriate when these facilities are not
available.
 Special Investigations
• ESR : -increased (in acute stage)
• Positive Mantoux test
• Needle biopsy is recommended in pt. with no
neurological signs -> to confirm the diagnosis by
histological and micrological investigations.
• If there are signs of neurological involvement, operative
debridgement & decompression of the spinal cord will be
required.
• Voluntary counselling & testing(VCT) ->pt. with
HIV(usually showing generalized lymphadenopathy, skin
& mucocutaneous lesions and marked weight loss)
• Synovial fluid microscopic examination
 Cloudy, increase protein concentration
 Increase white cell count
 Gram stain-acid fast bacilli
 Culture and sensitivity
 Differential Diagnosis

1. Spinal TB must be distinguished from other causes

vertebral pathology, particularly pyogenic & fungal
infection, malignant disease and parasitic infections such
as hyatid disease
2. Disc space collapse is typical of infection ; disc
preservation is typical of metastatic disease.
3. Metastases may cause vertebral body collapse similar to
that seen in TB (but in contrast in tuberculous spondilitis,
the disc space is usually preserved)
• To eradicate or arrest the disease
• To prevent or correct the deformity
• To prevent or treat major complication
CONSERVATIVE

1. REST
- Prolonged, uniterrupted, rigid, and enforced
- Involved splintage of the joint and traction
- To overcome muscle spasm and prevent collapse of articular surfaces
- Those who are diagnosed and treated early are kept in bed only until pain and
systemic changes subside ( 6 months to a year )
- Those with progressive joint destruction may need a longer period of rest, to
prevent ankylosis.
2. Anti – tuberculous Chemotherapy

- Daily dosage of Rifampicin (600 mg ), Isoniazid

(300 mg ), Pyrazinamide (2 g ).
- Must be given in combination for 6 months.
- Dropping the pyrazinamide after the first 2
months.
- Ethionamide and Streptomycin may have to be
substituted for Isoniazid in cases of drug
resistance.
OPERATIVE

• Indication :
- There is an abscess that can readily be drained.
- For advanced disease with marked bone destruction and severe
kyphosis.
- Neurological deficit including paraparesis that has not responded
to drug therapy
1. Through an anterior approach, all infected and necrotic
material is evacuated or excised, and the gap is filled
with iliac crest or rib grafts that act as a strut.
2. If several levels are involved, anterior or posterior fixation
and fusion may be needed for stabilisation.
1. Kyphosis: vertebral collapse and anterior angulation
2. Abscess and sinus formation : necrotic material from
vertebrae spread to cause paravertebral cold.
Abscess’s area Distribution track
Lower abdominal Along the intercostal, ilioinguinal and iliohypogastric nerves
wall
Thigh Along the psoas sheath
Buttock Along the superior gluteal nerve
Petit’s triangle Along the flat muscles of abdominal wall
Ischiorectal fossa Along the internal pudendal nerve
Retropharyngeal Enter trachea, esophagus, or pleura, can spread to sternocleidomastoid
muscle
3. Neurological deficit (paraplegia, bladder and bowel
dysfunction)
Pott’s Paraplegia
• most serious complication of spinal TB.
• Early onset paresis due to cord compression
• Abscess, caseous material, bony sequestrum
Clinical features
- Lower limb weakness
- UMNL signs (increase muscle tone, brisk reflex, clonus,
upright plantar reflex)
- Sensory dysfunction
- Vertebral disease
• Late onset paresis due to increasing deformity,
reactivation of the disease, vascular deficiency of the
cord.
• CT scan and MRI shows cord compression
• Myelography show block
Reference

• Apley's System of Orthopaedics and Fractures, 9th edition

by Louis S, David W et al
• Compilation of Notes Orthopaedics by Dr Najibah
Syakirah