Frequency
Pott Disease (Tuberculous
Spondylitis)
Jose A Hidalgo, MD, Assistant Professor, Universidad de San Marcos Medical
School; Attending Physician, Department of Internal Medicine, Division of
Infectious Diseases, Guillermo Almenara Hospital
George Alangaden, MD, Staff Physician, Associate Professor, Department of
Internal Medicine, Division of Infectious Diseases, Detroit Medical Center,
Wayne State University School of Medicine
Updated: Aug 29, 2008
Introduction
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 and in ancient mummies from Egypt and Peru.[1 ]In 1779,
Percivall Pott, for whom Pott disease is named, presented the classic description
of spinal tuberculosis.[2 ]
Since the advent of antituberculous drugs and improved public health measures,
spinal tuberculosis has become rare in developed countries, although it is still a
significant cause of disease in developing countries. 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. The basic
lesion involved in Pott disease is a combination of osteomyelitis and arthritis that
usually involves more than one vertebra. The anterior aspect of the vertebral
body adjacent to the subchondral plate is area 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, because
the disk is vascularized, it can be a primary site.[3 ]
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.
United States
 Although the incidence of tuberculosis increased in the late 1980s to
early 1990s, the total number of cases has decreased in recent years.
 The frequency of extrapulmonary tuberculosis has remained stable.
 Bone and soft-tissue tuberculosis accounts for approximately 10% 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.[4 ]
International
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).[5 ]
Mortality/Morbidity
 Pott disease is the most dangerous form of musculoskeletal tuberculosis
because it can cause bone destruction, deformity, and paraplegia.
 Pott disease most commonly involves the thoracic and lumbosacral
spine. However, published series have show some variation.[6,7,8,9 ]Lower
thoracic vertebrae is the most common area of involvement (40-50%),
followed closely by the lumbar spine (35-45%). In other series,
proportions are similar but favor lumbar spine involvement.[10 ]
 Approximately 10% of Pott disease cases involve the cervical spine.
Race
 Data from Los Angeles and New York show that musculoskeletal
tuberculosis primarily affects African Americans, Hispanic Americans,
Asian Americans, and foreign-born individuals.
 As with other forms of tuberculosis, the frequency of Pott Disease is
related to socioeconomic factors and historical exposure to the infection.
Sex
Although some series have found that Pott disease does not have a sexual
predilection, the disease is more common in males (male-to-female ratio of 1.5-
2:1).
Age
  In the United States and other developed countries, Pott disease occurs o Careful assessment of spinal alignment
primarily in adults. o Inspection of skin, with attention to detection of sinuses
 In countries with higher rates of Pott disease, involvement in young o Abdominal evaluation for subcutaneous flank mass
adults and older children predominates.
o Meticulous neurologic examination
Clinical  Although both the thoracic and lumbar spinal segments are nearly
History equally affected in persons with Pott disease, the thoracic spine is
 The presentation of Pott disease depends on the following: frequently reported as the most common site of involvement. Together,
they comprise 80-90% of spinal tuberculosis sites. The remaining cases
o Stage of disease correspond to the cervical spine.
o Affected site  Almost all patients with Pott disease have some degree of spine
o Presence of complications such as neurologic deficits, deformity (kyphosis).
abscesses, or sinus tracts  Large cold abscesses of paraspinal tissues or psoas muscle may protrude
 The reported average duration of symptoms at diagnosis is 4 months[7 ] under the inguinal ligament and may erode into the perineum or gluteal
but can be considerably longer, even in most recent series.[11,9 ]This is area.
due to the nonspecific presentation of chronic back pain.  Neurologic deficits may occur early in the course of Pott disease. Signs
 Back pain is the earliest and most common symptom. of such deficits depend on the level of spinal cord or nerve root
o Patients with Pott disease usually experience back pain for compression.
weeks before seeking treatment.  Pott disease that involves the upper cervical spine can cause rapidly
o The pain caused by Pott disease can be spinal or radicular. progressive symptoms.
 Potential constitutional symptoms of Pott disease include fever and o Retropharyngeal abscesses occur in almost all cases.
weight loss. o Neurologic manifestations occur early and range from a single
 Neurologic abnormalities occur in 50% of cases and can include spinal nerve palsy to hemiparesis or quadriplegia.
cord compression with paraplegia, paresis, impaired sensation, nerve  Many persons with Pott disease (62-90% of patients in reported
root pain, and/or cauda equina syndrome. series[6,7 ]) have no evidence of extraspinal tuberculosis, further
 Cervical spine tuberculosis is a less common presentation but is complicating a timely diagnosis.
potentially more serious because severe neurologic complications are  Information from imaging studies, microbiology, and anatomic
more likely. pathology should help establish the diagnosis.
o This condition is characterized by pain and stiffness. Differential Diagnoses
o Patients with lower cervical spine disease can present with Actinomycosis Multiple Myeloma
dysphagia or stridor.
Blastomycosis Mycobacterium Avium-Intracellulare
o Symptoms can also include torticollis, hoarseness, and
Brucellosis Mycobacterium Kansasii
neurologic deficits.
Candidiasis Nocardiosis
 The clinical presentation of spinal tuberculosis in patients infected with
the human immunodeficiency virus (HIV) is similar to that of patients Cryptococcosis Paracoccidioidomycosis
who are HIV negative; however, spinal tuberculosis seems to be more Histoplasmosis Septic Arthritis
common in persons infected with HIV.[12 ] Metastatic Cancer, Unknown Primary Site Spinal Cord Abscess
Physical Miliary Tuberculosis Tuberculosis
 The examination should include the following: Other Problems to Be Considered
Spinal tumors o CT scanning reveals early lesions and is more effective for
defining the shape and calcification of soft-tissue abscesses.
Workup
o In contrast to pyogenic disease, calcification is common in
Laboratory Studies tuberculous lesions.
 Tuberculin skin test (purified protein derivative [PPD]) results are  MRI
positive in 84-95% of patients with Pott disease who are not infected
with HIV. o MRI is the criterion standard for evaluating disk-space
infection and osteomyelitis of the spine and is most effective
 The erythrocyte sedimentation rate (ESR) may be markedly elevated for demonstrating the extension of disease into soft tissues and
(>100 mm/h). the spread of tuberculous debris under the anterior and
 Microbiology studies are used to confirm diagnosis. Bone tissue or posterior longitudinal ligaments. MRI is also the most effective
abscess samples are obtained to stain for acid-fast bacilli (AFB), and imaging study for demonstrating neural compression.[15,16 ]
organisms are isolated for culture and susceptibility. CT-guided o MRI findings useful to differentiate tuberculous spondylitis
procedures can be used to guide percutaneous sampling of affected bone from pyogenic spondylitis include thin and smooth
or soft-tissue structures. These study findings are positive in only about enhancement of the abscess wall and well-defined paraspinal
50% of the cases. abnormal signal, whereas thick and irregular enhancement of
Imaging Studies abscess wall and ill-defined paraspinal abnormal signal suggest
 Radiography pyogenic spondylitis. Thus, contrast-enhanced MRI appears to
be important in the differentiation of these two types of
o Radiographic changes associated with Pott disease present
spondylitis.[17 ]
relatively late. The following are radiographic changes
characteristic of spinal tuberculosis on plain radiography: [13 ]
 Lytic destruction of anterior portion of vertebral body
 Increased anterior wedging
 Collapse of vertebral body
 Reactive sclerosis on a progressive lytic process
 Enlarged psoas shadow with or without calcification
o Additional radiographic findings may include the following:
 Vertebral end plates are osteoporotic.
 Intervertebral disks may be shrunk or destroyed.
 Vertebral bodies show variable degrees of destruction.
 Fusiform paravertebral shadows suggest abscess
formation.
 Bone lesions may occur at more than one level.
 CT scanning [14 ]

o CT scanning provides much better bony detail of irregular lytic

lesions, sclerosis, disk collapse, and disruption of bone
circumference.
o Low-contrast resolution provides a better assessment of soft
tissue, particularly in epidural and paraspinal areas.
MRI of a 31-year-old man with tuberculosis of the spine. Images show the
thoracic spine before and after an infusion of intravenous gadolinium
contrast. The abscess and subsequent destruction of the T11-T12 disc
interspace is marked with arrowheads. Vertebral body alignment is normal.
Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit,
Mich.
MRI of the T11 in a 31-year-old man with tuberculosis of the spine (the
same patient as in picture 1). Extensive bone destruction consistent with
tuberculous osteomyelitis is evident. The spinal cord has normal caliber and
signal. No evidence of spinal cord compression or significant spinal stenosis
is distinguishable. Courtesy of Mark C. Diamond, MD, and J. Antonio
Bouffard, MD, Detroit, Mich.
Other Tests
 Radionuclide scanning findings are not specific for Pott disease.
 Gallium and Tc-bone scans yield high false-negative rates (70% and up
to 35%, respectively).[18 ]
Procedures
 Use a percutaneous CT-guided needle biopsy of bone lesions to obtain
tissue samples.
o This is a safe procedure that also allows therapeutic drainage of
large paraspinal abscesses.
o Obtain a tissue sample for microbiology and pathology studies
to confirm diagnosis and to isolate organisms for culture and
susceptibility.
 Some cases of Pott disease are diagnosed following an open drainage
procedure (eg, following presentation with acute neurologic
deterioration).
Histologic Findings
Because microbiologic studies may be nondiagnostic of Pott disease, anatomic
pathology can be significant. Gross pathologic findings include exudative
granulation tissue with interspersed abscesses. Coalescence of abscesses results
in areas of caseating necrosis.
Treatment
Medical Care
 Before the advent of effective antituberculosis chemotherapy, Pott
disease was treated with immobilization using prolonged bed rest or a
body cast. At the time, Pott disease carried a mortality rate of 20%, and
relapse was common (30%).
 The duration of treatment, surgical indications, and inpatient care have
since evolved.
 Studies performed by the British Medical Research Council indicate that
tuberculous spondylitis of the thoracolumbar spine should be treated
with combination chemotherapy for 6-9 months.[4 ]
 According to the most recent recommendations issued in 2003 by the
US Centers for Disease Control and Prevention, the Infectious Diseases
Society of America, and the American Thoracic Society, a 4-drug
regimen should be used empirically to treat Pott disease. [1 ] 
 Isoniazid and rifampin should be administered during the whole course
of therapy. Additional drugs are administered during the first 2 months
 of therapy. These are generally chosen among the first-line drugs, which
include pyrazinamide, ethambutol, and streptomycin. The use of second-
line drugs is indicated in cases of drug resistance.
 Regarding the duration of therapy, the British Medical Research Council
studies did not include patients with multiple vertebral involvement,
cervical lesions, or major neurologic involvement. Because of these
limitations, many experts still recommend chemotherapy for 9-12
months.
 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. Routine surgery does not to seem to be indicated. Most common
indications for surgical procedures are discussed below.
Surgical Care
 Indications for surgical treatment of Pott disease generally include the
following:[22,23 ]
o Neurologic deficit (acute neurologic deterioration, paraparesis,
paraplegia)
o Spinal deformity with instability or pain
o No response to medical therapy (continuing progression of
kyphosis or instability)
o Large paraspinal abscess
o Nondiagnostic percutaneous needle biopsy sample
 Resources and experience are key factors in the decision to use a
surgical approach.
 The lesion site, extent of vertebral destruction, and presence of cord
compression or spinal deformity determine the specific operative
approach (kyphosis, paraplegia, tuberculous abscess).
 Vertebral damage is considered significant if more than 50% of the
vertebral body is collapsed or destroyed or a spinal deformity of more
than 5° exists.
 The most conventional approaches include anterior radical focal
debridement and posterior stabilization with instrumentation.[24,10 ]
 In Pott disease that involves the cervical spine, the following factors
justify early surgical intervention:
o High frequency and severity of neurologic deficits
o Severe abscess compression that may induce dysphagia or
asphyxia
o Instability of the cervical spine
 Contraindications: Vertebral collapse of a lesser magnitude is not
considered an indication for surgery because, with appropriate treatment
and therapy compliance, it is less likely to progress to a severe
deformity.
Consultations
 Orthopedic surgeons
 Neurosurgeons
 Rehabilitation teams
Activity
 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.
Medication
 A 4-drug regimen should be used empirically to treat Pott disease.
Treatment can be adjusted when susceptibility information becomes
available. 
 Isoniazid and rifampin should be administered during the whole course
of therapy. Additional drugs are administered during the first 2 months
of therapy. These are generally chosen among the first-line drugs, which
include pyrazinamide, ethambutol, and streptomycin.
 A 3-drug regimen usually includes isoniazid, rifampin, and
pyrazinamide.
 The use of second-line drugs is indicated in cases of drug resistance.
 The duration of treatment is somewhat controversial. Although some
studies favor a 6- to 9-month course, traditional courses range from 9
months to longer than 1 year. The duration of therapy should be
individualized and based on the resolution of active symptoms and the
clinical stability of the patient.
Antituberculous drugs
These agents inhibit growth and proliferation of causative organism.
Isoniazid (Laniazid, Nydrazid)
Highly active against Mycobacterium tuberculosis. Has good GI absorption and Pediatric
penetrates well into all body fluids and cavities. 10-20 mg/kg PO qd; not to exceed 600 mg/d
Dosing Interactions
Adult Induces microsomal enzymes, which may decrease effects of acetaminophen,
300 mg PO qd; alternatively, 15 mg/kg IV qd oral anticoagulants, barbiturates, benzodiazepines, beta-blockers,
Pediatric chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine,
10 mg/kg PO qd digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine,
dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood
Interactions pressure may increase with coadministration of enalapril; coadministration with
Higher incidence of isoniazid-related hepatitis can occur with daily alcohol INH may result in higher rate of hepatotoxicity than with either agent alone
ingestion; aluminum salts may decrease isoniazid serum levels (administer 1-2 h (discontinue one or both agents if alterations in LFTs occur)
before taking aluminum salts); may increase anticoagulants effects with Contraindications
coadministration; may inhibit metabolic clearance of benzodiazepines;
carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent Documented hypersensitivity
use (monitor carbamazepine concentrations and liver function); coadministration Precautions
with cycloserine may increase adverse CNS effects (eg, dizziness); acute Pregnancy
behavioral and coordination changes may occur with coadministration of C - Fetal risk revealed in studies in animals but not established or not studied in
disulfiram; coadministration with rifampin after halothane anesthesia may result humans; may use if benefits outweigh risk to fetus
in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal Precautions
enzymes and increase toxicity of hydantoin
Obtain CBC counts and baseline clinical chemistries prior to and throughout
Contraindications therapy; in liver disease, weigh benefits against risk of further liver damage;
Documented hypersensitivity; previous isoniazid-associated hepatic injury or interruption of therapy and high-dose intermittent therapy are associated with
other severe adverse reactions reversible thrombocytopenia if therapy is discontinued as soon as purpura occurs;
Precautions if treatment is continued or resumed after appearance of purpura, cerebral
Pregnancy hemorrhage or death may occur
C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus
Precautions Pyrazinamide
Monitor patients with active chronic liver disease or severe renal dysfunction; Bactericidal against M tuberculosis in an acid environment (macrophages). Has
periodic ophthalmologic examinations during INH therapy are recommended good absorption from the GI tract and penetrates well into most tissues, including
even when visual symptoms do not occur CSF.
Dosing
Adult
Rifampin (Rifadin, Rimactane) 15-30 mg/kg PO qd
For use in combination with at least one other antituberculous drug; inhibits Pediatric
DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance Not established
may occur. Interactions
Dosing None reported
Adult
Contraindications
10 mg/kg PO qd; not to exceed 600 mg/d
Documented hypersensitivity; severe hepatic damage, acute gout
Precautions Bactericidal in an alkaline environment. Because it is not absorbed from the GI
Pregnancy tract, must be administered parenterally. Exerts action mainly on extracellular
C - Fetal risk revealed in studies in animals but not established or not studied in tubercle bacilli. Only about 10% of the drug penetrates cells that harbor
humans; may use if benefits outweigh risk to fetus organisms. Enters the CSF only in the presence of meningeal inflammation.
Precautions
Excretion is almost entirely renal.
Use only in combination with other effective antituberculous agents; inhibits Dosing
renal excretion of urates; may result in hyperuricemia (usually asymptomatic); Adult
perform baseline serum uric acid determinations; discontinue drug if signs of 15 mg/kg IM qd; not to exceed 1 g/d
hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor Pediatric
in liver disease); discontinue pyrazinamide if signs of hepatocellular damage 20-40 mg/kg IM qd; not to exceed 1 g/d
appear; caution in history of diabetes mellitus
Interactions
Nephrotoxicity may be increased with aminoglycosides, cephalosporins,
penicillins, amphotericin B, and loop diuretics
Ethambutol (Myambutol) Contraindications
Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF Documented hypersensitivity; non–dialysis-dependent renal insufficiency
concentrations remain low, even in the presence of meningeal inflammation.
Precautions
Dosing
Pregnancy
Adult
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
15-25 mg/kg PO qd
Precautions
Pediatric
Narrow therapeutic index; not intended for long-term therapy; caution in renal
15-25 mg/kg PO qd failure not on dialysis; caution with myasthenia gravis, hypocalcemia, and
Not recommended for young children because of difficulty monitoring vision conditions that depress neuromuscular transmission
Interactions
Aluminum salts may delay and reduce absorption (administer several hours
Follow-up
before or after ethambutol dose) Further Inpatient Care
Contraindications  Once the diagnosis of Pott disease is established and treatment is started,
Documented hypersensitivity; optic neuritis (unless clinically indicated) the duration of hospitalization depends on the need for surgery and the
clinical stability of the patient.
Precautions
Pregnancy
Further Outpatient Care
C - Fetal risk revealed in studies in animals but not established or not studied in  Patients with Pott disease should be closely monitored to assess their
humans; may use if benefits outweigh risk to fetus response to therapy and compliance with medication. Directly observed
Precautions
therapy may be required.
Reduce dose in impaired renal function; may have reversible visual adverse  The development or progression of neurologic deficits, spinal deformity,
effects if promptly discontinued 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
Streptomycin disease should undergo long-term follow-up until their entire growth
potential is completed.[25 ]
Complications Multimedia
 Abscess
 Spine deformities
 Neurologic deficits and paraplegia
Prognosis
 Current treatment modalities are highly effective if not complicated by
severe deformity or established neurologic deficit.
 Therapy compliance and drug resistance are additional factors that
significantly affect individual outcomes.
 Paraplegia resulting from the active disease causing cord compression
usually responds well to chemotherapy.
 If medical therapy does not result in rapid improvement, operative
decompression will greatly increase the recovery rate.
 Paraplegia can manifest or persist during healing because of permanent
spinal cord damage.
Patient Education
 Patients with Pott disease should be instructed on the importance of Media file 1: MRI of a 31-year-old man with tuberculosis of the spine.
therapy compliance. Images show the thoracic spine before and after an infusion of intravenous
 For excellent patient education resources, visit eMedicine's Bacterial gadolinium contrast. The abscess and subsequent destruction of the T11-T12
and Viral Infections Center. Also, see eMedicine's patient education disc interspace is marked with arrowheads. Vertebral body alignment is
article Tuberculosis. normal. Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD,
Detroit, Mich.
Miscellaneous
Medicolegal Pitfalls
 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.
 The diagnosis of tuberculous spondylitis should be investigated if strong
clinical suspicion exists, even if suggestive pulmonary radiology
findings are absent.
 Other features suggestive of tuberculosis include the following:
o Positive PPD result
o Chest radiograph that shows apical scarring, infiltrates, or
cavitary disease
o Presence of risk factors for tuberculosis
 Spinal tuberculosis should always be suspected when radiographs
demonstrate a destructive spine process.
 active M. tuberculosis cultured (if done)
Clinical, bacteriologic, or radiographic evidence of current disease 4 TB
Not clinically active History of episode(s) of TB
or
Abnormal but stable radiographic findings
Positive reaction to the tuberculin skin test
Negative bacteriologic studies (if done)
and
No clinical or radiographic evidence of current disease 5 TB suspect
Diagnosis pending
TB disease should be ruled in or out within 3 months

Media file 2: MRI of the T11 in a 31-year-old man with tuberculosis of the
spine (the same patient as in picture 1). Extensive bone destruction
consistent with tuberculous osteomyelitis is evident. The spinal cord has
normal caliber and signal. No evidence of spinal cord compression or
significant spinal stenosis is distinguishable. Courtesy of Mark C. Diamond,
MD, and J. Antonio Bouffard, MD, Detroit, Mich.

Class Type Description

0 No TB exposure
Not infected No history of exposure
Negative reaction to tuberculin skin test 1 TB exposure
No evidence of infection History of exposure
Negative reaction to tuberculin skin test 2 TB infection
No disease Positive reaction to tuberculin skin test
Negative bacteriologic studies (if done)
No clinical, bacteriologic, or radiographic evidence of TB 3 TB, clinically