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Definition
AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis
secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's
disease
Incidence
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
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).
Mortality/Morbidity
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 primarily
in adults.
• In countries with higher rates of Pott disease, involvement in young adults and
older children predominates.
• Bone/Spinal Disease
• Non-Communicable Disease
Pathophysiology
Extrapulmomary tuberculosis
Vertebral narrowing
Vertebral collapse
Spinal damage
POTT’S DISEASE
Diagnostic Studies
Laboratory Studies
• Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-
95% of patients with Pott disease who are not infected with HIV.
• The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100
mm/h).
• Microbiology studies are used to confirm diagnosis. Bone tissue or abscess
samples are obtained to stain for acid-fast bacilli (AFB), and organisms are
isolated for culture and susceptibility. CT-guided procedures can be used to
guide percutaneous sampling of affected bone or soft-tissue structures. These
study findings are positive in only about 50% of the cases.
Imaging Studies
• Radiography
• Radiographic changes associated with Pott disease present 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
• 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 scanning14
MRI
ο MRI is the criterion standard for evaluating disk-space infection and
osteomyelitis of the spine and is most effective for demonstrating the
extension of disease into soft tissues and the spread of tuberculous debris
under the anterior and posterior longitudinal ligaments. MRI is also the
most effective imaging study for demonstrating neural compression.
ο MRI findings useful to differentiate tuberculous spondylitis from pyogenic
spondylitis include thin and smooth enhancement of the abscess wall and
well-defined paraspinal abnormal signal, whereas thick and irregular
enhancement of abscess wall and ill-defined paraspinal abnormal signal
suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be
important in the differentiation of these two types of spondylitis.
Other Tests
Management
Medical Care
Surgical Care
• Indications for surgical treatment of Pott disease generally include the following:
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.
• 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.
Nursing Diagnosis
Nursing Responsibilities
• Drug treatment is generally sufficient for Pott’s disease, with spinal immobilization
if required.
• Surgery is required if there is spinal deformity or neurological signs of spinal cord
compression.
• Standard antituberculosis treatment is required. Duration of antituberculosis
treatment: If debridement and fusion with bone grafting are performed, treatment
can be for six months. If debridement and fusion with bone grafting are NOT
performed a minimum of 12 months’ treatment is required.
• It may also be necessary to immobilize the area of the spine affected by the
disease, or the person may need to undergo surgery in order to drain any
abscesses that may have formed or to stabilize the spine.
• Other interventions include application of knight/ taylor brace, head halter
traction. Surgery includes ADSF (Anterior decompression Spinal fusion).
Illustration:
Internet
http://www.patient.co.uk/showdoc/40001278/
http://emedicine.medscape.com/article/226141
http://www.scribd.com
Book
Medical Surgical Nursing by Suzanne Smeltzer and Brenda Bare, 10th Edition,
Chapter 68-Musculoskeletal
Medical Surgical Nursing by Joyce Black