Republic of the Philippines

UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal St. Extension, West Rembo, Makati City
1215 Philippines

POTTS DISEASE
(WRITTEN REPORT)

In Partial Fulfillment of the Requirements in the

Clinical Rotation at Philippine Orthopedic Center

Submitted to:

Ms. Zennaida Dela Cuesta RN, MAN

Submitted by:
Garcia, Arielle Ann L.
Mira, Carmela Lea R.
Pichay, Edd Neilzen T.
Villaflores, Lorie

January 14, 2015

Potts Disease
DEFINITION OF THE DISEASE

A rare infectious disease of the spine which is typically caused by an extraspinal

infection.
Presentation of extrapulmonary tuberculosis whereby disease is seen in the
spinal vertebrae. Tuberculosis of the spine is one of the oldest diseases afflicting
humans.
Named after Percivall Pott, a British Surgeon.

PHYSICAL FINDINGS:

Localized tenderness
Muscle spasms
Restricted Spinal Motion
Spinal Deformity
Neurological Deficits
Back pain
Neurological signs
o Paraplegia
o Paresis
o Impaired sensation
o Nerve root pain
o Cauda Equina Syndrome (CES)

SIGNS AND SYMPTOMS

Back pain
Fever
Night sweating
Anorexia
Spiral mass, sometimes associated with numbness, paraesthesia or muscle
weakness of the legs
Difficulty standing

PATHOPHYSIOLOGY:
RISK FACTORS:
Modifiable:
Environment, exposure to m.
tuberculosis, malnutrition, low socioeconomic status, lack of knowledge,
poor immune response

Non-modifiable:
Age (more common in children)

Exposure and entry of bacteria via the

respiratory tract

Activation of immune
response

Excessive
mucus
productio
n

Accumula
tion of
mucus in
`
the lungs

Bacterial accumulation and proliferation

in the lungs

Bacterial attachment in
the lung parenchyma

Pulmonary tuberculosis (infection)

Parenchymal injury

Hematogenous spread of bacteria going

to the intercostal lumbar arteries

Leakage of blood from

vessels to interstitium

Bacteria
will
secrete
endoxins

Activation
of
interleukin
1

Productive
cough and
crackles

Increase of
temperatur
e

Hemoptysis

Bacterial accumulation in spine

Secretion
of
pyrogens

Bacillus destruction of cancellous bones

and extends to the cortex

Fever

Infection spreads from one vertebra to

adjacent vertebra via vertebral disc

Progressive bone destruction

Infected anterior vertebral disc collapse

Caesation then narrowing of spinal

canal due to abscess and granulation

Kyphosis

Gibbus formation

Neurological and
motor effects
Numbness
`

Paralysis

Spinal cord compression

Back pain

LABORATORY TESTS

Lab studies used in the diagnosis of Pott disease include the following:

Tuberculin skin test (PPD) - Results are positive in 84-95% of patients with Pott
disease who are not infected with HIV

Erythrocyte sedimentation rate (ESR) - May be markedly elevated (>100 mm/h)

Microbiologic studies - Used to confirm the diagnosis

With regard to the above-mentioned microbiologic studies, bone tissue or abscess

samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for
culture and susceptibility. Procedures guided by computed tomography (CT) scanning
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.
Biopsy
Percutaneous, CT scan guided needle biopsy of bone lesions is a safe procedure that
also allows therapeutic drainage of large paraspinal abscesses. Obtain a tissue sample
for microbiologic and pathologic studies to confirm diagnosis and to isolate organisms
for culture and susceptibility. Positive culture yield of percutaneous is 50-83% and
appears to be influenced by technical details, such as decontamination of specimens
prior to culture.
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.
Drainage
Some cases of Pott disease are diagnosed following an open drainage procedure (eg,
following presentation with acute neurologic deterioration).
Scintigraphy
Radionuclide scanning findings are not specific for Pott disease. Gallium and
technetium bone scans yield high false-negative rates (70% and up to 35%,
respectively).
`

Radiography
Radiographic changes associated with Pott disease present relatively late. The
following are radiographic changes characteristic of spinal tuberculosis on plain
radiography :

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 1 level.

CT Scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk
collapse, and disruption of bone circumference.
Low-contrast resolution provides a better assessment of soft tissue, particularly in
epidural and paraspinal areas.
CT scanning reveals early lesions and is more effective for defining the shape and
calcification of soft-tissue abscesses. In contrast to pyogenic disease, calcification is
common in tuberculous lesions.
MRI

Magnetic resonance imaging (MRI) is the

criterion standard for evaluating diskspace 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.
Contrast-enhanced MRI findings are
useful in differentiating tuberculous spondylitis from pyogenic spondylitis. MRI findings
in Pott disease include thin and smooth enhancement of the abscess wall and a welldefined paraspinal abnormal signal. Thick and irregular enhancement of the abscess
wall and an ill-defined paraspinal abnormal signal suggest pyogenic spondylitis.

TREATMENT
Before the advent of effective antituberculosis chemotherapy, Pott disease was treated
with immobilization using prolonged bed rest or a body cast. At the time, the disease
carried a mortality rate of 20%, and relapse was common (30%).
The duration of treatment, surgical indications, and inpatient care for Pott disease have
since evolved. 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, although routine surgery
does not seem to be indicated.
Devices
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.
Inpatient care
Once the diagnosis of Pott disease is established and treatment is started, the duration
of hospitalization depends on the need for surgery and the clinical stability of the
patient.
`

Follow-up
Patients with Pott disease should be closely monitored to assess their response to
therapy and compliance with medication. Directly observed therapy may be required.
The development or progression of neurologic deficits, spinal deformity, 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 disease should
undergo long-term follow-up until their entire growth potential is completed. Older
patients can also present with late-onset complications such as reactivation, instability,
or deformity. Observation is warranted in all groups of patients.
Pharmacologic Therapy
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 from among the first-line drugs, which include pyrazinamide,
ethambutol, and streptomycin. The use of second-line drugs is indicated in cases of
drug resistance.

Treatment duration
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.
However, the research councils 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.
For selected cases with surgical indication that allows complete debridement of the
lesion, a combination of surgery and ultra-shortened course of therapy (4.5 mo),
appears to show comparable outcomes of a combination of surgery and 9 months of
drug therapy.
Surgical Indications and Contraindications
Indications
`

While most patients should respond to medical treatment, a surgical approach needs to
be evaluated and considered. Indications for surgical treatment of Pott disease
generally include the following :

Neurologic deficit - Acute neurologic deterioration, paraparesis, and paraplegia

Spinal deformity with instability or pain

No response to medical therapy - Continuing progression of kyphosis or

instability

Large paraspinal abscess

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. The specific advantages and limitations of
surgical techniques are unclear. Individualization of the case is of greatest importance.
Newer modalities and techniques are being reported, such as thoracoscopic
decompression.
In Pott disease that involves the cervical spine, the following factors justify early surgical
intervention:

High frequency and severity of neurologic deficits

Severe abscess compression that may induce dysphagia or asphyxia

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.