Tuberculosis (TB) of the spine (Pott’s disease) is the commonest form of the skeletal tuberculosis. Pott’s disease is a presentation of extra pulmonary tuberculosis that affects the spine. Precisely it is called tuberculosis spondylitis and the original name was formed after Percivall Pott, a London surgeon.It is most common during the first three decades, though the disease may occur at any age between 1 to 80 years Most commonly, it affects the thoracic and thoraco-lumbar spine.
PATHOGENESIS OF POTT’S DISEASE
Pott’s disease results from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining disc space. If only one vertebra is affected, the disc is normal, but if two are involved the intervertebral disc, which is avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage). A dry soft tissue mass often forms and superinfection is rare.
The prevalence of tuberculosis is around 30 million globally and approximately one-third of the cases are found in India. 1 to 3% of the 10 million have involvement of bones and joints. Vertebral tuberculosis is the commonest form of skeletal tuberculosis comprising about 50-70% of all bone and joint tuberculosis. The youth are more vulnerable to the disease but it can occur at any age. Acute presentations are uncommon. The usual presenting symptom of skeletal tuberculosis is pain.
- Weight loss, lassitude, loss of appetite and evening rise of temperature are common.
- There may be stiffness and painful, restricted joint movements in all planes.
- Severe spasm of adjacent muscles is common.
- A cold abscess may occur in long-standing cases which tracks it’s way through the intermuscular planes.
- A deformity in the spine can present as kyphosis, along with local tenderness
- Tuberculosis of the spine has the following distribution-thoracic 42%, lumbar 26%, thoracolumbar and cervical each 12%, cervicodorsal 5% and lumbosacral 3%.
The lesion in the spine is most often paradiscal in location with destruction of the disc, reduction of the disc space and concomitant destruction of the vertebral bodies on either side of disc space. The destruction occurs in the anterior aspect of the vertebral body and extends behind the anterior longitudinal ligament. It may remain confined to the centrum of the vertebrae, resulting in a concentric collapse. Lastly, posterior element disease can occur in the posterior neural arch. The disease can involve the vertebral bodies at two or three different sites and these are referred to as “Skipped lesions”, which occur in about 7% cases. 12% patients have associated involvement of other bones and joints (including spine)
Because of the subtle nature of the symptoms, diagnosis is often missed until the disease is advanced. Delay in diagnosis can be catastrophic in vertebral tuberculosis. The extension of disease process can cause compression of the spinal cord leading to severe and irreversible neurologic sequelae including paraplegia.
A lumbar cold abscess can spread along the aorta and its branches to present at the: (a) ischiorectal fossa, (b) in the buttock under the gluteus maximus, as in our case, because of the large size of the abscess in the prevertebral and paravertebral region it could rupture and track along the branches of aorta to manifest as a gluteal abscess, (c) along the psoas sheath or (d) in the lumbo-dorsal region (Petit’s triangle). It can also track down along the femoral or obturator artery and present on the medial side of the thigh, femoral triangle, popliteal fossa or on the medial side of the tendo-achilles.
DIAGNOSIS OF POTT’S DISEASE
The disease progresses slowly. Signs and symptoms include:
- Localised back pain
- Paravertebral swelling may be seen
- Systemic signs and symptoms of TB may be present
- Neurological signs may occur, leading to paraplegia.
- Needle biopsy of bone or synovial tissue. Numbers of tubercle bacilli present are usually low but are pathognomonic.
- Acid-fast stain and culture for Mycobacterium tuberculosis, plus fungi and other pathogens, should be performed.
- Spinal x-ray may not show early disease as 50% of bone mass must be lost for changes to be visible on x-ray. However, plain radiographs can show vertebral destruction and narrowed disc space.
- MRI is useful to demonstrate the extent of spinal compression and can show changes at an earlier stage than plain radiographs. Bone elements visible within the swelling, or abscesses, are strongly indicative of Pott’s disease as opposed to malignancy.
- CT scans and nuclear bone scans can also be used.
MANAGEMENT OF POTT’S DISEASE
Drug treatment is generally sufficient for Pott’s disease, with spinal immobilisation 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.
- non-operative – antituberculous drugs
- immobilization of the spine region by rod
- Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine
- Vertebral collapse resulting in kyphosis
- Spinal cord compression
- sinus formation
- paraplegia (so called Pott’s paraplegia)
Combination Therapy-. It consists of:-
-Mentamove therapy -an internationally recognized and scientifically proven therapy from Germany and customized exercise program which has revolutionized the treatment paralysis & other neurological disorders like crania-cerebral trauma, multiple sclerosis, nerve injuries, spinal cord injuries, cerebral palsy worldwide .This has lead to 95% recovery in stroke patients.
-Customized exercise program inclusive of stretching, Bobath and latest PNF techniques
– Balance Training
Benefits:-Helps in alleviating pain
Muscle re-education and strengthening
Improving over-all functional independences
VISIT PHYSIOLINE FOR FURTHER CONSULTATION AND TREATMENT