AUTHOR AND EDITOR INFORMATION

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• Follow-up
• Miscellaneous
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INTRODUCTION

Section 2 of 11  

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• Introduction
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• Differentials
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• Follow-up
• Miscellaneous
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Background

Tuberculous spondylitis has been documented in ancient mummies from Egypt and Peru and is one of the oldest demonstrated diseases of humankind. Percival Pott presented the classic description of spinal tuberculosis in 1779. Since the advent of antituberculous drugs and improved public health measures, spinal tuberculosis has become rare in industrialized countries, although it is still a significant cause of disease in developing countries. Tuberculous involvement of the spine has the potential for serious morbidity, including permanent neurologic deficits and severe deformity. 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 is a combination of osteomyelitis and arthritis. Typically, more than one vertebra is involved. The area usually affected is the anterior aspect of the vertebral body adjacent to the subchondral plate. 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.

Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurologic deficits. Kyphotic deformity occurs as a consequence of collapse in the anterior spine. Lesions in the thoracic spine have a greater tendency for 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.

Frequency

United States

• Although an increase occurred in the late 1980s to early 1990s, the total number of tuberculosis cases has decreased in recent years.
• Extrapulmonary case rates have remained stable.
• From 1986-1995, cases of bone and soft tissue tuberculosis comprised approximately 10% of extrapulmonary cases and 1.8% of total cases.
• Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis (40-50% of cases).

International

Approximately 1-2% of total tuberculosis cases are attributable to Pott disease.

Mortality/Morbidity

• Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia.
• The condition most commonly involves the thoracic and lumbosacral spine. Published series show some variation. Lower thoracic vertebrae account for the most common area of involvement (40-50%), with the lumbar spine in a close second place (35-45%). In other series, proportions are similar but favor lumbar spine involvement.
• Approximately 10% of 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 is related to socioeconomic factors and historical exposure to the infection.

Sex

Although some series found a similar proportion of affected men and women, males are more often affected (1.5-2:1).

Age

• In the United States, Pott disease primarily occurs in adults.
• In countries with higher rates of infection, it mainly occurs in children.

CLINICAL

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• Differentials
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• Follow-up
• Miscellaneous
• Multimedia
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History

• Presentation depends on the following:
• • Stage of disease
  • Site
  • Presence of complications such as neurologic deficits, abscesses, or sinus tracts
• The reported average duration of symptoms at the time of diagnosis is 3-4 months.
• Back pain is the earliest and most common symptom.
• • Patients have usually had back pain for weeks prior to presentation.
  • Pain can be spinal or radicular.
• Constitutional symptoms include fever and weight loss.
• Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome.
• Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely.
• • This condition is characterized by pain and stiffness.
  • Patients with lower cervical spine disease can present with dysphagia or stridor.
  • Symptoms can also include torticollis, hoarseness, and neurologic deficits.
• The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to that of patients who are HIV negative; however, the relative proportion of individuals who are HIV positive seems to be higher.

Physical

• Examination should include the following:
• • Careful assessment of spinal alignment
  • Inspection of skin, with attention to detection of sinuses
  • Abdominal evaluation for subcutaneous flank mass
  • Meticulous neurologic examination
• Although both the thoracic and lumbar spinal segments are nearly equally affected, the thoracic spine is frequently reported as the most common site of involvement. Together, they comprise 80-90% of spinal tuberculosis sites. The remaining cases correspond to the cervical spine.
• Spine deformity (kyphosis) of some degree occurs in almost every patient.
• There may be large cold abscesses of paraspinal tissues or psoas muscle that protrude under the inguinal ligament. They may erode into the perineum or gluteal area.
• Neurologic deficits may occur early in the course of disease. Signs depend on the level of spinal cord or nerve root compression.
• Disease involving the upper cervical spine can cause rapidly progressive symptoms.
• • Retropharyngeal abscesses occur in almost all cases.
  • Neurologic manifestations occur early and range from a single nerve palsy to hemiparesis or quadriplegia.
• If no evidence of extraspinal tuberculosis is present, diagnosis can be difficult. Unfortunately, 62-90% of patients in reported series present in this manner.
• Information from imaging studies, microbiology, and anatomic pathology should help establish the diagnosis.

DIFFERENTIALS

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Other Problems to be Considered

Spinal Tumors

WORKUP

Section 5 of 11  

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Lab Studies

• Tuberculin skin test (purified protein derivative [PPD]) demonstrates a positive finding in 84-95% of patients who are non–HIV-positive.
• Erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).
• Microbiology studies to confirm diagnosis: Obtain bone tissue or abscess samples to stain for acid-fast bacilli (AFB), and isolate organisms for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft tissue structures. These study findings may be positive in only about 50% of the cases.

Imaging Studies

• Radiographic changes present relatively late. Plain radiography demonstrates the following characteristic changes of spinal tuberculosis:
• • 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 findings
• • 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
• • 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.
  • It detects 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
• • 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 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 are suggestive of pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.
  • MRI is most effective for demonstrating neural compression.

Other Tests

• Radionuclide scanning is not useful.
• Gallium and bone scans have a high false-negative rate of 70% and 35%, respectively.

Procedures

• Use a percutaneous CT-guided needle biopsy of bone lesions to obtain tissue samples. Percutaneous needle biopsy is not diagnostic.
• • This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.
  • Obtain a tissue sample for microbiology and pathology studies to confirm diagnosis and to isolate organisms for culture and susceptibility.
• Some patients are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration).

Histologic Findings

Since microbiologic studies may be nondiagnostic, 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

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• Follow-up
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Medical Care

• Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization using prolonged bed rest or a body cast. The mortality rate was 20%, and relapse was frequent (30%).
• The duration of treatment, surgical indications, and inpatient care has 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. According to a 1994 recommendation by the US Centers for Disease Control and Prevention, this is the treatment of choice.

  Medical therapy requires combination regimens with at least 3 antituberculous drugs. In regions with less than 4% isoniazid (INH) resistance, a 4-drug regimen should be used empirically. Treatment can be adjusted when susceptibility information becomes available. INH 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 INH, rifampin, and pyrazinamide. 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.
  • Regardless, patients undergoing surgical procedures generally require a shorter duration of chemotherapy.
• 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 mentioned below.

Surgical Care

• Indications
• • Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)
  • Spinal deformity with instability
  • No response to medical therapy
  • Nondiagnostic percutaneous needle biopsy sample
• Resources and experience are key factors in the decision to use a surgical approach.
• The most appropriate method of reconstruction depends on the level of vertebral spine involved and the extent of bony destruction.
• The lesion site, extent of vertebral destruction, and presence of cord compression or spinal deformity determine the specific operative approach. 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 disease involving the cervical spine, the following factors justify early surgical intervention:
• • High incidence 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 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 should be treated with external bracing.

MEDICATION

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Medical therapy requires combination regimens with at least 3 antituberculous drugs. In regions with less than 4% INH resistance, a 4-drug regimen should be used empirically. Treatment can be adjusted when susceptibility information becomes available. INH 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 INH, 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. Duration of therapy should be individualized and based on the resolution of active symptoms and the clinical stability of the patient.

Drug Category: Antituberculous drugs

Inhibit growth and proliferation of causative organism.

Drug Name	Rifampin (Rifadin, Rimactane)
Description	For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur.
Adult Dose	10 mg/kg PO qd; not to exceed 600 mg/d
Pediatric Dose	10-20 mg/kg PO qd; not to exceed 600 mg/d
Contraindications	Documented hypersensitivity
Interactions	Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with INH may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with reversible thrombocytopenia if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur

Drug Name	Pyrazinamide
Description	Bactericidal against M tuberculosis in an acid environment (macrophages). Has good absorption from the GI tract and penetrates well into most tissues, including CSF.
Adult Dose	15-30 mg/kg PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; severe hepatic damage, acute gout
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Use only in combination with other effective antituberculous agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor in liver disease); discontinue pyrazinamide if signs of hepatocellular damage appear; caution in history of diabetes mellitus

Drug Name	Ethambutol (Myambutol)
Description	Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations remain low, even in the presence of meningeal inflammation.
Adult Dose	15-25 mg/kg PO qd
Pediatric Dose	15-25 mg/kg PO qd Not recommended for young children because of difficulty monitoring vision
Contraindications	Documented hypersensitivity; optic neuritis (unless clinically indicated)
Interactions	Aluminum salts may delay and reduce absorption (administer several hours before or after ethambutol dose)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Reduce dose in impaired renal function; may have reversible visual adverse effects if promptly discontinued

Drug Name	Streptomycin
Description	Bactericidal in an alkaline environment. Because it is not absorbed from the GI tract, must be administered parenterally. Exerts action mainly on extracellular tubercle bacilli. Only about 10% of the drug penetrates cells that harbor organisms. Enters the CSF only in the presence of meningeal inflammation. Excretion is almost entirely renal.
Adult Dose	15 mg/kg IM qd; not to exceed 1 g/d
Pediatric Dose	20-40 mg/kg IM qd; not to exceed 1 g/d
Contraindications	Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions	Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics
Pregnancy	D - Unsafe in pregnancy
Precautions	Narrow therapeutic index; not intended for long-term therapy; caution in renal failure not on dialysis; caution with myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission

FOLLOW-UP

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Further Inpatient Care

• Once the diagnosis is established and treatment is started, the duration of hospitalization depends on the need for surgery and the clinical stability of the patient.

Further Outpatient Care

• Patients 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.

Complications

• 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 should be instructed on the importance of therapy compliance.
• For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Tuberculosis.

MISCELLANEOUS

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Medical/Legal Pitfalls

• A large proportion of patients do not present with extraskeletal disease. In reported series, Pott disease is associated with extraskeletal tuberculosis in only 10-38% of cases.
• 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
• • Positive tuberculin skin test (PPD) finding
  • Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
  • Presence of risk factors for tuberculosis
• Spinal tuberculosis should always be suspected when radiographs demonstrate a destructive spine process.

MULTIMEDIA

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Media file 1:  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.
	View Full Size Image
Media type:  MRI

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.
	View Full Size Image
Media type:  MRI

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
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• Miscellaneous
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• References

• Davidson PT, Le HQ. Musculoskeletal Tuberculosis. In: Schlossberg D, ed. Tuberculosis and Nontuberculous Mycobacterial Infections. 4th ed. Saint Louis, MO: W B Saunders; 1999;204-20.
• Jung NY, Jee WH, Ha KY, et al. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol. Jun 2004;182(6):1405-10.
• Jutte PC, Van Loenhout-Rooyackers JH. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Database Syst Rev. 2006;CD004532.
• Leibert E, Haralambou G. Spinal tuberculosis. In: Rom WN and Garay S, eds. Tuberculosis. Lippincott, Williams and Wilkins. 2004.;565-77.
• Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am. 1985;67:1405-13.
• Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine. Aug 1 1997;22:1791-7. [Medline].
• Moorthy S, Prabhu NK. Spectrum of MR imaging findings in spinal tuberculosis. AJR Am J Roentgenol. Oct 2002;179(4):979-83. [Medline].
• Pertuiset E, Beaudreuil J, Liote F, et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994. Medicine (Baltimore). Sep 1999;78(5):309-20. [Medline].
• Pott P. The chirurgical works of Percivall Pott, F.R.S., surgeon to St. Bartholomew''s Hospital, a new edition, with his last corrections. 1808. Clin Orthop Relat Res. May 2002;4-10. [Medline].
• Ridley N, Shaikh MI, Remedios D, Mitchell R. Radiology of skeletal tuberculosis. Orthopedics. Nov 1998;21(11):1213-20. [Medline].
• Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY. Role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am. Jul 1995;33(4):787-804. [Medline].
• Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am. Feb 1996;78:288-98. [Medline].

Article Last Updated: Aug 25, 2006