POTTS DISEASE

Partial Fulfilment in Orthopaedic Nursing DE RAMOS, MARY GRACE L. BSN-III March 08, 2013

Potts Disease is a combination of osteomyelitis and arthritis which involves multiple vertebra. Is a presentation of extrapulmonary tuberculosis that affectsthe spine, a kind of tuberculous arthritis of the intervertebral joints. It has been documented in ancient mummies in peru and one of the oldest demonstrated disease of human kind It is named after Percivall Pott (17141788), a London surgeon who trained at St Bartholomew's Hospital, London. He presented the classic description of spinal tuberculosis in 1779 Synonyms: 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

Etiology Causative organism: Mycobacterium tuberculosis. Spread: Haematogenous. (by blood) Commonly associated with: Debilitating diseases, AIDS, Drug addiction, Alcoholism.

Distribution The commonest area affected is T10 to L1. The lower thoracic region is the most common area of involvement at 40 to 50%, with the lumbar spine in a close second place at 35 to 45%. The cervical spine accounts for about 10%. CLINICAL FINDINGS The onset is gradual. 3-4months, duration of symptoms at the time of onset Back pain is localised (earliest and most common sign) Restricted spinal movements. Constitutional symptoms---- fever and weightloss Neurologic abnormalities o Spinal cord compression o Nerve root pain or cauda equina syndrome o Paraplegia o Paresis o Impaired sensation Cervical spine tuberculosis is less common presentation but is potentially more serious; characteri o

A psoas abscess (may present as a lump in the groin and resemble a hernia).

 Complications Vertebral collapse resulting in kyphosis. Spinal cord compression. Sinus formation. Paraplegia (so called Pott's paraplegia).

Diagnostic exams 1. The Mantoux Test (Tuberculin Skin Test) Injection of a purified protein derivative (PPD). 2. Erythrocyte Sedimentation Rate (ESR) ESR may be markedly elevated (>100 mm/h) 3. Microbiology Studies 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 4. Radiography Radiographic changes associated with Potts disease present relatively late. The following are radiographic changes characteristics of spinal tuberculosis on plain radiography 5. 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 which is common in TB lesions. 6. MRI is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments.

7. Biopsy Use of a percutaneous CT-guided needle biopsy of bone lesions can be used to obtain tissue samples. This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses

8. Polymerase Chain Reaction (PCR) PCR techniques amplify species-specific DNA sequences which is able to rapidly detect and diagnose several strains of mycobacterium without the need for prolonged culture. They have also been used to identify discrete genetic mutations in DNA sequences associated with drug resistance.

Management Bed rest. Immobilisation of affected joint by splintage. Nutritious, high protein diet. Drainage of abscess. Surgical decompression. Physiotherapy. Therapy non-operative antituberculous drugs The duration of treatment is somewhat controversial. Although some studies favor 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 The main drug class consists of agents that inhibit growth and proliferation of the causative bacteria. Isoniazid and rifampin should be administered during the whole course of therapy. Additional drugs are administered during the first two months of therapy and these are generally chosen among the first-line drugs which include pyrazinamide, ethambutol, and streptomycin. The use of secondline drugs is indicated in cases of drug resistance Chiropractic treatments analgesics immobilization of the spine region by rod (Hull) Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine Richards intramedullary hip screw facilitating for bone healing Kuntcher Nail intramedullary rod Austin Moore intrameduallary rod (for Hemiarthroplasty) Thoracic spinal fusion as a last resort

Prevention As for all tuberculosis, BCG vaccination. Improvement of socio-economic conditions. Prevention of HIV and AIDS.

Prognosis The progress is slow and lasts for months or even years. Prognosis is better if caught early and modern regimes of chemotherapy are more effective. A study from London showed that diagnosis can be difficult and is often late

Pathophysiology Potts disease is usually secondary to an extraspinal source of infection. Thebasic lesion involved in Potts disease is a combination of osteomyelitis andarthritisthatusually involves more than one vertebra. The anterior aspect of the vertebral bodyadjacent to the subchondral plate is area usually affected.Tuberculosismay spreadfrom that area to adjacent intervertebral disks. In adults, disk disease is secondary tothe spread of infection from the vertebral body. In children, because the disk isvascularized, it can be a primary site.Progressive bone destruction leads to vertebral collapse andkyphosis.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 iscaused by collapse in the anterior spine. Lesions in the thoracic spine are more likely tolead to kyphosis than those in the lumbar spine. A cold abscess can occur if theinfection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar regionmay descend down the sheath of the psoas to the femoral trigone region and eventuallyerode into the skin

MRI of the thoracic spine (T2-weighted, sagittal reconstruction). The dorsal fluid collection suggests a paravertebral abscess (large arrow) just above the fractured and operated third thoracic vertebra (small arrow