Definition

Pott’s disease is a presentation of extrapulmonary tuberculosis that affects the spine,

a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott
(1714-1788), a London surgeon who trained at Barts. Scientifically, it is called tuberculous
spondylitis and it is most commonly localized in the thoracic portion of the spine.

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

Cause:

Mycobacterium Tuberculous

Vertebral Column

Anatomy and Physiology:

The vertebral column (spine) consists of 26 vertebrae bones. It provides support for the
head and trunk of the body, protection for the spinal cord, and connecting points for the
ribs and muscles.
TABLE 1 Bones of the Vertebral Column
Transverse Vertebral
Vertebra Body Spinous Process Process Process
Cervical
C1 (atlas) none, bony ring none with transverse large;
foramen lightbulb-
shaped
C2 (axis) relatively small; with bifid with transverse large; heart-
dens (odontoid process) foramen shaped
C3-C6 relatively small; oval bifid with transverse large;
foramen triangular
C7 (vertebra relatively small; oval prominently long; with transverse large;
prominens) not bifid foramen triangular
Thoracic
T1-T10 C2-C7, heart-shaped; 2 long; points down with facets for circular
facets or demifacets for articulating with
articulating with rib rib tubercle
head
T11-T12 larger than C2-C7, heart- long; points down no facets for rib circular
shaped; 1 demifacets for joints
articulating with rib
 Transverse Vertebral
Vertebra Body Spinous Process Process Process
head
Lumbar
L1–L5 largest of all vertebrae; short, thick;
kidney- shaped points
horizontally
Sacrum
5 fused S1-S5 fusion of 5 vertebrae fuse to become becomes the becomes
forms a triangular bone the median sacral lateral sacral sacral canal
crest crest
Coccyx
4 fused
 Pulmonary tuberculosis

Spread of mycobacterium tuberculosis from other site

Extrapulmomary tuberculosis

The infection spreads from two adjacent vertebrae into the adjoining disc space

Back pain, Fever, Night sweats, Anorexia, Weight loss, and easy fatigability.

One vertebra is affected, the disc is normal

Two are involved; the avascular intervertebral disc cannot receive nutrients and collapse

Disk tissue dies and broken down by caseation

Vertebral narrowing

Vertebral collapse

Spinal damage

POTT’S DISEASE

Kyphosis, paraplegia, bowel and urinary incontinenece

Surgery: evacuation of pus, Anterior decompression spinal fusion

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

o CT scanning provides much better bony detail of irregular lytic lesions,

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

 MRI
o 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.
 o 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

 Radionuclide scanning findings are not specific for Pott disease.

 Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%,
respectively).

Management

Medical Care

 Before the advent of effective antituberculosis chemotherapy, Pott disease was

treated with immobilization using prolonged bed rest or a body cast. At the time, Pott
disease carried a mortality rate of 20%, and relapse was common (30%).
 The duration of treatment, surgical indications, and inpatient care have 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 the most recent recommendations issued in 2003 by the US Centers for
Disease Control and Prevention, the Infectious Diseases Society of America, and
the American Thoracic Society, a 4-drug regimen should be used empirically to treat
Pott disease.
 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 among the first-line drugs, which include pyrazinamide, ethambutol,
and streptomycin. 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.
 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 discussed below.

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.

Clinical manifestation:

 back pain
 fever
 night sweating
 anorexia
 weight loss
 Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of
the legs

Nursing Diagnosis

 Acute pain related to inflammatory process

 Disturbed body image related to trauma/injury to spinal cord
 Self – bathing hygiene deficit related to musculoskeletal impairment
 Impaired physical mobility related to therapeutic restriction of movement
 Imbalance nutrition related to inadequate food intake

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).

Isoniazid (Laniazid, Nydrazid)

Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates
well into all body fluids and cavities.

Adult
300 mg PO qd; alternatively, 15 mg/kg IV qd

Pediatric
10 mg/kg PO qd

Higher incidence of isoniazid-related hepatitis can occur with daily alcohol ingestion;
aluminum salts may decrease isoniazid serum levels (administer 1-2 h before taking aluminum
salts); may increase anticoagulants effects with coadministration; may inhibit metabolic
clearance of benzodiazepines; carbamazepine toxicity or isoniazid hepatotoxicity may result
from concurrent use (monitor carbamazepine concentrations and liver function);
coadministration with cycloserine may increase adverse CNS effects (eg, dizziness); acute
behavioral and coordination changes may occur with coadministration of disulfiram;
coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and
hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of
hydantoin

Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe

adverse reactions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic
ophthalmologic examinations during INH therapy are recommended even when visual
symptoms do not occur

Rifampin (Rifadin, Rimactane)

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
10 mg/kg PO qd; not to exceed 600 mg/d

Pediatric
10-20 mg/kg PO qd; not to exceed 600 mg/d
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)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

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

Pyrazinamide
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
15-30 mg/kg PO qd

Pediatric
Not established

Documented hypersensitivity; severe hepatic damage, acute gout

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

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

Ethambutol (Myambutol)
Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF
concentrations remain low, even in the presence of meningeal inflammation.

Adult
15-25 mg/kg PO qd
Pediatric
15-25 mg/kg PO qd
Not recommended for young children because of difficulty monitoring vision

Aluminum salts may delay and reduce absorption (administer several hours before or after
ethambutol dose)

Documented hypersensitivity; optic neuritis (unless clinically indicated)

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

Precautions
Reduce dose in impaired renal function; may have reversible visual adverse effects if promptly
discontinued

Streptomycin
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
15 mg/kg IM qd; not to exceed 1 g/d

Pediatric
20-40 mg/kg IM qd; not to exceed 1 g/d

Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins,

amphotericin B, and loop diuretics

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

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

Nursing Responsibilities:

Further 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.

Further Outpatient Care

 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. 25

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 with Pott disease 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.