Tuberculous Spondylitis

Pott’s Disease
 Background
“Tuberculosis of the Spine”

Pott disease, also known as tuberculous spondylitis, is a classic

presentation of extrapulmonary tuberculosis (TB). It is
associated with significant morbidity and can lead to severe
functional impairment.

Refers to vertebral body osteomyelitis and

intervertebral discitis from tuberculosis (TB). The
spine is the most frequent location of musculoskeletal
tuberculosis, and commonly related symptoms are
back pain, kyphotic deformity of the spine, lower limb
weakness, and paraplegia.
 Background
“Tuberculosis of the Spine”

Lately the disease has shown a significant

increase in developed nations, particularly
among the immunosuppressed population
secondary to global migration and travel. There
has been an ominous, increasing trend in the
occurrence of multidrug-resistant bacterial
strains of tuberculosis in the developing
nations over the past decades, a tough
challenge to the global community.
 Epidemiolgy of
Tuberculous spondylitis is one of the more
common infections of spine in countries
where TB is prevalent. Unfortunately, the

Pott’s Disease
incidence of Pott Disease, as with other
forms of TB, is on the rise, due to new
multiple drug resistant strains:

Discitis and/or osteomyelitis comprise

approximately 50% of all
musculoskeletal tuberculosis, and
usually affects the lower thoracic and
upper lumbar levels of the spine.

The World Health Organisation (WHO)

reported an incidence of 10.4 million new
cases of tuberculosis in 2016, among which
46.5% of cases were reported from the
South East Asian Region alone. India
contributed to 23% of the global TB burden
Etiology of Pott’s Disease

Overview 01 Overview 02

Pott's disease can develop when air From the lungs, an infection can
that contains the tuberculosis-causing spread to the spine. The spread is
bacteria Mycobacterium tuberculosis hematogenous ie transmitted through
is inhaled into the lungs. the blood.

Overview 03 Overview 04
Bacteria reach the spine via the Some known risk factors for TB include
hematogenous route, from the lungs or prolonged exposure to infected patients,
lymph nodes. It spreads via the immunodeficiencies (HIV, alcohol, drug
paravertebral plexus of veins i.e abuse), overcrowding, malnutrition,
poverty, and lower socio-economic
Batson's plexus.
situation.
 Types of Vertebral
Tuberculosis
Paradiscal Central

Anterior Posterior
 Signs and Symptoms

In uncomplicated disease, the patient

The clinical presentation of typically presents with back pain.
spinal tuberculosis is Back pain in tuberculosis can be
variable. The manifestations related to the active disease itself
depend upon the duration of (secondary to inflammation), bone
destruction and instability. Rest pain
illness, severity of the
is pathognomonic, and rarely,
disease, site of the lesion, radicular pain can be the main
and presence of associated presenting symptom.
complications including
In complicated tubercular spine
deformity and neurological disease patient may present with
deficit. deformity, instability, and neuro
deficit.
 Signs and Symptoms

Constitutional symptoms Deformity: Owing to the greater

including weight or appetite involvement of the anterior spinal
column in TB, the spinal column
loss, fever, and malaise/
progressively develops a kyphosis,
fatigue are less commonly especially in the thoracic and
associated with thoracolumbar spine.
extrapulmonary tuberculosis Neurological Deficit: Can occur either
than pulmonary disease. at the active stage of the disease
(secondary to compression from an
Cold Abscess: These abscesses
abscess, inflammatory tissue,
typically lack all the inflammatory
sequestrum or spinal instability) or
signs obvious in abscesses; and
during the healed stage (usually
hence the name.
secondary to mechanical traction
spinal defect.
 Diagnostic Exams

Chest X-ray Sputum cultures

The x-ray is in use to diagnose spinal
tuberculosis. It is a painless procedure
To look for the presence of bacteria
that can take place in a hospital or
clinic x-ray room.

Blood culture
Positive culture yield of percutaneous
is 50% to 83% and appears to be
influenced by technical details, such
as decontamination of specimens prior
to culture.
 Diagnostic Exams

Tissue biopsy Mantoux Tuberculin skin tests

To check for the possibilities of cancer Results are positive in 84-95% of the
patients having Pott’s disease

CT scanning
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.
 Diagnostic Exams

MRI Biopsy: Use of a percutaneous CT-guided

needle

The criterion gold standard for evaluating bone lesions can be used to obtain
disk-space infection and osteomyelitis of the
tissue samples. This is a safe
spine and is most effective for demonstrating
the extension of disease into soft tissue and procedure that also allows therapeutic
the spread of tuberculous debris under the drainage of large paraspinal
anterior and posterior longitudinal ligaments. abscesses.

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.
Pathophy Pott disease usually results from an

siology
extraspinal source of infection and
hematogenous dissemination. Pott
disease manifests as a combination

of Pott’s
of osteomyelitis and arthritis that
usually involves more than one
vertebra. The anterior aspect of the

Disease
vertebral body adjacent to the
subchondral plate is usually
affected. 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, the disk, because it is
vascularized, can be the primary site.
Pathophy Progressive bone destruction leads to

siology
vertebral collapse and kyphosis. The
spinal canal can be narrowed by
abscesses, granulation tissue, or

of Pott’s
direct dural invasion, leading to spinal
cord compression and neurologic
deficits.
The kyphotic deformity is caused by

Disease
collapse in the anterior spine. Lesions
in the thoracic spine are more likely to
lead to 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.
 Treatment and
Management
Uncomplicated disease
Uncomplicated spinal TB is
essentially a medical
The mainstay of treatment in spinal TB is chemotherapy
disease. (antitubercular treatment). Tubercle bacilli may exist as intracellular
or extracellular forms or as dormant or rapidly multiplying forms.
Complicated disease Multi-drug treatment is essential to attack the bacilli in various
The first line of treatment for Pott’s disease is
the surgical removal of the tubercular stages or forms and reduce the instance of drug resistance.
infection. Administration of anti-tubercular
medications is done before and after the
surgery. This procedure is followed by the
surgical reconstruction of the spine.
The treatment protocol is formulated based on
the presence or absence of neurological
involvement. In case of neurological
involvement usually, pharmacotherapy is
preferred over surgery. The anti-tubercular
medications employed in the pharmacotherapy
are Isoniazid, Rifampicin, Ethambutol, and
Pyrazinamide.
Surgery done during the active course of the
disease is much safer with a faster and better “It is essential to classify spinal TB disease
response.
into a complicated and uncomplicated
disease, based on their presentation.”
 Nursing Care
Promote optimal mobility Manage Pain
Collaborate with physical therapists Administer prescribed analgesics and
to develop an individualized exercise anti-inflammatory medications to
and mobility plan. manage pain and reduce inflammation.
Assist the individual with proper Implement non-pharmacological pain
body mechanics and safe transfers management strategies, such as heat
to minimize the risk of injury. or cold therapy, massage, or relaxation
Provide assistive devices, such as techniques.
walkers or braces, as needed, to Encourage the individual to report pain
support mobility and stability. promptly and provide ongoing
Educate the individual on the assessment and evaluation of pain
importance of regular exercise, relief measures.
proper posture, and maintaining an Collaborate with the healthcare team
active lifestyle within their to explore advanced pain management
capabilities. techniques if necessary.
 Nursing Care
Promote medication adherance Prevent infection transmission
Educate the individual and their Educate the individual and their close
family about the importance of contacts about tuberculosis
adhering to the prescribed anti- transmission and the importance of
tuberculosis medication regimen. adhering to respiratory hygiene
Explain the potential side effects of practices.
the medications and provide Implement airborne precautions as
strategies to manage them. indicated, including the use of
Monitor medication compliance and personal protective equipment (PPE)
provide support and reminders as and proper ventilation in healthcare
needed. settings.
Collaborate with the healthcare team Monitor for signs and symptoms of
to address any barriers to medication active infection, such as cough, fever,
adherence and ensure a consistent or night sweats, and report them
supply of medications. promptly to the healthcare team.
 Nursing Care
Provide Emotional Support and Prevent Complications and
Education Promote Self-care
Offer emotional support, active Monitor for signs of complications,
listening, and therapeutic such as neurological deficits or
communication to address the respiratory distress, and report them
individual’s fears, concerns, and promptly to the healthcare team.
anxieties related to the diagnosis Promote proper respiratory hygiene,
and treatment. including covering the mouth and nose
Provide education on tuberculosis, when coughing or sneezing, to prevent
including its transmission, treatment, the spread of infection.
and the importance of adherence to Educate the individual on self-care
medication. measures, including the importance of
Facilitate support groups or nutrition, hydration, and maintaining
counseling services to promote good personal hygiene.
coping strategies and provide a
sense of community.
Resources
used in
Pons T, Shipton EA. Multilevel lumbar
fusion and postoperative physiotherapy
rehabilitation in a patient with persistent
pain. Physiotherapy Theory and Practice.

presentation
2011; 27(3):238-245.
Admin. (2022, 25). Spinal tuberculosis
symptoms and treatment. Best Neuro
Surgeon.
https://drmanishbudhiraja.com/spinal-
tuberculosis-symptoms-and-treatment/
What is spinal tuberculosis in 2022? | Dr.
Himanshu Gupta - Spine surgeon. (2021,
August 27). cms.
https://www.drhimanshugupta.com/blogs/
what-is-spinal-tuberculosis
Sarwar, A. (2023, July 16). Nursing care plan
for spinal tuberculosis. Made For Medical.
https://www.madeformedical.com/nursing-
care-plan-for-spinal-tuberculosis/
Thank you for
your attention