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Pott's Disease: Medical and surgical treatment

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Pott’s Disease: Medical and surgical treatment 1

Original article Clin Ter 2013; 164 (2):1-3. doi: 10.7417/CT.2013.1501

Pott’s Disease: Medical and surgical treatment

R. Tarantino, P. Donnarumma, B. Fazzolari, D. Marruzzo, R. Delfini
Department of Neurological Sciences, Neurosurgery, University “Sapienza” of Rome, Italy

Abstract Once in decline and almost eradicated in the first world, TB

has made a dramatic resurgence (3): according to the World
Objectives. To evaluate the best treatment of Pott’s disease.
Health Organization (WHO), TB infection affects an esti-
Matherials and Methods. 7 cases of Pott’s disease were treated
mated 2 billion people all over the world. South Africa has
in the department of Neurosurgery of “Sapienza” University of Rome
the world’s highest reported incidence (718/100,000 reach-
(Italy) between 2004 to 2011.
ing 1.2% of the population in certain areas) (3). Vertebral
Results. All patients underwent surgical drainage of abscess and
disease is the most common form of skeletal TB, accounting
vertebral stabilization. In all cases culture exam showed positivity after
for half of the cases (4, 5), and thoraco-lumbar spine is the
40 days of incubation. After surgery for a period of one year chemo-
most frequent site of involvement. In Italy, Pott’s disease
therapy was administered. In all cases MRI scan with gd of the spinal
hits 10/100,000 people. However latest infections interest
column were performed 12 months after surgery and no recurrence of
more immigrants (4). It has the potential to cause serious
disease has been shown.
morbidity, including permanent neurological deficits and
Discussion. Pott’s disease is defined as vertebral involvement of
severe deformities. Medical treatment or combined medi-
extrapulmonary Tubercolosis (TB), involving mainly toraco-lumbar
cal and surgical strategies can control the disease in most
tract of the spine. MRI with gd represents the gold standard for the
patients (6).
diagnosis. Treatment can be medical, surgical or usually both. The
slippery course of the disease often causes a delay in getting to a
diagnosis that is not made prior to rising signs, such as large abscess,
Materials And Methods
neurological impairment or vertebral fractures. In these cases medi-
cal treatment alone did not show effective results, because no specific
7 cases of Pott’s disease were treated in the department
antibiotic drug can permeate the abscess’s capsule, and an effective
of Neurosurgery at the “Sapienza” University of Rome
concentration is not achieved in the infection’s site. Therefore, surgical
(Italy) between 2004 to 2011. All the patients presented to
treatment is necessary to abscess draining and setting the correct medi-
the emergency room of Umberto I’s hospital. Standard XR,
cal treatment to mycobacterial eradication. Clin Ter 2013; 164(2):1-3.
CT scan and MRI with gadolinuim (gd) were performed on
doi: 10.7417/CT.2013.1501
admission. The neurological exam was used to evaluate any
sensitive-motor deficits. All patients underwent surgical
Key words: extrapulmonary TB, Pott’s disease, spinal TB, Tuber-
culosis, TB, thoraco-lumbar TB drainage of abscess, vertebral stabilization and myelora-
dicular decompression in the case of descending suppura-
tive tissue in vertebral canal. In 2 cases anterior approach
was preferred; in 2 cases posterior approach was used and
Introduction in other 3 cases surgery has been performed by both ante-
rior and posterior approaches. In 3 cases laminectomy and
Pott’s disease is defined as vertebral involvement of myeloradicular decompression were performed for clinical
extrapulmonary Tubercolosis (TB). It is one of the oldest evidence of neurological deterioration. Histological exami-
demonstrated diseases, having been documented in spinal nation, bacterioscopic and culture exams were taken. The
remains from the Iron Age and in ancient mummies from follow-up range from 12 months to 5 years. In all cases MRI
Egypt and Peru (1). In 1779, Percivall Pott, for whom is scan with gd and standard XR of the spinal column were
named, presented the classic description of spinal TB (2). performed 12 months after surgery.

Correspondence: Dott. Pasquale Donnarumma, MD, Via Degli Ausoni 9, 00161 Roma, Italia. Tel./Fax: +39.06.4997.9113.
E-mail: padonnarumma@hotmail.it

Copyright © Società Editrice Universo (SEU)

2 R. Tarantino, et al.

Table 1. Demographic characteristics of investigated patients affected by Pott’s disease.

Case number Age(y); sex Location Ethnicity Others

1 21; M D9 Somali Immunosuppressed

2 34; M D1-D12 Ethiopian Cachectic

3 25; M D7-D8 Sudafrican
4 38, F D7-L1 Zambia HIV+
5 17,M D9-D11 Italian Addicts
6 40; M D6-D7 Italian Addicts, HIV+

7 32; M D8 Romanian

Results Discussion

Results are summarized in Table 1.
Patients were 6M and 1F, mean age was 29 years (range
17-40). 2 of them came from the European Union and 5 came
from non-EU countries. All of them had back pain. In 3 cases
we have found signs of pyramidal tract lesion, as paraparesis,
bilateral Babinski positivity, hyperactive reflexes. 2 were
HIV-positive, 2 addicts, 1 cachectic, 1 immunosuppressed.
Neuroimaging (XR, CT) constantly showed one or more
vertebral fractures. On MRI imaging, paravertebral abscess
was shown as an hyperintense area on T2-weighted sequen-
ces, hypointense on T1-weighted, with capsular gadolinium
enhancement. Only in 2 cases Koch bacillus was disclosed
on bacterioscopic exam. In all cases culture exam showed
positivity after 40 days of incubation. After surgery for a
period of one year chemotherapy was administered, consist-
ing of: Isoniazid: 6 mg/kg body weight orally, Rifampicin:
15 mg/kg body weight orally, Streptomycin: 20 mg/kg body
weight intramuscularly, Ethambutol: 15–25 mg/kg according
to age and PAS: 0.2 g/kg body weight orally. A year later
MRI scan didn’t show recurrence of disease.
TB spondylitis (Pott’s disease) is defined as the spinal
thoraco-lumbar involvement of extrapulmonary TB and
frequently affects multiple adjacent spinal vertebrae, with
the formation of a caseous abscess; noncontiguous, remote
involvement is reported as rare in literature (3). Involvement
of two adjacent vertebrae causes the hindering of nutrients
to the intervertebral disc, that subsequently degenerate and
collapse. Back pain is the presenting symptom in most cases;
in half of cases several levels of neurological deficits are
present (7), particularly in thoracic region, where vertebral
canal can be directly compromised. In the lumbar region
neurological symptoms are similar to those seen in nerve
root compressions. Main localization in the thoraco-lumbar
and lumbar region goes with abscesses paraspinal and often
tracked to the psoas muscle; epidural abscesses were ad-
ditionally observed. Neuroimaging (CT and MRI scans)
are important for the diagnosis, pre-operative planning and
prognostic evaluation (Fig. 1 and 2).
MRI with gd is the gold standard to point out the site
and the width of the lesion, compression of the spinal cord,

Fig. 1. MRI scan with

gd: TB abscess invol-
ving spinal cord, with
vertebral collapse.
Fig. 2. TC scan: large abscess involving 10 vertebrae.
Pott’s Disease: Medical and surgical treatment
and vertebral fracture (4). In the early stages single-level
disc degeneration can be detected by MRI scan and a CT-
controlled biopsy could be performed to obtain an early
histopathological diagnosis. An early medical treatment
can protect the patient from vertebral collapse and from the
appearance of neurological deficits (10). If there is no evi-
dence of compressive effect on the spinal cord and absence
of vertebral collapse, TB spondylitis could be treated with
medical treatment alone. The slippery course of the disease
often causes a delay in getting to a diagnosis that is not made
prior to rising signs, such as large abscess, neurological im-
pairment or vertebral fractures. In these cases medical treat-
ment alone hasn’t shown effective results, because no specific
antibiotic drug can permeate the abscess’s capsule, and an
effective concentration is not achieved in the infection’s site.
Therefore surgical treatment is necessary to abscess draining
and setting the correct medical treatment. In three randomized
trial analyzed by MRC Working Party on Tuberculosis of the
Spine (11), early results are that chemotherapy with a then
standard 18 month chemotherapy regimen of Isoniazid plus
Para-AminoSalicylic acid (PAS) had been found to be highly
effective and there has been no therapeutic benefit from the
addition of certain other interventions including surgical
debridement (MRC 1985). The results of a second study
have demonstrated that 6-month and 9-month short-course
regimens based on Isoniazid and Rifampicin combined with
surgical intervention were equally effective and at least as
successful as the 18-month regimen (1986). The surgical
treatment and chemotherapy had shown some advantage,
namely less subsequent deformity, more rapid bony fusion
and more rapid resolution of mediastinal abscesses. The drug
dosages were as follows: Isoniazid: 6 mg/kg body weight
orally (maximum 300 mg); Rifampicin: 15 mg/kg body
weight orally (maximum 600 mg); Streptomycin: 20 mg/kg
body weight intramuscularly (maximum 1 g); Ethambutol:
15–25 mg/kg according to age and PAS: 0.2 g/kg body weight
orally (maximum 10 g). Results achieved by the 6- and
9-month regimens of Isoniazid plus Rifampicin were excel-
lent in terms of the proportion of patients achieving a favour-
able status by 5 years, most of whom had already achieved
it by 3 years. If, as may be expected from the longer-term
results of the first group of studies, the 5-year results of che-
motherapy prove to be permanent, short-term chemotherapy
based upon Rifampicin in patients ambulatory from the start
would appear to be the best available method of treatment
for this disease. There are new Rifampicin derivatives with
much longer half lives than Rifampicin, and then the better
sterilizing role different from that of Rifampicin its addition
to the 6-month regimen of Isoniazid and Rifampicin in their
study would be expected to give even better results. In our
department treatment with Ethambutol, Rifampicin, Isoni-
cotinic acid Hydrazide and Folic acid supplement continued
for a year to mycobacterial eradication. Best assessment of
treatment outcome used was achievement of a favourable
status, for which patients had to have full physical activity
with clinically and radiographical quiescent disease, with
no abscesses or myelopathy with functional impairment,
all without modification of the allocated regimen. The most
common complication of TB abscess is local kyphosis,
delayed surgery is useful to treat local instability and disc
degeneration by vertebral fusion (Fig, 3).
3
Fig. 3. Post-operative 3D-TC: vertebral stabilization.
The best surgical method has to be decided case by
case (12).
In conclusion, medical treatment alone is effective only
in rare early-diagnosed cases of Pott’s disease. In almost all
cases large size of the abscess or the presence of vertebral
collapse a surgical intervention is of essence for myelo-
radicular decompression, abscess drainage and vertebral
stabilization. In all cases a postoperative medical treatment
is indicated for mycobacterial eradication.
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