Pott Disease Treatment & Management
- Author: Jose A Hidalgo, MD; Chief Editor: John L Brusch, MD, FACP more...
Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization using prolonged bed rest or a body cast. At the time, the disease carried a mortality rate of 20%, and relapse was common (30%).
The duration of treatment, surgical indications, and inpatient care for Pott disease have since evolved. 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, although routine surgery does not seem to be indicated.
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 with Pott disease should be treated with external bracing.
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.
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. Older patients can also present with late-onset complications such as reactivation, instability, or deformity. Observation is warranted in all groups of patients.
Consultations in Pott disease can include the following:
According to recommendations issued in 2003 by the US Centers for Disease Control and Prevention (CDC), 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 from among the first-line drugs, which include pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is indicated in cases of drug resistance.
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.
However, the research council’s 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.
For selected cases with surgical indication that allows complete debridement of the lesion, a combination of surgery and ultra-shortened course of therapy (4.5 mo), appears to show comparable outcomes of a combination of surgery and 9 months of drug therapy.
Surgical Indications and Contraindications
While most patients should respond to medical treatment, a surgical approach needs to be evaluated and considered. Indications for surgical treatment of Pott disease generally include the following:[43, 44]
Neurologic deficit - Acute neurologic deterioration, paraparesis, and paraplegia
Spinal deformity with instability or pain
No response to medical therapy - Continuing progression of kyphosis or instability
Large paraspinal abscess
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. The specific advantages and limitations of surgical techniques vary. Individualization of the case is of greatest importance.[18, 47, 48, 49, 50] Newer modalities and techniques are being reported, such as thoracoscopic decompression.
In Pott disease that involves the cervical spine, the following factors justify early surgical intervention:
High frequency and severity of neurologic deficits
Severe abscess compression that may induce dysphagia or asphyxia
Instability of the cervical spine
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.
Tubercular epidural abscess may produce spinal cord and nerve root compression leading to significant deficits. The American Spinal Injury Association impairment scale (ASIA) is useful to document neurological recovery from Pott disease. A designation of ASIA A indicates the most severe neurological compromise, ASIA E the least. At the beginning of treatment, most individuals are characterized as ASIA D. Large epidural abscesses correlated with a poor prognosis in terms of recovery from neurological deficits.
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