Pott Disease Workup
- Author: Jose A Hidalgo, MD; Chief Editor: John L Brusch, MD, FACP more...
Lab studies used in the diagnosis of Pott disease include the following:
Tuberculin skin test (PPD) - Results are positive in 84-95% of patients with Pott disease who are not infected with HIV
Erythrocyte sedimentation rate (ESR) - May be markedly elevated (>100 mm/h)
Microbiologic studies - Used to confirm the diagnosis
With regard to the above-mentioned microbiologic studies, bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. Procedures guided by computed tomography (CT) scanning 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. A 2015 multicentric, multinational study involving 35 centers and 314 cases reported that the causative agent was identified in 41% of cases.
It is expected that nonculture methods (DNA amplification) using skeletal tissue samples will become additional routine diagnostic methodologies. Their main advantages include high specificity, high sensitivity, and rapid results.[24, 25, 26]
Percutaneous, CT scan ̶ guided needle biopsy of bone lesions is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses. Obtain a tissue sample for microbiologic and pathologic studies to confirm diagnosis and to isolate organisms for culture and susceptibility. Positive culture yield of percutaneous is 50-83% and appears to be influenced by technical details, such as decontamination of specimens prior to culture.
Because microbiologic studies may be nondiagnostic of Pott disease, anatomic pathology can be significant. Gross pathologic findings include exudative granulation tissue with interspersed abscesses. Coalescence of abscesses results in areas of caseating necrosis.
Some cases of Pott disease are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration).
Radionuclide scanning findings are not specific for Pott disease. Gallium and technetium bone scans yield high false-negative rates (70% and up to 35%, respectively).
Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography:
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 1 level.
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. In contrast to pyogenic disease, calcification is common in tuberculous lesions.
Magnetic resonance imaging (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.[31, 32]
Contrast-enhanced MRI findings are useful in differentiating tuberculous spondylitis from pyogenic spondylitis. MRI findings in Pott disease include thin and smooth enhancement of the abscess wall and a well-defined paraspinal abnormal signal. Thick and irregular enhancement of the abscess wall and an ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. The images below are studies of a man aged 31 years with spinal tuberculosis.
Involvement of the disk is typically a characteristic of infectious spondylitis; however, this may not always be the case, and Pott disease can present with atypical features resembling neoplastic lesions. Findings of an intradural extramedullary mass at the lower end of the spinal cord associated with holocord T2 hyperintensities of the choroid has been described in intramedullary tubercular abscesses ”precipitation sign."[34, 35, 36]
Taylor GM, Murphy E, Hopkins R, et al. First report of Mycobacterium bovis DNA in human remains from the Iron Age. Microbiology. 2007 Apr. 153:1243-9. [Medline].
Helen Bynum. Spitting blood. The history of tuberculosis. Oxford: Oxford University Press; 2012. 6-10.
Pott P. The chirurgical works of Percivall Pott, F.R.S., surgeon to St. Bartholomew's Hospital, a new edition, with his last corrections. 1808. Clin Orthop Relat Res. 2002 May. 4-10. [Medline].
Murray MR, Schroeder GD, Hsu WK. Granulomatous Vertebral Osteomyelitis: An Update. J Am Acad Orthop Surg. 2015 Sep. 23 (9):529-38. [Medline].
Ekinci S, Tatar O, Akpancar S, Bilgic S, Ersen O. Spinal Tuberculosis. J Exp Neurosci. 2015. 9:89-90. [Medline].
Davidson PT, Le HQ. Tuberculosis and Nontuberculous Mycobacterial Infections. Schlossberg D, ed. Musculoskeletal Tuberculosis. 4th ed. Saint Louis, MO: W B Saunders; 1999. 204-20.
Leibert E, Haralambou G. Tuberculosis. Rom WN and Garay S, eds. Spinal tuberculosis. Lippincott, Williams and Wilkins; 2004. 565-77.
te Beek LA, van der Werf MJ, Richter C, et al. Extrapulmonary tuberculosis by nationality, The Netherlands, 1993-2001. Emerg Infect Dis. 2006 Sep. 12(9):1375-82. [Medline].
Pola E, Rossi B, Nasto LA, Colangelo D, Logroscino CA. Surgical treatment of tuberculous spondylodiscitis. Eur Rev Med Pharmacol Sci. 2012 Apr. 16 Suppl 2:79-85. [Medline].
Cheung WY, Luk KD. Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years' follow-up in the MRC study long enough?. Eur Spine J. 2012 May 8. [Medline].
Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am. 1985 Dec. 67(9):1405-13. [Medline].
Pertuiset E, Beaudreuil J, Liote F, et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994. Medicine (Baltimore). 1999 Sep. 78(5):309-20. [Medline].
Turgut M. Spinal tuberculosis (Pott's disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurg Rev. 2001 Mar. 24(1):8-13. [Medline].
Le Page L, Feydy A, Rillardon L, et al. Spinal tuberculosis: a longitudinal study with clinical, laboratory, and imaging outcomes. Semin Arthritis Rheum. 2006 Oct. 36(2):124-9. [Medline].
Park DW, Sohn JW, Kim EH, et al. Outcome and management of spinal tuberculosis according to the severity of disease: a retrospective study of 137 adult patients at Korean teaching hospitals. Spine. 2007 Feb 15. 32(4):E130-5. [Medline].
Ferrer MF, Torres LG, Ramírez OA, Zarzuelo MR, Del Prado González N. Tuberculosis of the spine. A systematic review of case series. Int Orthop. 2011 Nov 25. [Medline].
Cormican L, Hammal R, Messenger J, et al. Current difficulties in the diagnosis and management of spinal tuberculosis. Postgrad Med J. 2006 Jan. 82(963):46-51. [Medline].
Jellis JE. Human immunodeficiency virus and osteoarticular tuberculosis. Clin Orthop Relat Res. 2002 May. 27-31. [Medline].
Erdem H, Elaldi N, Batirel A, Aliyu S, Sengoz G, Pehlivanoglu F, et al. Comparison of brucellar and tuberculous spondylodiscitis patients: results of the multicenter "Backbone-1 Study". Spine J. 2015 Dec 1. 15 (12):2509-17. [Medline].
Batirel A, Erdem H, Sengoz G, et al. The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study. Clin Microbiol Infect. 2015 Nov. 21 (11):1008.e9-1008.e18. [Medline].
Held M, Laubscher M, Zar HJ, Dunn RN. GeneXpert polymerase chain reaction for spinal tuberculosis: an accurate and rapid diagnostic test. Bone Joint J. 2014 Oct. 96-B (10):1366-9. [Medline].
Merino P, Candel FJ, Gestoso I, Baos E, Picazo J. Microbiological diagnosis of spinal tuberculosis. Int Orthop. 2012 Feb. 36 (2):233-8. [Medline].
Amin I, Idrees M, Awan Z, Shahid M, Afzal S, Hussain A. PCR could be a method of choice for identification of both pulmonary and extra-pulmonary tuberculosis. BMC Res Notes. 2011 Sep 8. 4:332. [Medline].
Watt JP, Davis JH. Percutaneous core needle biopsies: the yield in spinal tuberculosis. S Afr Med J. 2013 Oct 11. 104 (1):29-32. [Medline].
Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol. 1984. 12 (3):178-86. [Medline].
Ridley N, Shaikh MI, Remedios D, Mitchell R. Radiology of skeletal tuberculosis. Orthopedics. 1998 Nov. 21 (11):1213-20. [Medline].
Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY. Role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am. 1995 Jul. 33 (4):787-804. [Medline].
Moorthy S, Prabhu NK. Spectrum of MR imaging findings in spinal tuberculosis. AJR Am J Roentgenol. 2002 Oct. 179 (4):979-83. [Medline].
Almeida A. Tuberculosis of the spine and spinal cord. Eur J Radiol. 2005 Aug. 55 (2):193-201. [Medline].
Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol. 2004 Jun. 182 (6):1405-10. [Medline].
Sivalingam J, Kumar A. Spinal Tuberculosis Resembling Neoplastic Lesions on MRI. J Clin Diagn Res. 2015 Nov. 9 (11):TC01-3. [Medline].
Lang N, Su MY, Yu HJ, Yuan H. Differentiation of tuberculosis and metastatic cancer in the spine using dynamic contrast-enhanced MRI. Eur Spine J. 2015 Aug. 24 (8):1729-37. [Medline].
Momjian R, George M. Atypical imaging features of tuberculous spondylitis: case report with literature review. J Radiol Case Rep. 2014 Nov. 8 (11):1-14. [Medline].
Zhang X, Ji J, Liu B. Management of spinal tuberculosis: a systematic review and meta-analysis. J Int Med Res. 2013 Oct. 41 (5):1395-407. [Medline].
Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T. Morphological changes during growth in healed childhood spinal tuberculosis: a 15-year prospective study of 61 children treated with ambulatory chemotherapy. J Pediatr Orthop. 2006 Nov-Dec. 26 (6):716-24. [Medline].
Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med. 2003 Feb 15. 167 (4):603-62. [Medline].
Li L, Zhang Z, Luo F, Xu J, Cheng P, Wu Z, et al. Management of drug-resistant spinal tuberculosis with a combination of surgery and individualised chemotherapy: a retrospective analysis of thirty-five patients. Int Orthop. 2012 Feb. 36 (2):277-83. [Medline].
Controlled trial of short-course regimens of chemotherapy in the ambulatory treatment of spinal tuberculosis. Results at three years of a study in Korea. Twelfth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg Br. 1993 Mar. 75 (2):240-8. [Medline].
Wang Z, Shi J, Geng G, Qiu H. Ultra-short-course chemotherapy for spinal tuberculosis: five years of observation. Eur Spine J. 2013 Feb. 22 (2):274-81. [Medline].
Jain AK. Tuberculosis of the spine. Clin Orthop Relat Res. 2007 Jul. 460:2-3. [Medline].
Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am. 1996 Feb. 78 (2):288-98. [Medline].
Tuli SM. Tuberculosis of the spine: a historical review. Clin Orthop Relat Res. 2007 Jul. 460:29-38. [Medline].
Yang P, Zang Q, Kang J, Li H, He X. Comparison of clinical efficacy and safety among three surgical approaches for the treatment of spinal tuberculosis: a meta-analysis. Eur Spine J. 2016 Mar 31. [Medline].
Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine (Phila Pa 1976). 1997 Aug 1. 22 (15):1791-7. [Medline].
Cui X, Ma YZ, Chen X, Cai XJ, Li HW, Bai YB. Outcomes of different surgical procedures in the treatment of spinal tuberculosis in adults. Med Princ Pract. 2013. 22 (4):346-50. [Medline].
Meena S, Mittal S, Chowdhary B. Spinal tuberculosis: which is the best surgical approach?. Med Princ Pract. 2014. 23 (1):96. [Medline].
Tuli SM. Historical aspects of Pott's disease (spinal tuberculosis) management. Eur Spine J. 2013 Jun. 22 Suppl 4:529-38. [Medline].
Kapoor S, Kapoor S, Agrawal M, Aggarwal P, Jain BK Jr. Thoracoscopic decompression in Pott's spine and its long-term follow-up. Int Orthop. 2012 Feb. 36 (2):331-7. [Medline].
Gupta AK, Kumar C, Kumar P, Verma AK, Nath R, Kulkarni CD. Correlation between neurological recovery and magnetic resonance imaging in Pott's paraplegia. Indian J Orthop. 2014 Jul. 48 (4):366-73. [Medline].
Jutte PC, Van Loenhout-Rooyackers JH. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Database Syst Rev. 2006 Jan 25. CD004532. [Medline].
Agrawal V, Patgaonkar PR, Nagariya SP. Tuberculosis of spine. J Craniovertebr Junction Spine. 2010 Jul. 1 (2):74-85. [Medline].