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For further information, see CMDT Part 20-41: Spinal Tuberculosis (Pott Disease)

Key Features

Essentials of Diagnosis

  • Seen primarily in immigrants from developing countries or immunocompromised patients

  • Back pain and gibbus deformity

  • Radiographic evidence of vertebral involvement

  • Evidence of Mycobacterium tuberculosis in aspirates or biopsies of spinal lesions

General Considerations

  • Typically seen in adult immigrants from countries where tuberculosis is prevalent

  • May develop in the setting of immunosuppression (eg, HIV infection, therapy with TNF inhibitors)

  • Spinal tuberculosis accounts for about 50% of musculoskeletal infection due to M tuberculosis

  • Seeding of the vertebrae may occur through

    • Hematogenous spread from the respiratory tract at the time of primary infection, with clinical disease developing years later as a consequence of reactivation

    • Lymphatics from infected foci in the pleura or kidneys

  • The thoracic and lumbar vertebrae are the most common sites of spinal involvement

  • Vertebral infection is associated with paravertebral cold abscesses in 75% of cases

Clinical Findings

Symptoms and Signs

  • Patients complain of back pain, often present for months and sometimes associated with radicular pain and lower extremity weakness

  • Constitutional symptoms are usually absent, and < 20% have active pulmonary disease

  • Destruction of the anterior aspect of the vertebral body can produce the characteristic gibbus deformity

Differential Diagnosis

  • All subacute and chronic bacterial infections of bone, eg, Brucella

  • Gonococcal arthritis

  • Mycotic bone infection

  • Pyogenic osteomyelitis or septic arthritis

  • Rheumatoid arthritis

  • Sporotrichosis

  • Metastatic cancer

  • Osseous dysplasia

Diagnosis

Laboratory Tests

  • Most patients have a positive reaction to purified protein derivative (PPD) or a positive interferon-gamma release assay

  • Cultures of paravertebral abscesses and biopsies of vertebral lesions are positive in up to 70–90%

Imaging Studies

  • Radiographs can reveal lytic and sclerotic lesions and bony destruction of vertebrae but are normal early in the disease course

  • CT scanning can demonstrate paraspinal soft tissue extensions of the infection

  • MRI is the imaging technique of choice to detect compression of the spinal cord or cauda equina

Diagnostic Procedures

  • Biopsies reveal characteristic caseating granulomas in most cases

  • Isolation of M tuberculosis from an extraspinal site is sufficient to establish the diagnosis in the proper clinical setting

  • Recovery of the acid-fast organism from joint fluid, pus, or tissue specimens using culture or polymerase chain reaction

Treatment

Medications

  • Antimicrobial therapy should be administered for 6–9 months, usually in the form of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months followed by isoniazid and rifampin for an additional 4–7 months

  • Medical management alone is often sufficient

Surgery

  • Surgical intervention, however, may be indicated when there is neurologic compromise or severe spinal instability

Outcome

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