1. Pott Disease The presentation of Pott disease depends on the following:  Stage of disease  Affected site  Presence of complications such as neurologic deficits, abscesses, or sinus tracts

2. Pott Disease The reported average duration of symptoms at diagnosis is 4 months but can be considerably longer, even in most recent series. This is due to the nonspecific presentation of CHRONIC BACK PAIN. 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). Sep 1999;78(5):309-20.

3. Pott Disease Back pain is the earliest and most common symptom. The pain caused by Pott disease can be spinal or radicular. Potential constitutional symptoms of Pott disease include fever and weight loss. Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome.

4. Pott Disease Although both the thoracic and lumbar spinal segments are nearly equally affected in persons with Pott disease, the thoracic spine is frequently reported as the most common site of involvement. Together, they comprise 80-90% of spinal tuberculosis sites.

5. Pott Disease Many persons with Pott disease (62-90% of patients in reported series) have no evidence of extraspinal tuberculosis, further complicating a timely diagnosis. Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am. Dec 1985;67(9):1405-13. 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). Sep 1999;78(5):309-20.

6. Radiography 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 Ridley N, Shaikh MI, Remedios D, et al. Radiology of skeletal tuberculosis. Orthopedics. Nov 1998;21(11):1213-20.

7. Radiography 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 one level.

8. CT Scanning  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. Sharif HS, Morgan JL, al Shahed MS, et al. Role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am. Jul 1995;33(4):787-804

9. MRI 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. Moorthy S, Prabhu NK. Spectrum of MR imaging findings in spinal tuberculosis. AJR Am J Roentgenol. Oct 2002;179(4):979-83. Almeida A. Tuberculosis of the spine and spinal cord. Eur J Radiol. Aug 2005;55(2):193-201.

10. Tuberculous vs Pyogenic Spondylitis The incidence of spinal infection varies from 1 in 125000 to 1 in 250000 cases of which two thirds being pyogenic and only one third having tuberculosis Spinal TB is the most common form of skeletal system TB, comprising 50% of all cases In spinal TB, the anterior portions of two or more contiguous vertebrae are involved owing to hematogenous spread through one intervertebral artery feeding two adjacent vertebrae

11. Tuberculous vs Pyogenic Spondylitis MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis. Jung NY, Jee WH, Ha KY, et al. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol. Jun 2004;182(6):1405-10

12. Treatment 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. Leibert E, Haralambou G. Tuberculosis. In: Rom WN and Garay S, eds. Spinal tuberculosis. Lippincott, Williams and Wilkins; 2004:565-77.

13. Surgery Indications for surgical treatment of Pott disease generally include the following:  Neurologic deficit (acute neurologic deterioration, paraparesis, 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 Jain AK. Tuberculosis of the spine. Clin Orthop Relat Res. Jul 2007;460:2-3. Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am. Feb 1996;78(2):288-98.

14. Surgery 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. Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine. Aug 1 1997;22(15):1791-7. 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. Feb 15 2007;32(4):E130-5.

15. Contraindications 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.