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Tuberculosis of Spine (Pott’s Spine)

  1. The spine is the most common site of skeletal tuberculosis, accounting for 50% of cases followed by hip and knee.
  2. Any level of the spine may be involved, the lower thoracic region being the most common; next in decreasing order of frequency are the lumbar, upper dorsal, cervical and sacral region. So dorso lumbar region is the most commonly involved segment.
  3. The most common type of spondylodiscitis (spondylitis) occurs in paradiscal region

    Description: potts

Fig. Paradiscal (commonest)-adjacent bone end plates

  1. The route of spread is mostly hematogenous (through artery and Bateson’s plexus). The initial focus of infection usually begins in the cancellous bone of vertebral body near the disc (in most common paradiscal type)
  2. Bone destruction and caseation follow with infection spreading to the disc space. The vertebral body lose their mechanical strength and eventually collapse under the body weight, with the intervertebral joint & posterior neural arch intact; thus an angular kyphotic deformity is produced. In the thoracic region kyphosis is most marked because of normal kyphotic curvature. In lumbar region it is slight because of normal lordosis in which most of body weight is transmitted posteriorly and collapse is partial And in cervical spine collapse is minimal, if present at all, because most of bony weight is borne through articular process. Tuberculosis is the most common cause of kyphosis in males. The deformity being maximum in dorsal spine>> lumbar spine>> cervical spine.
  3. Paravertebral abscess formation occurs almost in every case. Tuberculosis is the most common cause of cold abscess. These abscess travel along fascial planes or neurovascular bundles. So cervical abscess may burst into retropharangeal brachial plexus, axilla. Abscess of thoracic spine may rupture into mediastinum (bird’s nest abscess)

Bird nest appearance in chest xray due to cold abscess

or may reach anterior chest wall in parasternal area by tracking via intercostal vessels. In lumbar region, abscess may gravitate along psoas fascial sheath and usually point into groin just below inguinal ligament.

  1. GPotts spine with neurological deficit
    1. Paraplegia of early onset-active stage & in first two years
      (Inflammatory oedema, granulation tissue, abscess, ischemic lesion)
    2. Paraplegia of late onset-late after apparent quiescence
      (recrudescence, sequestra from body and disc, internal gibbus, stenosis of vertebral canal, severe deformity)
  2. Paraplegia occurs most often in mid or upper thoracic region, where kyphosis is most acute, the spinal canal is narrow and spinal cord is relatively large.
  3. Early onset paresis is due to pressure by an abscess, caseous material or bony sequestrum. It has good prognosis Late onset: paresis is due to increasing deformity or reactivation of disease, fibrosis or vascular insufficiency and has poor prognosis
  4. Fibrous ankylosis is usual outcome of healed tuberculosis of joints except in spine where bony ankylosis takes place.

Bony ankylosis in potts spine

  1. Clinical Feature
    1. Constitutional features as generalized malaise, easy fatigability, loss of appetite and weight.
    2. Back pain, Usually minimal, is the Commonest symptom. (1st symptom)
    3. Paravertebral muscle spasm resulting in stiffness in the affected region is a constant early finding.

Description: Description: C:\Documents and Settings\Dr. Ramkinkar\Desktop\potts spine\New Folder\PottsDisese-Clinical.gif  Description: Description: DSCF0082

  • Typical deformity is kyphosis
  • Less commonly kyphoscoliosis
  • Rarely scoliosis
  1. Cold abscess and deformity (kyphosis in thoracic region or loss of lumbar lordosis) is seen.
    Due to exudative reaction
    Composed of: WBC, serum, caseous material, bone debris, TB bacilli
    Penetrates ligaments and various facial planes
    Feels warm
    Sinus, ulcer
    Present clinically depending upon region of involvement or pressure effect (dysphagia, dypnea, peudo-flexion deformity of hip or rarely neurological deficit)
  2. Paraplegia due to cord compression, the earliest feature of which is spasticity, or clonus can be detected.

Prognostic Factor of Pott’s Spine



Better Prognosis

Poor prognosis

Degree of cord involvement

Partial(eg only sensory or motor)

Complete (grade IV)

Duration of cord involvement


Longer (>12 months)

Speed of onset




Early onset

Late onset




General condition



Vertebral disease



Kyphotic deformity



Cord on MRI


Myelomalacia/ syrinx (Cord changes)


Wet lesion

Dry lesion

  1. Radiological Feature
    1. The earliest feature of spinal tuberculosis is reduction of intervertebral disc space and osteoporosis of two adjacent vertebrae sometimes with fuzziness of the end plates.
    2. Paraspinal abscess appears as fusiform shadows along vertebral column. Later there are more obvious sign of bone destruction & collapse of adjacent vertebrae into each other, producing angular deformity
    3. Disc space collapse is typical of infection; disc preservation is typical of metastatic disease .Metastasis may cause vertebral body collapse, but in contrast to TB, the disc space is usually preserved
      • 1 pre-destructive - Straitening of curvature
      • 2 early destructive - Diminished disc space, knucle<10 degrees
      • 3 mild angular kyphos - 2/3 vertebra involved (K:10-30)
      • 4 moderate angular kyphos - 3 vertebra involved (K:30-60)
      • 5 severe kyphos(humpback) - 3 vertebra involved (K:>60)
  2. Treatment
    1. Antitubercular therapy, immobilization by spinal cast or brace and bed rest

Taylor brace

  1. Indications of operative treatment are When there is an abscess that can readily be drained
    1. Advanced disease with marked bone destruction and threatened or actual severe kyphosis or paraparesis.
    2. Neurological complication which failed to respond to conservative therapy for 3 —6 weeks / too advanced.
    3. For mechanical instability after healing
    4. In recurrence of disease or neural complication
  1. Surgical debridement (removal of necrotic & caseous material) and autogenous strut grafting of rib by anterior approach is treatment of choice.

Fig: Costo transversectomy

Anterolateral decompression (ALD)

Radical (Hongkong surgery)

Decompression and instrumentation

  1. Psoas abscess can give rise to pseudo - hip flexion deformity. The flexion deformity of hip joint due to spasm of iliopsoas muscle does not show any limitation of external or internal rotation of hip joint when tested in the position of flexion deformity. Ipsilateral flexion of hip joint (more than the deformity) relieves pain and extension increases pain (by stretching muscle)
  2. Spina Ventosa is short tubular bones tuberculosis.
  3. Tuberculosis of shoulder is dry- caries sica
  1. Tuberculosis of knee

  1. Tubercular arthritis is insidious in onset and often nonoarticular in involvement. It is the most common cause of monoarticular arthritis in children.
  2. Tubercular arthritis is a synovial disease, so peripheral destruction of joint occurs earlier than the central part and movements are lost gradually.
  3. At times with tubercular arthritis both sides of joint are involved and two foci of tuberculosis will be directly opposite each other (kissing arthritis)
  4. Tubercular arthritis is most common cause of fibrous ankylosis
  5. Classic triple deformity is seen (flexion, external rotation and posterior subluxation of knee). This triple deformity is also seen in other conditions. (mnemonic TRIPle- TB, Rheumatoid arthritis, Illiotibial band contracture and Polio)
  1. Sequale of Tubercular Arthritis
    1. Hip & knee-Fibrous ankylosis
    2. Spine-Bony ankylosis
  2. Sequale of TB knee
    1. Tuberculosis of the knee is the classical cause of triple deformity, which includes.
      1. Flexion
      2. Posterior subluxation of tibia
      3. External (lateral) rotation of tibia
    2. It can be treated by ATT and arthrodesis
    3. It can also be seen in rheumatoid arthritis, Poliomyelitis and Hemophilia.

Description: Tb_hip1

Sequale of TB HIP


Stages of T.B. Hip:

  1. Stage of Synovitis
    1. Flexion, Abduction and external rotation of hip
    2. Apparent lengthening
  2. Stage of early Arthritis:
    1. Flexion adduction and internal rotation deformity
    2. True shortening < 1cm
    3. Washing of muscles with decreased movements
  3. Stage of late Arthritis:
    1. Exaggerated flexion, adduction and internal rotation
    2. True shortening > 1 cm
  4. Stage of Subluxation/ Dislocation due to advanced arthritis, leading to wandering acetabulum.
  5. Stage of Aftermath – Fibrous ankylosis
  1. Treatment:
    1. Stage of Synovitis and early arthritis:-Chemotherapy and Traction
      Gradual mobilization: Synovectomy and Debridement may be done in few cases.
    2. Stage of advanced arthritis and further stages
      1. Arthrodesis: For painful ankylosis
      2. Girdlestone Arthroplasty
      3. Replacement

Tubercular Arthritis

Carries sicca (shoulder)

Spina ventosa

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