Pott's disease: Diagnosis and management (What to do?)

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Pott's disease is an infectious disease of vertebrae original tuberculosis. It is a form extra-pulmonary caused by the tuberculosis germ which affects the spine.

This disease has become quite rare today and is observed almost exclusively in unvaccinated and North African migrant. It is a medical emergency requiring early management, which is based on a fairly long treatment, but which almost always gives good results.

In this article, we will discuss together the origin of Pott's disease, its clinical presentation, how to establish its diagnosis and how to manage it. 

Pott's Disease: What is it?

Tuberculosis is an infectious bacterial disease whose causative organism is Mycobacterium tuberculosis. This condition mainly affects the lungs, but can also affect other organs such as the brain, bone, vertebrae, etc.

Le Pott's disease, whose name we owe to the British surgeon Percival Pott, is one of the forms of tuberculosis affecting the osteoarticular system. It is localized at the level of the vertebrae and intervertebral discs where it causes what is called a spondylodiscitis, that is, an infection of the vertebral bodies and intervertebral discs.

Dissemination of Mycobacterium to the vertebrae is by hematogenous, i.e. via the bloodstream.

Pott's disease represents 50% of the osteoarticular forms of the TB, and preferentially concerns the Lumbar spine and dorsal.

At present, thanks to the early treatment of primary tuberculosis infections and prevention via BCG vaccination, Pott's disease is increasingly rare in developed countries.

The causes and risk factors of Pott's disease 

As mentioned in the definition, Pott's disease is one of the most frequent osteoarticular manifestations of tuberculosis. This is caused by mycobacterium tuberculosis, an aerobic bacterium that grows in an oxygen-rich body environment such as the lungs. It is transmitted through the air via Flügge droplets released by coughing.

Naturally, the risk of contamination increases in the event of frequent and close contact with a symptomatic person, more particularly in the case of workers in the health sector who are regularly exposed to patients with pulmonary tuberculosis.

In the absence of treatment, the tuberculosis germ will migrate via the bloodstream to other organs including the vertebral disco site where it will cause destruction and softening of the vertebral bodies, responsible for a kyphosis or curvature of the spine called " Pott's curvature ».

In addition, many risk factors have been implicated in the promotion of this condition:

  • THEimmunosuppression: diabetes, HIV, corticosteroid therapy, etc.
  • Radiation therapy
  • Postoperative bacteremia or post urinary endoscopy
  • Malnutrition
  • Transplantation in Black Africans
  • The pregnancy

Clinical picture of Pott's disease 

The symptomatology of Pott's disease can be very variable, ranging from mild back pain (back pain) or lumbar (low back pain) to severe forms with significant neurological repercussions and complications such as spinal deformity.

The symptoms most frequently reported by patients are:

  • General signs: deterioration in general condition, fever, weight loss, fatigue, etc.
  • Spinal pain predominant in the dorsal and lumbar areas. These are inflammatory pains that are triggered by palpation of the vertebral spines.
  • Spinal stiffness
  • Deformities of the spine of the type kyphosis ou Scoliosis
  • Neurological impairment ranging from sensory and motor impairment to compression of the spinal cord and nerve roots causing sphincter disorders (cauda equina syndrome).
  • Local signs: potassium abscess

How to establish the diagnosis of Pott's disease?

Once suspected, the diagnostic approach consists in carrying out a series of complementary examinations in order to support or eliminate the diagnosis.

One of the mainstays of the diagnosis of Pott's disease is themedical imaging. Imaging mainly includes: standard x-ray of the spine, scanner (CT) of the spine and MRI.

Standard radiography is always requested as a first-line treatment for its cost and its non-invasive nature. It allows the doctor to highlight characteristic lesions such as peri-wound condensation, vertebrate ivory, or even osteophytosis ; and to monitor the evolution of these lesions. 

The scanner usually highlights foci of osteitis with the presence of one or more geodes, associated with a disc pinching in pseudo-tumor forms.

MRI shows lesions that cannot be visualized with a standard X-ray or CT scan. You can view a posterior spondylitis (inflammation of the posterior arch), osteitis associated with the iliac, costal or even on the diaphysis of the long bones.

You can also use a tuberculin skin test (Mantoux test) or a spinal biopsy to detect the presence of the germ responsible for tuberculosis. 

Treatment of Pott's disease 

The therapeutic management of Pott's disease is mainly based on 3 components:

  • Drug treatment: Antibiotics
  • Orthopedic treatment: cast immobilization
  • Surgery

As a general rule, the introduction of drug treatment for Pott's disease is done according to a scheme that follows the same rules as that for pulmonary tuberculosis.

The scheme includes the prescription of four anti-TB antibiotics: Rifampicin, isoniazid, ethambutol and pyrazinamide over a phase lasting two months, followed by dual therapy (rifampicin and isoniazid) corresponding to the consolidation phase lasting 4 to 7 months. The total duration of treatment is generally 6 to 12 months.

For a better prognosis of the disease, it will be necessary to regularly monitor the side effects of these antibiotics, adjust their dosages, especially when it comes to an AIDS patient on antivirals that can interact with antituberculosis drugs.

Systematic recourse to orthopedic treatment (wearing a corset ou cast shell), or surgery not having been proven by the literature, the attitude differs from one surgical team to another and must be discussed on a case-by-case basis.

When it comes to an abscess or a nerve compression syndrome, the indication for surgery is in this case clear since these are emergencies that must be taken care of quickly at the risk compromise the patient's functional prognosis.

However, these cases are increasingly rare given the resolution of the origin of these deficits thanks to drug treatment.

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