What is Pott's Disease (Tuberculous Spondylitis)? Symptoms, Diagnosis, and Treatment

Pott's disease is the most common form of tuberculosis affecting the bones. Worldwide, approximately 10.6 million people were affected by tuberculosis in 2022. With early diagnosis and treatment, an estimated 95% of patients treated for Pott's disease recover. Therefore, it is crucial to recognize the symptoms of the disease.

In this article, you will find answers to questions such as what Pott's disease is, what its symptoms are, how it is diagnosed, and how it is treated. You will also learn about the causes of Pott's disease and ways to prevent it.

What is Pott's Disease?

Pott's disease, known as spinal tuberculosis, occurs when the Mycobacterium tuberculosis bacterium infects the spine. It was first described in 1779 by the British surgeon Sir Percival Pott as a distinct disease accompanied by paralysis.

When tuberculosis is mentioned, lung disease usually comes to mind. However, the tuberculosis bacterium can also affect different organs of the body. Tuberculosis infections seen in organs outside the lungs are called extrapulmonary tuberculosis. Pott's disease also falls into this category.

Bone involvement in tuberculosis patients is seen at a rate of approximately 3-5%. Spinal involvement accounts for 50% of bone tuberculosis. Therefore, Pott's disease is the most common form of bone and joint tuberculosis.

How the disease affects the spine

Tuberculosis bacilli reach the spine via the bloodstream and can create different patterns of involvement. The bacteria primarily settle in the anterior superior or inferior corners of the vertebrae (spinal bones). From there, they spread to the intervertebral disc and adjacent vertebrae.

The infection begins in regions of the spine with a rich blood supply. In adults, the parts of the vertebral body close to the disc are usually involved. In children, disc involvement is more prominent.

As the disease progresses, destruction of the spinal bones begins. A loss of height occurs in the anterior part of the spine, resulting in a hump-like deformation. This condition is called a gibbus or kyphosis deformity. At the same time, it can cause spinal cord compression and neurological problems.

As the infection progresses beneath the ligament, abscess formation may be observed. These abscesses frequently calcify and are referred to as paraspinal cold abscesses.

How common is Pott's disease?

Pott's disease accounts for 1-5% of all tuberculosis cases. Similarly, spinal tuberculosis constitutes 10-35% of reported extrapulmonary tuberculosis cases worldwide.

The disease is most frequently seen in the thoracic (chest) and lumbar (lower back) regions. Thoracic vertebrae are affected in 37-67% of cases. Lumbar vertebra involvement occurs at a rate of 19-59%, while cervical (neck) vertebra involvement appears in 0-21%. Involvement in multiple regions can occur very rarely.

The disease frequently occurs within the first three decades of life and in younger age groups. The lower thoracic and upper lumbar vertebrae are the most heavily affected regions. Lower chest region involvement is predominant in young individuals, while upper lower-back region involvement is predominant in older cases.

Pott's disease continues to be a significant health problem in developing countries. It is still a serious infectious disease encountered in our country as well.

Pott's Disease Symptoms and Causes

Most common symptoms

Due to the slow-running nature of the disease, symptoms develop gradually over weeks or even months. Back and lower back pain is the most common symptom of Pott's disease. The pain usually arises without a history of trauma and intensifies over time.

Night sweats are one of the characteristic findings of the disease. These are accompanied by fever, usually running at a mild elevation. Loss of appetite and consequently weight loss are observed in the majority of patients. Complaints of fatigue and easy tiring are also frequently encountered.

As the disease progresses, spinal deformities may develop. Severe neurological losses can occur following spinal cord compression. Neurological problems such as paraparesis or paraplegia occur in 23-76% of patients. Weakness in the arms and legs, loss of sensation, and problems with urinary control may be experienced.

Paraspinal muscle spasm is another finding that increases pain. Spinal movements and situations such as heavy lifting can exacerbate the pain. In advanced stages, cold abscess formation is characteristic, and these abscesses can advance along the psoas muscle and become palpable in the groin region.

Which regions of the spine are affected?

Pott's disease is most frequently seen in the thoracolumbar region. That is, the junction of the chest and lower back spine is the most heavily involved area. The lower thoracic and upper lumbar vertebrae are particularly at risk.

The most commonly involved vertebra is at the L1 level. The first lumbar vertebra becomes the main target of the infection. Similarly, thoracic vertebrae are affected in 37-67% of cases. Lumbar region involvement is encountered at a rate of 19-59%, and the cervical region at 0-21%.

Involvement is seen in 50% of the vertebrae. The disease generally affects multiple vertebrae. Single vertebra involvement or involvement at different levels are atypical forms and are rarely seen.

Bacteria causing Pott's disease

The Mycobacterium tuberculosis bacterium causes Pott's disease. This bacillus is a slow-growing microorganism and is transmitted from person to person via airborne droplets. The infection first begins in the lungs, then reaches the spine via the bloodstream.

The bacteria begin at the vertebral metaphysis and damage the adjacent endplates. Caseation necrosis develops, and destruction of the spinal bones begins. As the infection progresses, the intervertebral disc and adjacent soft tissues are also affected.

Risk factors and transmission routes

Diabetes mellitus is a significant risk factor for Pott's disease. Poor nutritional status weakens the immune system, creating a susceptibility to infection. The risk of the disease increases in individuals with substance or alcohol dependence.

Conditions that suppress the immune system facilitate the development of infection. HIV infections, kidney failures, and diseases such as cancer fall into this category. Long-term steroid use is also among the risk factors. The probability of contracting the disease increases in smokers.

Close contact with a tuberculosis patient increases the risk. Those living in crowded environments or with limited access to healthcare services carry a higher risk. The infection spreads via the air, but once it reaches the spine, it is no longer contagious.

How is Pott's Disease Diagnosed?

Physical examination process

Your doctor will first perform a detailed physical examination. They will check whether there is tenderness in the suspected regions of your spine. Pain is investigated by lightly tapping (percussion) over the spinous processes of the vertebrae.

Your spinal movements are carefully evaluated. You are checked for restriction or pain during bending movements forward, backward, to the right, and to the left. In advanced cases, hump-like deformation may be observed.

Paraspinal muscle spasm is a frequently encountered finding. Your doctor evaluates whether you feel stiffness and tension in your muscles. During the neurological examination, loss of strength and sensory changes in your arms and legs are investigated.

Tuberculosis skin test

The tuberculin skin test or PPD test is one of the screening methods used in the diagnosis of Pott's disease. This test shows whether your body has previously encountered the tuberculosis bacillus.

For the test, a tuberculin solution is injected into the inner surface of your forearm with a very fine needle. A small bump forms at the injection site. You must return to the healthcare center 48-72 hours later for the test to be read.

When reading the test, redness on the skin is not measured, but rather hardness and swelling. The diameter of this hardness (induration) is measured in millimeters. It is considered positive at 15 mm and above in individuals who have received the BCG vaccine. It is significant at 10 mm and above in those who have not received the BCG vaccine. In immunocompromised individuals, even 5 mm and above is considered positive.

However, the sensitivity of the PPD test is between 62-72%. The test cannot distinguish active disease from past infections. Additionally, it may give a positive result in those who have been administered the BCG vaccine.

Blood tests and imaging methods

In blood tests, sedimentation rate and C-reactive protein (CRP) values are checked. Elevated sedimentation is an indicator of inflammation. CRP values also reflect disease activity.

MRI imaging is the best diagnostic method for spinal tuberculosis. Its sensitivity has been reported as 96% and specificity as 93%. MRI shows both bone and soft tissue involvement in detail.

Characteristic MRI findings include destruction in the vertebrae, paraspinal soft tissue involvement, and abscess formation. Interosseous abscess is particularly important in terms of diagnosis. Epidural spread and subligamentous progression can be observed.

Computed tomography shows soft tissue changes around the vertebrae and in the spinal canal. In direct X-ray radiographs, destruction in the vertebrae and narrowing of the disc space can be detected.

For definitive diagnosis, a sample must be taken from the infected region. Needle biopsy can be performed under radiological guidance. Isolation of Mycobacterium tuberculosis in cultures from the obtained samples is the gold standard in diagnosis. Acid-fast staining and molecular methods are also used.

Challenges encountered in diagnosis

The slow course of the disease and non-specific symptoms lead to delays in diagnosis. It is common for non-specific symptoms to persist for several months. Delays averaging 5 months may occur.

Pott's disease does not have a unique radiological finding. It is necessary to distinguish it from other diseases that give a similar appearance. Pyogenic vertebral infections, fungal infections, and tumors should be considered in the differential diagnosis.

Bacteriological confirmation is not always easy. A waiting period of 3-8 weeks is required for culture results. Therefore, diagnosis is made by evaluating clinical and radiological findings together.

Pott's Disease Treatment and Management

Drug therapy and antibiotics used

Anti-tuberculosis treatment is the main approach for Pott's disease. Approximately 90% of patients can recover with drug therapy. Treatment is carried out by using multiple antibiotics together. This combination prevents the bacterium from developing drug resistance.

Isoniazid, rifampicin, ethambutol, and pyrazinamide are used in treatment. Streptomycin may also be added to the treatment in some cases. Four or five drugs are administered together for the first two months. Afterwards, isoniazid and rifampicin are continued.

It is recommended that you take your medications on an empty stomach. You should take them at least 1 hour before or 2 hours after a meal. If you experience stomach discomfort, you can take them with a meal, but consult your doctor.

Duration of treatment and medication schedule

Spinal tuberculosis treatment takes longer than pulmonary tuberculosis treatment. The duration of treatment varies between 6 and 18 months. American organizations recommend 6-9 months of treatment for bone and joint tuberculosis.

Regular use of treatment is extremely important. Stopping medications early causes treatment to fail. With the directly observed therapy method, each dose is administered under the supervision of healthcare personnel.

Treatment of drug-resistant tuberculosis

Resistant tuberculosis is the case in situations unresponsive to standard drugs. The treatment of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) is more difficult.

In resistant cases, second-line drugs such as kanamycin, capreomycin, amikacin, and fluoroquinolones are used. This treatment includes at least 5 effective drugs. Treatment is continued for another 18-24 months after cultures become negative.

Surgical intervention necessity and types

Surgery may be required in certain situations. Spinal cord compression, advanced deformation of the spine, unresponsiveness to drug therapy, and large abscesses are surgical indications. Surgery is considered in the presence of kyphosis over 30 degrees.

Damaged tissues are cleaned in debridement surgery. The abscess is drained through a drainage procedure. Metal plates and screws are used for stabilization. In fusion surgery, two vertebrae are permanently fused.

Anterior radical debridement and graft application is the gold standard. Better results are obtained by adding posterior instrumentation as well. Neurological recovery after surgery begins within 1-6 weeks.

Prognosis, Prevention, and Complications

Course of the disease and recovery rates

95% of patients who receive early diagnosis and appropriate treatment recover completely. This rate demonstrates that Pott's disease treatment is successful. However, outcomes vary depending on the timing of starting treatment.

Active symptoms gradually disappear after treatment begins. The sedimentation rate begins to drop from the third month after surgery. In the majority of patients, follow-ups are performed monthly for the first three months, and at three-month intervals thereafter.

Recovery is possible even in patients experiencing neurological problems. When surgery is applied to those who have developed motor and sensory loss, complications are not seen except for a minimal decrease in movement capacity. Partial or complete resolution is achieved in urine and stool control problems.

Complications that may occur if left untreated

If left untreated, Pott's disease leads to serious consequences. The two fundamental problems of the disease are vertebral deformity formation and neurological losses. Progressing damage in the spinal bones leads to permanent deformities in the form of a hump.

Cold abscesses and fistulas can form as a result of the progression of the infection. Damage occurs in the psoas muscle and adjacent nerve tissues. Collapse of the spine causes spinal instability.

The most serious complication is paralysis. Paraplegia or tetraplegia can develop if left untreated. Spinal cord compression creates difficulty in moving and walking. Bladder and bowel control may be lost. The infection can spread to other organs such as the brain and kidneys.

Ways to prevent Pott's disease

Reducing the risk of contracting a tuberculosis infection is the basic principle of prevention. You should avoid long-term close contact with someone who has an active tuberculosis infection. It is recommended that you stay away from crowded and poorly ventilated environments.

If your risk of tuberculosis is high or you live in a region where the disease is common, have regular tests. The BCG vaccine significantly reduces deaths from tuberculosis in children. Eat a balanced diet and adopt a healthy lifestyle to keep your immune system strong.

Life expectancy and long-term outlook

If diagnosed early, Pott's disease may not affect life expectancy. Outcomes are generally worse in young children, adults over 65, and immunocompromised individuals. For these groups, the disease can be life-threatening.

Life expectancy depends on several factors. Your age and general health status are important. When you received treatment, the severity of the infection, and the complications you experienced play a decisive role. Whether your body is resistant to drugs also affects the outcome.

Regular follow-up and medication adherence guarantee long-term success. Disease relapse or reactivation is rare. You can return to your normal life activities after treatment is completed.

Frequently Asked Questions

No, Pott's disease is not contagious. Tuberculosis is contagious only when it is active in the lungs. For example, when a person with the infection coughs or speaks, droplets spread into the air. However, after the infection moves to the spine, the risk of transmission disappears.

The tuberculosis bacterium completely leaves the lungs and settles in the spine. At this stage, bacteria are no longer shed into the air. Therefore, being in the same environment, shaking hands, or using the same items with someone who has Pott's disease is safe. The disease does not pass from person to person.

Pott's disease can be treated with medications. However, complete recovery cannot be guaranteed in every case. Treatment becomes difficult especially if the tuberculosis bacterium has developed drug resistance.

When early diagnosis is made and correct drug therapy is applied, damage is generally reversible. Bone and spinal destruction can be halted. Even neurological problems can resolve with treatment. Therefore, timely intervention is extremely important.

You should go to a doctor immediately when you notice tuberculosis symptoms. A persistent cough lasting longer than two weeks is a serious warning sign. If you are experiencing chest pain or coughing up blood, seek emergency help.

Additionally, constant fatigue, muscle weakness, and loss of appetite are also important findings. If accompanied by fever and chills, definitely go to a healthcare facility. Even if there are no lung symptoms, spinal tuberculosis is possible. If you are experiencing back pain, movement restriction, or weakness in your legs, do not waste time.

Treatment for Pott's disease occurs in stages and lasts for several months. In the first stage, four or five drugs are used together. This stage usually continues for two months. Isoniazid, rifampicin, pyrazinamide, ethambutol, and sometimes streptomycin are given.

In the second stage, isoniazid and rifampicin are continued for 4 to 12 months or longer. Total treatment duration varies between 6-18 months. The severity of the disease and your body's response to medications affect the duration. You must strictly follow your doctor's instructions. Stopping medications early causes treatment to become ineffective.

Pott's Disease in Summary

Although Pott's disease is a serious health problem, it can be treated with early diagnosis. Recognizing symptoms and consulting a doctor in a timely manner is extremely important. Do not waste time when you notice symptoms such as back pain, night sweats, and weight loss.

The treatment process can last for several months, but the success rate is quite high with regular medication use. 95% of patients recover completely. Use your medications regularly and follow your doctor's instructions. With early intervention, complete recovery can be achieved before permanent damage forms in the spine. To protect your health, eat a balanced diet and keep your immune system strong.

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