Treatment Of Pott’s Disease
According to the World Health Organization, tuberculosis has become the world's most deadly infectious disease, killing nearly 3 million people per year. Each year there are 8 million new cases of tuberculosis, and 50% of them are infectious.
Spinal tuberculosis is the most common form of musculoskeletal tuberculosis. In HIV-negative patients, between 3% and 5% of tuberculosis cases are skeletal, compared with 60% of cases in HIV-positive patients.
The incidence and the site of involvement
Spinal tuberculosis is the most dangerous form of skeletal tuberculosis because of its ability to cause bone destruction, deformity, and paraplegia. Paraplegia is more common in tuberculosis than in pyogenic spondylitis because the neural arch is involved more often with the former. The spine is involved in 50% of cases of musculoskeletal tuberculosis: 4.2% in the cervical spine, 55.8% in the thoracic spine, 16.9% in the thoracolumbar spine, and 22.8% in the lumbar and lumbosacral spine. Three forms of vertebral involvement have been described; peridiscal, central, and anterior. Two-thirds of the classifiable cases present with peridiscal involvement, while in more than 50% of the cases the primary focus can not be determined because of the extension of the disease. Progression of the vertebral disease is usually by direct subperiosteal or subligamentous spread.
Diagnosis
Tuberculosis constitutes a diagnostic challenge. Diagnosis is usually a long and tedious process. Usually the clinical manifestation favors the diagnosis however, diagnosis should be confirmed by evaluating the radiographic changes, computed tomography (CT) and magnetic resonance image (MRI) findings, cultures of blood, and/or percutaneous vertebral aspirates, then bone biopsy, either by an open or percutaneous procedure. PPD is predictive in 86% of the cases. Tc99 MDP scintigraphy may be negative in 35% and furthermore Gallium scans could be negative in nearly 70%. No single imaging finding is pathognomonic of Pott’s disease. Slow growth rate of mycobacteria on solid media is a problem due to the nature of the mycobacteria and direct microscopy is insensitive, because samples may contain only a few organisms. And yet, low number of mycobacteria are detected at spine. Diagnostic procedures such as culture, antigen demonstration, serology tests, and polymerase chain reaction are of high priority. The polymerase chain reaction has facilitated the diagnosis and management of tuberculosis.
Treatment
There have been discussions on whether the treatment of choice should be conservative chemotherapy for 12 months or chemotherapy and surgery combined. Management should be based on the goals of treatment for each individual case.
Effective chemotherapy for spinal tuberculosis is the gold standard and mainstay of the treatment and all other methods of treatment are regarded as supplementary.
Drug Treatment Regimens
The standard triple chemotherapy (isoniazid, rifampin, and pyrazinamide), should be given for at least 12 months, rather than the 6- to 9-month short-term chemotherapy that has been proposed by some authors. Upadhyay et al reported that 6 months of three-drug chemotherapy in conjunction with radical surgery was adequate for the management of tuberculosis of the spine because it produced results comparable with 9-month and 18-month chemotherapeutic regimens, however this should be taken cautiously. Good general supportive care and an effective chemotherapy started at the early stages of the disease are the keys to early and effective eradication and minimizing complications.
MRC Working Party showed that the combined standard 18-month chemotherapy with isoniazid and PAS produced a cure rate of 90% in children, which was identical to the results obtained with an additional initial 3-month streptomycin treatment. Ambulant chemotherapy alone provided treatment of tuberculosis with a minimum increase of kyphosis. The results of ambulant chemotherapy, however, were not always satisfactory.
Surgery
Although chemotherapy is the mainstay in the management of tuberculosis spondylitis, surgical procedures still play an important role. Problems arising from bone destruction, paraplegia, and pulmonary insufficiency due to spinal deformity can not be solved with chemotherapy alone. Indications for surgical treatment include 1) neurological involvement, 2) deformity and/or impending increase in deformity, and 3) the presence of large tuberculosis abscess and/or abundant necrotic tissue.
Abscess, tuberculosis lesion, paraplegia, and kyphosis, have been managed surgically by various procedures:
Cold Abscess.
Aspiration or surgical drainage was carried out for some patients with a large cold abscess because it was thought that evacuation of the abscess improved the patient's general condition, and rapid progression of the abscess along the spine was prevented.
Tuberculous destructive lesion.
Two surgical methods-focal débridement and anterior radical surgery-are available to eradicate the lesion.
1. Focal débridement. Focal débridement can effectively remove the diseased tissue and sequestra and also can evacuate the abscess; however, it does not prevent the progression of kyphosis due to the lack of anterior support. Focal débridement and simple abscess evacuation provide no long-term advantage over ambulant chemotherapy alone and therefore are no longer accepted as a preferred method of treatment.
2. Anterior radical surgery. Anterior radical debridement and arthrodesis with a strut graft and chemotherapy has been the treatment of choice. There is evidence that better results regarding deformity, recurrence, development of paralysis, and resolution are obtained when radical surgery is performed combined with chemotherapy.
Paraplegia.
During the early phases of the disease with active infection, possible reasons include direct compression of the neural structures by the abscess and/or sequestrated bone fragments, direct dural invasion, vascular compromise due to compression or thrombosis, acute instability, or severe deformity. Direct compression by abscess or necrotic tissue is the most frequent cause of early onset paralysis and generally has a good prognosis and a relatively high probability to resolve with effective treatment. Paraplegia due to vertebral tuberculous lesion is caused by direct impingement of the abscess, ischemia due to altered blood supply, intra dural abscess and kyphosis. It is generally known that the recovery rate from paraplegia is influenced by many factors: the patient's general state, age, and spinal cord condition; the level and the number of involved vertebrae; the severity of spinal deformity; the duration and severity of paraplegia; the time to initiation of treatment; the type of treatment; and drug sensitivity. Paralysis occurring in children generally have a better prognosis compared to adults
Paralysis lasting longer than 6 months is most unlikely to improve, and late paralysis with inactive disease and significant kyphosis is much less responsive to treatment. Paralysis due to vascular insufficiency has a worse prognosis. Several methods have been used for the treatment of patients with paraplegia:
1) chemotherapy alone,
2) laminectomy,
3) costotransversectomy, and
4) radical surgery.
In the early stages of the disease, paraplegia caused by abscess can be resolved by effective chemotherapy alone as by decompressive surgery, however, chemotherapy alone is inappropriate management of paraplegia in the patient with advanced tuberculosis and deformity. It is unfair to allow a patient to lie paralyzed for some weeks to months awaiting a cure through conservative care. Decompressive laminectomy will destabilize already hampered spine therefore should not be done. When patients with Pott's paraplegia and severe spinal deformity do not respond to chemotherapy and have worsening neurology, decompressive surgery is indicated to arrest the progress of paralysis and hopefully to restore normal neurology.
Kyphosis /Deformity
Tuberculosis kyphosis is an unstable lesion that tends to progress until there is sound bony fusion anteriorly.
Kyphosis has been managed by several surgical procedures:
posterior fusion,
anterior radical surgery, and
various combined operations such as a one-stage, two-stage, or three-stage procedures.
Each patient should be cautioned about the high neurologic risk with corrective surgery of the rigid deformed spine.
Until now, the following surgical procedures have been practiced by various surgeons:
1. Flexible Kyphosis:
Skeletal traction
Posterior fusion
Anterior radical surgery
Two-stage operation:
Posterior instrumentation followed by anterior radical surgery
Anterior release and graft, followed by posterior instrumentation
Three-stage operation (anterior release followed by posterior instrumentation and delayed anterior radical surgery).
2. Fixed Kyphosis.
One-stage operation
Two-stage operation (anterior release, deformity correction and anterior graft, followed by posterior instrumentation)
Multi-stage operation (osteotomy, halopelvic device, posterior instrumentation and fusion).
Skeletal traction for cervical kyphosis.
Posterior fusion for kyphosis. Disproportionate posterior spinal growth has been suspected as a contributing factor in the progression of kyphotic deformity after management of spinal tuberculosis by posterior fusion only.
Especially, in children frequently there will be a loss of the initial gain of correction and progression of kyphosis after noninstrumented posterior spinal fusion if anterior fusion is not achieved. Additional instrumentation seems to prevent the progression of kyphosis.
Anterior radical surgery for kyphosis. Radical surgery (Hong Kong Operation) was found to give better results than focal débridement for the correction and prevention of kyphosis. Progression of kyphosis is more observed in multilevel lesions
Posterior closing wedge osteotomy for kyphosis (Galveston one-stage operation). This technique is a very effective one-stage operation. It involves a modified bilateral costotransversectomy approach to the spine, followed by removal of structures in a wedge shape, including the vertebral arch, the disk, and a portion of the centrum. The wedge is closed by posterior compression instrumentation, enabling an angular correction of 30° to 50°.
Decancellation or corporal eggshell procedure. This posterior close wedge procedure involves transpedicular curettage or evacuation of the cancellous bone of the vertebral body, excision of the posterior elements and posterior wall of the body, and correction of kyphosis by closing the wedge. This is a highly demanding procedure with additional surgical risks.
Two-stage operations.
1. Anterior radical surgery, followed by posterior resection and instrumentation. Yau et al used Luque instrumentation in a two-stage procedure to correct the deformity.
2. Combined posterior instrumentation plus anterior radical surgery for flexible kyphosis (two-stage operation). This procedure may be most appropriate for active cases of progressive kyphosis where the curve is stil flexible.
Prevention and correction of kyphosis and kyphoscoliosis by posterior instrumentation has three advantages. Posterior stabilization of the spine arrests the disease early, encourages early fusion, and enables correction of the deformity. The procedure is indicated only in those patients who are likely to develop or who have a pre-existing deformity. It is suggested that a formula be used to predict the kyphosis that will remain at the end of chemotherapy to determine if prophylactic or corrective spinal instrumentation surgery is indicated. (Rajasekaran formula: Y=a+bX (Y= deformity, X=pretreatment loss in VB, a= constant value of 5.5, b= constant value of 30.5))
A two-stage operation, combining posterior instrumentation and anterior interbody fusion, can be an option for multisegmental tuberculosis of more than two segments. Instrumentation at a distance from the infective process restores spinal stability and prevents graft fracture, slipping, sagging, and resorption. Because of the anterior column deficiency due to the anterior column destruction posterior instrumented correction of kyphosis produces an anterior bone gap that should be reconstructed by anterior strut graft; otherwise, recollapse, instrumentation failure, and recurrent kyphosis will be inevitable.
After it has been shown that anterior instruments can be used safely at the infected site in tuberculosis patients there have been reports showing the advantages of anterior radical debridement strut grafting and anterior instrumentation.
Of course anti tuberculosis drug treatment should never be replaced by any kind of surgery alone.
References
Anti-TB drugs
First line drugs
İsoniazid bactericidal 5mg/kg
Rifampicin bactericidal 10mg/kg
Streptomycin bactericidal 15mg/kg
Pyrazinamide bactericidal 35mg/kg
Etambutol bacteriostatic 30mg/kg
Thiacetazone bacteriostatic 350mg/d
Principles
Mechanism of action
Against large population of mb actively multiplying in the walls of the cavity
Isoniasid (bactericidal)
Rifampicin (bactericidal)
Streptomycin (bactericidal)
Etambutol (bacteriostatic)
Pyrazinamide (ineffective)
Against small population of mb slowly multiplying inside macrophage and low pH
Pyrazinamide (most effective)
Isoniasid (ineffective)
Rifampicin (ineffective)
Streptomycin (ineffective)
Intermittently multiplying bacilli in solid caseous material
Only rifampin is active
Spinal tuberculosis is the most common form of musculoskeletal tuberculosis. In HIV-negative patients, between 3% and 5% of tuberculosis cases are skeletal, compared with 60% of cases in HIV-positive patients.
The incidence and the site of involvement
Spinal tuberculosis is the most dangerous form of skeletal tuberculosis because of its ability to cause bone destruction, deformity, and paraplegia. Paraplegia is more common in tuberculosis than in pyogenic spondylitis because the neural arch is involved more often with the former. The spine is involved in 50% of cases of musculoskeletal tuberculosis: 4.2% in the cervical spine, 55.8% in the thoracic spine, 16.9% in the thoracolumbar spine, and 22.8% in the lumbar and lumbosacral spine. Three forms of vertebral involvement have been described; peridiscal, central, and anterior. Two-thirds of the classifiable cases present with peridiscal involvement, while in more than 50% of the cases the primary focus can not be determined because of the extension of the disease. Progression of the vertebral disease is usually by direct subperiosteal or subligamentous spread.
Diagnosis
Tuberculosis constitutes a diagnostic challenge. Diagnosis is usually a long and tedious process. Usually the clinical manifestation favors the diagnosis however, diagnosis should be confirmed by evaluating the radiographic changes, computed tomography (CT) and magnetic resonance image (MRI) findings, cultures of blood, and/or percutaneous vertebral aspirates, then bone biopsy, either by an open or percutaneous procedure. PPD is predictive in 86% of the cases. Tc99 MDP scintigraphy may be negative in 35% and furthermore Gallium scans could be negative in nearly 70%. No single imaging finding is pathognomonic of Pott’s disease. Slow growth rate of mycobacteria on solid media is a problem due to the nature of the mycobacteria and direct microscopy is insensitive, because samples may contain only a few organisms. And yet, low number of mycobacteria are detected at spine. Diagnostic procedures such as culture, antigen demonstration, serology tests, and polymerase chain reaction are of high priority. The polymerase chain reaction has facilitated the diagnosis and management of tuberculosis.
Treatment
There have been discussions on whether the treatment of choice should be conservative chemotherapy for 12 months or chemotherapy and surgery combined. Management should be based on the goals of treatment for each individual case.
Effective chemotherapy for spinal tuberculosis is the gold standard and mainstay of the treatment and all other methods of treatment are regarded as supplementary.
Drug Treatment Regimens
The standard triple chemotherapy (isoniazid, rifampin, and pyrazinamide), should be given for at least 12 months, rather than the 6- to 9-month short-term chemotherapy that has been proposed by some authors. Upadhyay et al reported that 6 months of three-drug chemotherapy in conjunction with radical surgery was adequate for the management of tuberculosis of the spine because it produced results comparable with 9-month and 18-month chemotherapeutic regimens, however this should be taken cautiously. Good general supportive care and an effective chemotherapy started at the early stages of the disease are the keys to early and effective eradication and minimizing complications.
MRC Working Party showed that the combined standard 18-month chemotherapy with isoniazid and PAS produced a cure rate of 90% in children, which was identical to the results obtained with an additional initial 3-month streptomycin treatment. Ambulant chemotherapy alone provided treatment of tuberculosis with a minimum increase of kyphosis. The results of ambulant chemotherapy, however, were not always satisfactory.
Surgery
Although chemotherapy is the mainstay in the management of tuberculosis spondylitis, surgical procedures still play an important role. Problems arising from bone destruction, paraplegia, and pulmonary insufficiency due to spinal deformity can not be solved with chemotherapy alone. Indications for surgical treatment include 1) neurological involvement, 2) deformity and/or impending increase in deformity, and 3) the presence of large tuberculosis abscess and/or abundant necrotic tissue.
Abscess, tuberculosis lesion, paraplegia, and kyphosis, have been managed surgically by various procedures:
Cold Abscess.
Aspiration or surgical drainage was carried out for some patients with a large cold abscess because it was thought that evacuation of the abscess improved the patient's general condition, and rapid progression of the abscess along the spine was prevented.
Tuberculous destructive lesion.
Two surgical methods-focal débridement and anterior radical surgery-are available to eradicate the lesion.
1. Focal débridement. Focal débridement can effectively remove the diseased tissue and sequestra and also can evacuate the abscess; however, it does not prevent the progression of kyphosis due to the lack of anterior support. Focal débridement and simple abscess evacuation provide no long-term advantage over ambulant chemotherapy alone and therefore are no longer accepted as a preferred method of treatment.
2. Anterior radical surgery. Anterior radical debridement and arthrodesis with a strut graft and chemotherapy has been the treatment of choice. There is evidence that better results regarding deformity, recurrence, development of paralysis, and resolution are obtained when radical surgery is performed combined with chemotherapy.
Paraplegia.
During the early phases of the disease with active infection, possible reasons include direct compression of the neural structures by the abscess and/or sequestrated bone fragments, direct dural invasion, vascular compromise due to compression or thrombosis, acute instability, or severe deformity. Direct compression by abscess or necrotic tissue is the most frequent cause of early onset paralysis and generally has a good prognosis and a relatively high probability to resolve with effective treatment. Paraplegia due to vertebral tuberculous lesion is caused by direct impingement of the abscess, ischemia due to altered blood supply, intra dural abscess and kyphosis. It is generally known that the recovery rate from paraplegia is influenced by many factors: the patient's general state, age, and spinal cord condition; the level and the number of involved vertebrae; the severity of spinal deformity; the duration and severity of paraplegia; the time to initiation of treatment; the type of treatment; and drug sensitivity. Paralysis occurring in children generally have a better prognosis compared to adults
Paralysis lasting longer than 6 months is most unlikely to improve, and late paralysis with inactive disease and significant kyphosis is much less responsive to treatment. Paralysis due to vascular insufficiency has a worse prognosis. Several methods have been used for the treatment of patients with paraplegia:
1) chemotherapy alone,
2) laminectomy,
3) costotransversectomy, and
4) radical surgery.
In the early stages of the disease, paraplegia caused by abscess can be resolved by effective chemotherapy alone as by decompressive surgery, however, chemotherapy alone is inappropriate management of paraplegia in the patient with advanced tuberculosis and deformity. It is unfair to allow a patient to lie paralyzed for some weeks to months awaiting a cure through conservative care. Decompressive laminectomy will destabilize already hampered spine therefore should not be done. When patients with Pott's paraplegia and severe spinal deformity do not respond to chemotherapy and have worsening neurology, decompressive surgery is indicated to arrest the progress of paralysis and hopefully to restore normal neurology.
Kyphosis /Deformity
Tuberculosis kyphosis is an unstable lesion that tends to progress until there is sound bony fusion anteriorly.
Kyphosis has been managed by several surgical procedures:
posterior fusion,
anterior radical surgery, and
various combined operations such as a one-stage, two-stage, or three-stage procedures.
Each patient should be cautioned about the high neurologic risk with corrective surgery of the rigid deformed spine.
Until now, the following surgical procedures have been practiced by various surgeons:
1. Flexible Kyphosis:
Skeletal traction
Posterior fusion
Anterior radical surgery
Two-stage operation:
Posterior instrumentation followed by anterior radical surgery
Anterior release and graft, followed by posterior instrumentation
Three-stage operation (anterior release followed by posterior instrumentation and delayed anterior radical surgery).
2. Fixed Kyphosis.
One-stage operation
Two-stage operation (anterior release, deformity correction and anterior graft, followed by posterior instrumentation)
Multi-stage operation (osteotomy, halopelvic device, posterior instrumentation and fusion).
Skeletal traction for cervical kyphosis.
Posterior fusion for kyphosis. Disproportionate posterior spinal growth has been suspected as a contributing factor in the progression of kyphotic deformity after management of spinal tuberculosis by posterior fusion only.
Especially, in children frequently there will be a loss of the initial gain of correction and progression of kyphosis after noninstrumented posterior spinal fusion if anterior fusion is not achieved. Additional instrumentation seems to prevent the progression of kyphosis.
Anterior radical surgery for kyphosis. Radical surgery (Hong Kong Operation) was found to give better results than focal débridement for the correction and prevention of kyphosis. Progression of kyphosis is more observed in multilevel lesions
Posterior closing wedge osteotomy for kyphosis (Galveston one-stage operation). This technique is a very effective one-stage operation. It involves a modified bilateral costotransversectomy approach to the spine, followed by removal of structures in a wedge shape, including the vertebral arch, the disk, and a portion of the centrum. The wedge is closed by posterior compression instrumentation, enabling an angular correction of 30° to 50°.
Decancellation or corporal eggshell procedure. This posterior close wedge procedure involves transpedicular curettage or evacuation of the cancellous bone of the vertebral body, excision of the posterior elements and posterior wall of the body, and correction of kyphosis by closing the wedge. This is a highly demanding procedure with additional surgical risks.
Two-stage operations.
1. Anterior radical surgery, followed by posterior resection and instrumentation. Yau et al used Luque instrumentation in a two-stage procedure to correct the deformity.
2. Combined posterior instrumentation plus anterior radical surgery for flexible kyphosis (two-stage operation). This procedure may be most appropriate for active cases of progressive kyphosis where the curve is stil flexible.
Prevention and correction of kyphosis and kyphoscoliosis by posterior instrumentation has three advantages. Posterior stabilization of the spine arrests the disease early, encourages early fusion, and enables correction of the deformity. The procedure is indicated only in those patients who are likely to develop or who have a pre-existing deformity. It is suggested that a formula be used to predict the kyphosis that will remain at the end of chemotherapy to determine if prophylactic or corrective spinal instrumentation surgery is indicated. (Rajasekaran formula: Y=a+bX (Y= deformity, X=pretreatment loss in VB, a= constant value of 5.5, b= constant value of 30.5))
A two-stage operation, combining posterior instrumentation and anterior interbody fusion, can be an option for multisegmental tuberculosis of more than two segments. Instrumentation at a distance from the infective process restores spinal stability and prevents graft fracture, slipping, sagging, and resorption. Because of the anterior column deficiency due to the anterior column destruction posterior instrumented correction of kyphosis produces an anterior bone gap that should be reconstructed by anterior strut graft; otherwise, recollapse, instrumentation failure, and recurrent kyphosis will be inevitable.
After it has been shown that anterior instruments can be used safely at the infected site in tuberculosis patients there have been reports showing the advantages of anterior radical debridement strut grafting and anterior instrumentation.
Of course anti tuberculosis drug treatment should never be replaced by any kind of surgery alone.
References
- Akman S, Şirvancı M, Talu U, Gogus A, Hamzaoglu A. Magnetic resonance imaging of tuberculous spondylitis. Orthopedics. 2003 Jan;26(1):69-73.
- Aksoy MC, Acaroglu RE, Tokgozoglu AM, Ozdemir N, and Surat A. Retrospective evaluation of treatment methods in tuberculosis spondylitis. Hacettepe J Orthop Surg 1995 ; 5:207-209.
- Alıcı E, Akcalı O, Tatari H, Gunal I. Effect of preoperative chemotherapy on the outcome of surgical treatment of vertebral tuberculosis: retrospective analysis of 434 cases. Arch Orthop Trauma Surg. 2001;121(1-2):65-6.
- Aydın E, Solak AS, Tuzuner MM, Benli IT, and Kis M. Z-plate instrumentation in thoracolumbar spinal fractures. Bull Hosp Jt Dis 1999 ; 58 (2) : 92-97.
- Aydin E, Solak S, Kis M, Gider M, Benli T, Yücesoy C; Pott’s Disease: Retrospective evaluation of treatment results. J Tur Spinal Surg 1994, 5, 166-169
- Bailey HL, Gabriel SM, Hodgson AR, Shin JS; Tuberculosis of the spine in children. J Bone Joint Surg 1972, 54A, 1633-1657
- Benli IT , Aydın E, Kis M, Akalın S, Tuzuner M, and Baz AB. The results of anterior instrumentation in vertebral tuberculosis. J Turkish Spine Surg 1996 ; 7(3):98-101.
- Benli IT, Acaroglu E, Akalin S, Kis M, Duman E, and Un A. Anterior radical debridement and anterior instrumentation in tubercolous spondylitis. Eur Spine J 2003; 12 : 224 – 234.
- Benli IT, Akalin S, Kis M, Citak M, Kurtulus B, and Duman E. The results of anterior fusion and Cotrel – Dubousset – Hopf instrumentation in idiopathic scoliosis. Eur Spine J 2000; 9(6):5005-15.
- Benli İT, Alanay A, Akalın S, Kış M, Acaroğlu E, Ateş B, Aydın E. Comparison of Anterior Instrumentation Systems and the Results of Minimum 5 Years Follow – up in the Treatment of Tuberculosis Spondylitis. Kobe J. Med. Sci., Vol. 50, No. 6, pp. 167-180, 2004
- Benli IT, Kis M, Akalın S, Citak M, Kanevetci S, and Duman E. The results of anterior radical debridement and anterior instrumentation in Pott's disease and comparison with other surgical techniques. Kobe J Med Sci 2000 ; 46 :39 - 68.
- Berk RH, Yazıcı M, Atabey N, Ozdamar OS, Pabuççuoğlu U, Alıcı E. Detection of Mycobacterium tuberculosis in formaldehyde solution-fixed paraffin embedded tissue by polymerase chain reaction in Pott’s disease. Spine 1996; 21:1991-1995
- Bezer M, Kucukdurmaz F, Aydin N, Kocaoglu B, Guven O. Tuberculous spondylitis of the lumbosacral region: long-term follow-up of patients treated by chemotherapy, transpedicular drainage, posterior instrumentation, and fusion. J Spinal Disord Tech. 2005 Oct;18(5):425-9.
- Bilsel N, Aydingoz O, Hanci M, Erdogan F. Late onset Pott's paraplegia. Spinal Cord. 2000 Nov;38(11):669-74.
- Dinc H, Ahmetoglu A, Baykal S, Sari A, Sayil O, Gumele HR. Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses: midterm results. Radiology. 2002 Nov;225(2):353-8
- Domanic U, Hamzaoglu A, Sar C, and Yavuzer Y. Posterior fusion and instrumentation after anterior radical debridement and fusion in the surgical treatment of Pott's disease. J Turkish Spine Surg 1993 ; 4(1): 16-19.
- Govender S. The outcome of allografts and anterior instrumentation in spinal tuberculosis. Clin Orthop 2002 ; 398 : 60 – 66.
- Güven O, Kumano K, Yalçin S, Karahan M, Tsuji S; A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of spinal tuberculosis. Spine 1994, 19, 1039-1043
- Güven O, Yalçin S, Karahan M; Egg shell procedure in correction of neglected cases of Pott’s kyphosis. Trans ESDS 5th biannual conference 1994, 84
- Guzey FK, Emel E, Bas NS, Hacisalihoglu S, Seyithanoglu MH, Karacor SE, Ozkan N, Alatas I, Sel B. Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases. J Neurosurg Spine. 2005 Dec;3(6):450-8.
- Hodgson AR, and Stock FE. Anterior spinal fusion. A preliminary communication on the radical treatment of Pott's disease and Pott paraplegia. Clin Orthop 1994 ; 300:16-23.
- Hodgson AR, Stock FE, Forg HSY, and Ong GB. Anterior spinal fusion : the operative approach and pathological findings in 412 patients with Pott's disease of the spine. Br J Surg 1960; 48:172 178.
- Hodgson AR, Stock FE; Anterior spine fusion for the treatment of tuberculosis of the spine. The operative findings and results of treatment in the first one hundred cases. J Bone Joint Surg 1960, 42A, 295-310
- Hodgson AR, Yau A, Kwon JS, Kim D; A clinical study of 100 consecutive cases of Pott’s paraplegia. Clin Orthop 1964, 36, 128-150
- Hsu LC, Cheng CL, and Leong JC. Pott's paraplegia of late onset: The cause of compression and results after anterior decompression. J Bone Joint Surg 1988 ; 70-B : 534-538.
- Korkusuz F, Islam C, and Korkusuz Z. Prevention of postoperative late kyphosis in Pott's diseaseby anterior decompession and intervertebral grafting. World J Surg 1997; 21(5) : 524-528.
- Korkusuz Z, Binnet MS, Isiklar ZU; Pott’s disease and extrapleural anterior decompression. Arch Orthop Trauma Surg 1989, 108, 349-352
- Kostuik JP; Anterior spinal cord decompression for lesions of the thoracic and lumbar spine: Techniques, new methods of internal fixation. Spine 1983, 8, 512-531
- Medical Research Council Working Party on Tuberculosis of the Spine. A 15 – year assessment of controlled trials of the management of tuberculosis of the spine in Korea and Hong Kong. Thirteenth Report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg 1998 ; 80-B(3): 456-462.
- Medical Research Council Working Party on Tuberculosis of the Spine. A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy. A study in Hong Kong. British J Surg 1974 ; 61 : 853-866.
- Medical Research Council Working Party on Tuberculosis of the Spine. Five-year assessments of controlled trials of ambulatory treatment, debridement and anterior spinal fusion in the management of tuberculosis of the spine: Studies in Bulawayo (Rhodesia) and in Hong Kong. J Bone Joint Surg 1978 ; 60-B : 163-177.
- Medical Research Council Working Party on Tuberculosis of the Spine. A ten-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. J Bone Joint Surg 1982 ; 64-B : 393-398.
- Medical Research Council Working Party on Tuberculosis of the Spine. Five-year assessment of controlled trials of short - course chemotherapy regimens of 6, 9 or 18 months' duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery. Fourteenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. Int Orthop 1999 ; 23(2):73-81.
- Medical Research Council Working Party on Tuberculosis of the Spine; A controlled trial of ambulant out-patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy: A study in Masan, Korea. J Bone Joint Surg 1973, 55B, 678-697
- Medical Research Council Working Party on Tuberculosis of the Spine; A controlled trial of debridement and ambulatory treatment in the management of tuberculosis of the spine in patients on standard chemotherapy: A study in Bulawayo, Rhodesia. J Trop Med and Hyg 1974, 77, 72-92
- Medical Research Council Working Party on Tuberculosis of the Spine; A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy. A study in Hong Kong. British J Surg 1974, 61, 853-866
- Medical Research Council Working Party on Tuberculosis of the Spine; A five-year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy: Studies in Masan and Pusan, Korea. J Bone Joint Surg 1976, 58B, 399-411
- Medical Research Council Working Party on Tuberculosis of the Spine; A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy: A study in two centers in South Africa. Tubercle 1978, 59, 79-105
- Moon MS, Ha KY, Sun DH, Moon JL, Moon YW, Chung JH; Pott’s paraplegia: 67 cases. Clin Orthop 1996, 323, 122-128
- Moon MS, Kim I, Woo YK, Park YO; Conservative treatment of tuberculosis of the thoracic and lumbar spine in adults and children. Int Orthop 1987, 11, 315-322
- Moon MS; Spine update: Tuberculosis of the spine, Controversies and a new challenge. Spine 1997, 22, 1791-1797
- Moula T, Fowles JV, Kassab MT, and Sliman N. Pott's paraplegia : a clinical review of operative and conservative treatment in 63 adults and children. Int Orthop 1981 ; 5(1) : 23-29.
- Oga M, Arizono T, Takasita M, and Sugioka Y. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis: Clinical and biologic study. Spine 1993 ; 18 :1890-1894.
- Ozdemir HM, Us AK, and Ogun T. The rol of anterior spinal instrumentation and allograft fibula for thetreatment of Pott’s disease. Spine 2003 ; 28 (5) : 474 – 479.
- Rajasekaran S, and Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg 1989 ; 71-A : 1314-1323.
- Rezai AR, Lee M, Cooper PR, Errico TJ, and Koslow M. Modern management of spinal tuberculosis. Neurosurgery 1995 ; 36 (1): 87-97.
- Schulitz KP, Kothe R, and Leong JCY, Wehling P. Growth changes of solid fusion kyphotic bloc after surgery for tuberculosis. Spine 1997 ; 22 (10): 1150-1155.
- Surat A, Acaroglu E, Özdemir N, Yazici M, Memikoglu S; Pott’s disease. Hacettepe J Orthop Surg 1992, 2, 73-76
- Tuli SM. Current concept. Severe kyphotic deformity in tuberculosis of the spine. Int Orthop 1995 ; 19 : 327-331.
- Tuli SM; Results of treatment of spinal tuberculosis by “Middle Path” regime. J Bone Joint Surg 1975, 57B, 13-23
- Turgut M. Multifocal extensive spinal tuberculosis (Pott's disease) involving cervical, thoracic and lumbar vertebrae. Br J Neurosurg 2001;15:142-6.
- Upadhyay SS, Saji MJ, and Yau ACMC. Duration of antituberculous chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis. Spine 1996; 21:1898 1903.
- Upadhyay SS, Saji MJ, Sell P, and Yau ACMC. The effect of age on the change in deformity after radical resection and anterior arthrodesis for tuberculosis of the spine. J Bone Joint Surg 1994 ; 76-A : 701-708.
- Upadhyay SS, Saji MJ, Sell P, Sell B, Hsu LCS; Spinal deformity after childhood surgery for tuberculosis of the spine. A comparison of radical surgery and debridement. J Bone Joint Surg 1994, 76B, 91-98
- Upadhyay SS, Saji MJ, Sell P, Sell B, Yau ACMC; Longitudinal changes in spinal deformity after anterior spinal surgery for tuberculosis of the spine in adults: A comparative analysis between radical and debridement surgery. Spine 1994, 19, 542-549
- Upadhyay SS, Sell P, Saji MJ, Sell B, and Hsu LC. Surgical management of spinal tuberculosis in adults: Hong Kong operation compared with debridement surgery for short and long term outcome of deformity. Clin Orthop Rel Res 1994 ; 302 : 173-182.
- Yalnız E, Pekindil G, Aktaş S. Atypical tuberculosis of the spine. Yonsei Med J. 2000 Oct;41(5):657-61.
- Yau ACMC, Hsu LCS, O’Brien JP, Hodgson AR; Tuberculous kyphosis: Correction with spinal osteotomy, halo-pelvic distraction, and anterior and posterior fusion. J Bone Joint Surg 1974, 56A, 1419-1434
- Yazici M, Atilla B, Gülman B; Anterior debridement and grafting in the treatment of Pott’s disease. Hacettepe J Orthop Surg 1996, 6, 190-193
- Yilmaz C, Selek HY, Gurkan I, Erdemli B, and Korkusuz Z. Anterior instrumentation for the treatment of spinal tuberculosis. J Bone Joint Surg 1999 ; 81-A (9): 1261-1267.
Anti-TB drugs
First line drugs
İsoniazid bactericidal 5mg/kg
Rifampicin bactericidal 10mg/kg
Streptomycin bactericidal 15mg/kg
Pyrazinamide bactericidal 35mg/kg
Etambutol bacteriostatic 30mg/kg
Thiacetazone bacteriostatic 350mg/d
Principles
- A combination of at least 3 bactericidal antibiotic should be used initially
- Isoniasid and Rifampicin are the most effective and basic combination
- In poor patient compliance
- Supervised regimen 2 or 3 times/week
- NEVER less than 6 months
- Initially 3-4 drugs for 2 months, then 2 drugs
Mechanism of action
Against large population of mb actively multiplying in the walls of the cavity
Isoniasid (bactericidal)
Rifampicin (bactericidal)
Streptomycin (bactericidal)
Etambutol (bacteriostatic)
Pyrazinamide (ineffective)
Against small population of mb slowly multiplying inside macrophage and low pH
Pyrazinamide (most effective)
Isoniasid (ineffective)
Rifampicin (ineffective)
Streptomycin (ineffective)
Intermittently multiplying bacilli in solid caseous material
Only rifampin is active
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