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Musculoskeletal System & Rheumatology

Tuberculosis of the Spine (Pott's Disease)

Tuberculosis infection affecting the spine, most commonly the lower thoracic and upper lumbar vertebrae. Can lead to vertebral body destruction, collapse, kyphotic deformity (gibbus), and neurological complications (cord compression, paraplegia).

Also known as: Pott's Disease, Tuberculous Spondylitis, Spinal TB

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Referral and warning signs

When to refer

Referral to hospital (HC4/H/RR) / Specialist required for ALL suspected cases for diagnosis, ATT initiation, assessment for stability/neuro compromise, potential bracing/surgery.

Red flags

  • Progressive neurological deficit
  • Signs of spinal instability
  • Significant kyphotic deformity
  • Large cold abscess
  • Failure to improve on ATT

Signs and symptoms

  • Back pain: Insidious onset, localized, progressive.
  • Constitutional symptoms: Fever (often low-grade), night sweats, weight loss, malaise (<40% cases).
  • Muscle spasm and rigidity.
  • Spinal tenderness.
  • Visible deformity: Angular kyphosis (gibbus).
  • Neurological deficits (Pott's Paraplegia): Leg weakness, sensory loss, bowel/bladder dysfunction.
  • Paravertebral abscess / Cold abscess (may present as swelling elsewhere, e.g., psoas abscess).

Risk factors

  • Living in or travelling from TB endemic areas.
  • HIV co-infection (major risk factor).
  • Immunosuppression (other causes).
  • Malnutrition.
  • Close contact with active pulmonary TB case.

Diagnosis

Clinical assessment

Suspect in patients from endemic areas with chronic back pain, +/- constitutional symptoms, +/- spinal deformity, +/- neurological deficits. Differentiate from pyogenic spondylodiscitis, brucellosis, fungal osteomyelitis, metastases, primary bone tumours.

Investigations

  • Imaging: Plain X-ray (Spine) - may show late changes (disc space narrowing, vertebral destruction, paravertebral shadow, gibbus). MRI Scan (Spine) - Modality of choice (shows vertebral/disc involvement, abscesses, cord compression). CT Scan (Spine) - good for bony detail.
  • Microbiological/Histological Confirmation: CT-guided Biopsy/Aspiration of vertebra/abscess - AFB smear, GeneXpert MTB/RIF, TB culture, Histology (caseating granulomas).
  • Sputum AFB/Xpert: Check for concurrent pulmonary TB (~50%).
  • Blood tests: ESR/CRP (often elevated).
  • HIV testing.
  • TST/IGRA: Indicate exposure/LTBI, not active disease.

Diagnostic criteria

Combination of clinical features, characteristic imaging findings (esp. MRI), and ideally microbiological/histological confirmation or strong evidence of TB elsewhere.

Management

Non-pharmacological management

  • Spinal Immobilisation/Rest: Bed rest, spinal brace/corset/plaster jacket.
  • Physiotherapy/Rehabilitation.
  • Nutritional support.
  • Surgical Intervention: Indications - Significant/progressive neurological deficit, Spinal instability, Large abscess needing drainage, Failure of medical therapy, Diagnostic uncertainty, Severe deformity.

Pharmacological treatment

  • Anti-Tuberculosis Therapy (ATT): Mainstay. Standard multi-drug regimens, longer duration (9-12 months).
  • - Standard Regimen (DS-TB): 2 months RHZE followed by 7-10 months RH.
  • - Pyridoxine (B6) with Isoniazid.
  • - Drug-Resistant Spinal TB: Specialized regimens.
  • Analgesia (Paracetamol, NSAIDs, Opioids).
  • Corticosteroids: Controversial, may be considered by specialists for cord compression due to inflammation.

Monitoring

Monitor clinical response (pain, neuro status). Monitor inflammatory markers. Periodic imaging. Monitor ATT side effects.

Complications

  • Vertebral collapse / Kyphosis (Gibbus deformity)
  • Spinal instability
  • Neurological deficit / Paraplegia (Pott's paraplegia)
  • Abscess formation (Paravertebral, Psoas, Cold)
  • Sinus tract formation
  • Chronic pain
  • Secondary bacterial infection

Prevention

  • BCG vaccination (limited protection).
  • Early diagnosis/treatment of pulmonary TB.
  • Treatment of latent TB infection (TPT).

Patient education

  • Explain Pott's disease as TB of the spine.
  • Necessity of prolonged ATT.
  • Importance of adherence.
  • Potential side effects of ATT.
  • Role of bracing/rest.
  • Symptoms of neurological worsening to report immediately.
  • Importance of follow-up.
  • Nutritional advice.

Uganda-specific notes

Significant form of EPTB, esp. with HIV. Diagnosis often delayed. Access to MRI/biopsy limited. Management relies on clinical/X-ray diagnosis and standard ATT (often 12 months). Surgical capacity restricted.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 10, Section 10.1.4

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 5, Section 5.3 (General TB Treatment)

  • Manual of the National TB/Leprosy Programme (NTLP) Uganda

    (Refer to latest NTLP guidelines)

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