pott-s disease
description
Transcript of pott-s disease
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POTT SDISEASE: ARadiologicalReviewof
Tuberculous
Spondylitis
StellaSafo
GillianLieberman,MD
April2009
HarvardMedicalSchool
BethIsraelDeaconessMedicalCenter
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Agenda1.Explaintheevaluation,diagnosisand
treatment
of
spinaltuberculosis.
2.Reviewfeaturesofspinaltuberculosisonradiographs,CT andMRI.
3.FocusonthediagnosisofspinalTBusingradiographs,as thisistheprimarymodalityavailableinmanyresource
limitedsettingswherespinalTBisendemic.
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OurPatient:InitialPresentation
A40yearoldhealthyKenyanwoman,MsB.G,presentedtoherPCP
witha1yrhistoryoflowbackpain(LBP)
thatbeganafterafall.
Sharp,unremittingpainexacerbatedbymovement,withoutradiculopathy
Physicalexamwasunremarkable
MinimalreliefwithNSAIDSandphysicaltherapy
Shebecamepregnant
threemonthslater.
LBPcontinuedandworsenedthroughoutpregnancy
Postpartum
Developedbilateralanteriorthighparesthesias
exacerbatedbysitting
Duetofailuretorespondtoconservativetherapy,shewassentfor
radiologicalevaluation.
Further exploration of this topic requires a review of the anatomy of the spine and of a differential diagnosis of low back pain
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SpineAnatomy
http://www.columbiaspine.org
http://www.fla-ortho.com
http://www.sofamordanek.com
CERVICAL
THORACIC
LUMBAR
Transverse process
Spinous process
Vertebral body
Intervertebral disc
Pedicle
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DifferentialDiagnosisLowBackPain
MECHANICAL Degenerativediskdisease,compressionfracture,musculoskeletal
sprainorstrain
NEUROGENIC Diskherniation,sciatica,spinalstenosis,infection,malignancy,
connectivetissuedisorder(ie.ankylosing
spondylitis)
Others: VISCEROGENIC
UTI,pyelonephritis,retroperitonealtumororbleed VASCULAR
Abdominalaorticaneurysm PSYCHOGENIC
With this differential in mind for patient BG, further imaging revealed infection of the spine.
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IntroducingPottDisease Knownbymanynames:spinaltuberculosis,tuberculous
spondylitis,PottdiseaseorPottsdisease
Firstdescribedin1782byPercivalPott,aBritish orthopedicsurgeon.
DifferentialdiagnosisofPottdisease Pyogenicorfungalosteomyelitis Eosinophilicgranuloma Multiplemyeloma Multiplecompressionfractures Note:BrucellosisofthespineandPottdiseaseareradiologically
indistinct.
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OurPatient:Imaging
Ms.BGsdiagnosiswasmadebasedonherimaging
Imaging
Plainfilmofthespinedemonstratedcompression
fractureL12withanteriorkyphosis
MRIspinerevealed
T12 L3vertebralosteomyelitis
L12compressionfractureswithforwardangulation
Cauda
equina
impingement
Leftpsoas
abscess
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OurPatient:Radiograph
PACS, BIDMC
Lateral radiograph
Anterior collapse of L1,L2 vertebrae with loss of diskspace. (*).
Central lucencies
within the L1vertebrae (*).
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OurPatient:CTTorso
PACS, BIDMC
Noncontrast
axial CT
Large left psoas
abscess with hypoattenuated
core region.
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OurPatient:MRI
Spine
PACS, BIDMC
Sagittal
T2W
Destruction of L1-L2 disk space and collapse of adjacent vertebral bodies (*) with retropulsion
into the spinal canal(*). In image, edema in T12 to L3 vertebral bodies (*), suggestive of spinal osteomyelitis.
1 2
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OurPatient:ClinicalOutcome
Diagnosis:Pott
diseasewasdiagnosedbasedon Radiologic
findings1)psoas
abscess2)continuousanteriorvertebralbodydestruction3)cordcompression
Emigrationfromanareawithendemictuberculosis Indolentnatureofsymptoms
Treatment: Patientwasplacedonbedrestandfittedforathoracolumbosacral
orthosis
(TLSO)
Underwentdebridement
andspinalstabilization Mycobacteriumtuberculosiswasisolatedfromsurgicalspecimensand
sputum
PlacedonalongcourseofRifampin,Isoniazid,Pyrazinamide,&Ethambutol
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Pott
Disease:Epidemiology Pott
diseaseisuncommonintheUnitedStates
U.S.versusKenya(homelandofcasepatient)4/100,000/yr:384/100,000/yr
Spinaltuberculosislooselyreportedas100200casesyearly
Skeletaltuberculosis Accountsfor10%ofallcasesofextrapulmonary
TB
Targetsthehips,knees,spine Spinaltuberculosisismostcommon,accountsfor50%allskeletalTBcases
Clinicalpresentationvariesbygeographiclocation HighTBprevalence
Pott
diseaseiscommonlyseeninchildren Targetsthoracicvertebrae
UnitedStates Seeninimmigrantsfromendemiccountries,immunocompromised,
men>women Targetslumbarvertebrae
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Pott
Disease:Pathophysiology Tuberculosisinfiltratesthespinevia
Hematogenous
spreadthroughthedensevasculatureofcancellous
boneoftheanteriorvertebralbodies
Lymphaticspreadfromparaaorticlymphnodespossiblebutrare
Upto75%ofinfectedindividualsdevelopasofttissue infection Commonlyoccursinthepsoas
muscle coldabscess Knownascoldabscessbecauseformsslowlyanddoesnotnormally
presentwith
heat,inflammationorpain
Paraspinal
fistulawhichmayformacommunicationwiththechest
wallorpelvicfloor
Leftuntreated,degenerationandinflammationofthe vertebraecauses Herniation
intothecordspace cordcompressionandcauda equina Kyphosis gibbous(severekyphosis) Paraplegia
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Pott
Disease:Complications
Pappou et al.- http://ovidsp.tx.ovid.com.ezp- prod1.hul.harvard.edu/spb/ovidweb.cgi?WebLinkFrameset
Oguz et al.- http://www.springerlink.com.ezp- prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf
Gibbous
Lateral radiographs and T2W MRI
Young male with gibbus
deformtity
(A) at thoracolumbar
junction seen on radiograph (B) and T2W MRI (C).
Cord Compression
Radiograph (1), sagittal
CT reconsturction
(2) and MRI (3) of a 70 year old man with Pott
disease.
Note continuous vertebral body destruction of thoracolumbar
spine, causing severe kyphosis.
Patient developed compression of the conus
medullaris, resulting in inability to ambulate.
2 3
1
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Pott
Disease:Diagnosis PhysicalDiagnosis:
Usuallypresentswith4monthto3yearhistoryoflowbackpain
with
orwithoutassociatedneurologicaldeficits.
Signsofnearbycoldabscessorfistulamaybepresent
Only20%presentwithconcomitantTBlunginfection
RoutinelabtestsandtheMantoux
skintestareoflittlediagnosticaid
KEY POINT: Must maintain high clinical suspicion in order to make the diagnosis of tuberculous spondylitis in a timely fashion.
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Pott
Disease:Pathology
Definitivediagnosis: Madeviasputumorbiopsyshowingacidfastbacilli
orpathognomonic
caseating
granulomas
intissuesample
http://library.med.utah.edu/WebPath
http://www.med.nus.edu.sg/path
Caseatinggranuloma
Acid fast bacilli
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Pott
Disease:Imaging Menuoftests
Maystartwithplainfilm
tovisualizegrossdeformitiesi.e.kyphosis,fracture. CTisgoodforvisualizingdiscovertebrallesionsandparavertebral
abscess,
particularlyforabscesscalcification.
MRI
providesthebestvisualizationoftheextentofspinalcanalandsoft
tissueinvolvement.Allowsforearlydetection.
Examples of types of imaging modalities
>
Lateral Radiograph-
shows signs of early disk destruction (*)
> Coronal T2W MRI-
disk destruction and bone marrow edema (*)
> Transaxial
CT-
large left paravertebral
abscess (*)
RADIOGRAPH CT MRI Oguz et al.- http://www.springerlink.com.ezp- prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf
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Pott
Disease:
AdditionalImaging
Lesserusedimagingmodalities include:
Bonescintigraphy
Ultrasound
usefulinvisualizing
paraspinal
abscessesNigg et al.- http://www.springerlink.com.ezp- prod1.hul.harvard.edu/content/74l418224t055432/full text.pdf
46 year old male with spinal TB on bone scintigraphy
Increased radionuclide uptake in thoracic and lumbar spine (*) secondary to increased bony metabolism from infection.
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Radiographs:GeneralFeatures FeaturesofPotts
onradiographinclude
Signsofinfectionwithlytic
lucencies
inanteriorportionofvertebrae
Diskspacenarrowing Erosionsoftheendplate Sclerosisresultingfromchronicinfection Compressionfracture Continuousvertebralbodycollapse Kyphosis;gibbous(severekyphosis)
Atypicalfeatures Softtissueswellingfromparaspinal
abscesses,+/
calcification
Involvementofonlyonevertebralbody Involvementofseveralvertebralbodieswithout
intervertebral
discitis
Bowingofribcagesecondarytocollapseofmultiplevertebralbodies Destructionoflateralorposterioraspectsofvertebralbodies
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Radiographs:Erosions Lucentareainlateralaspectofadjacentvertebralbodies erosions(*) Lossofintervertebral
diskspace(*) Centrallucency
(*)withsurroundingsclerosissuggestingchronicinfection(*)
Pertuiset et al.- http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?QS2
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Radiographs:EndplateDestruction
Private Collection of Ferris Hall MD
Private Collection of Ferris Hall MD
Image 1Lateral radiograph of spinal TB in a 23 yo
man showing endplate erosion, loss of disk space(*), and anterior compression fracture of the lumbar spine.
Image 2Lateral radiograph of 56 yo
man with Pott
disease with additional features of sclerosis at vertebral endplates that have undergone severe compression and erosion(*).
2 1
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Radiographs:Osteosclerosis
Private Collection of Ferris Hall MD
Private Collection of Ferris Hall MD
1 2
Image 1Frontal radiograph 45 yo
female. Note compression fracture with loss of intervertbral
disk space (*).
Image 2Lateral radiograph of 56 yo
male. Similarly, note compression fracture and secondary osteosclerosis
(*).
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Radiographs: AtypicalFeatures
72 yo
M with
long history of longhistory of spinal TB.
Note collapse of multiple thoracic vertebrae (*) with resulting bowing in of ribs (*).
Paraspinal
abscess seen with circularcalcified mass (*).
Private Collection of Ferris Hall MD
Private Collection of Ferris Hall MD
72 yo
M with long history of longhistory of spinal TB.
Collapse of mulitplethoracic vertebrae (*)resulting in severekyphosis
(*).
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CT:Features
FeaturesonCT
Softtissuefindings
AbscesswithcalcificationisdiagnosticofspinalTB;CTis
excellentmodalitytovisualizesofttissuecalcifications
Patternandseverityofbonydestruction
Patternofvertebralbodydestruction
framentary,osteolytic,
localizedandsclerotic,andsubperiosteal
Usedtoguideneedleinpercutaneous
needlebiopsyof
paraspinal
abscess
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CT:Calcification
PACS, BIDMC
Noncontrast
axial CT
Large psoas
abscess (*) with central calcification (*); these features are highly diagnostic of spinal TB.
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CT:BonyDestruction
Noncontrast
axial CT
Extensive vertebral body destruction causing bony fragments (*). Destruction of cancellous
bone indicated by hypoattenuation
of central vertebral body (*).
PACS, BIDMC
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MRI:Features
HighlysensitiveandspecificforspinalTB Providesearlydetection Besttodistinguishexactextentofspinalcordandsoft
tissueinvolvement
Features Edemaofvertebraeanddiskspace Signsofspinalcompromisei.e.cordcompression Note:Poorlyvisualizescalcificationinabscesses
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MRI:SpinalCordInvolvement
PACS, BIDMC
Sagittal
T2W (Images 1-3)and axial T1W (Image 4)
High intensity activity in T12 to L3 vertebrae indicative of infection (*) (*). Complete destruction of vertebral bodies with osseous retropulsion
into the spinal canal, causing cauda
equina
(*). On axial view, note destruction of vertebral body with loss of circular shape(*).
1 2 3
4
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Pott
Disease:Treatment Variousimagingmodalitiesareusefulindeterminingextentofdisease. Treatmentoptionsthendependonthedegreeofspinaldestruction.
Mostpracticing
clinicianssimply
definePotts
as
EARLY
orLATE
disease.
GATA ClassificationOguz et al.- http://www.springerlink.com.ezp- prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf
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ConservativeTreatment
EarlyDisease:
Treatwithafourdrugregimenforsixtotwelvemonths
CommonantibioticsareRifampin,Isoniazid, Pyrazinamide,Ethambutol
Mostindividualsexperiencefullresolutionofsymptoms withappropriateantituberculosistreatment
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SurgicalInterventions LateDisease:
Looselydefinedbyneurologicdeficits,spinalkyphosis
>40%,orfailure
ofmedicaltherapy Surgicaldebridement,abscessdrainage,and/orvertebralfusionin
additiontoantibiotics
PACS, BIDMC
Ms. BG post surgery
Young man with gibbous deformity (*) status post instrumentation surgery.Note stabilization of spine and resolution of gibbous (*).
Lateral radiograph
Our index patient, Ms. BG after spinal debridement and vertebral fusion.
Oguz et al.- http://www.springerlink.com.ezp- prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf
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Summary Imagingmodalities
areplainfilm,CTandMRI;MRIisgoldstandardfor
imagingspinalTB.
SpinaltuberculosisisnotcommoninU.S.,thereforemustmaintainhigh
clinicalsuspicionsoasnottooverlookdiagnosis,especiallyamong
immigrantpopulations.
DiagnosisandtreatmentofspinalTBinendemicareasisdifficultgiven
resourcelimitations;relyonradiographsandclinicalsignstofacilitate
earlydiagnosis.
ConservativeversussurgicaltreatmentofPott
diseasedependson
degreeofspinaldestruction,
makingearlydiagnosisessentialfora
positiveoutcome.
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J
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Acknowledgements
Manythankstothefollowingcontributorsfor theirmuchappreciatedassistance.
GillianLieberman,MD
FerrisHall,MD
Gul
Moonis,MD
AlexanderCarbo,MD
MariaLevantakis
MichaelLarson
P O T T S D I S E A S E: A Radiological Review of Tuberculous Spondylitis AgendaOur Patient: Initial PresentationSpine Anatomy Differential Diagnosis Low Back PainIntroducing Pott DiseaseOur Patient: ImagingOur Patient: Radiograph Our Patient: CT Torso Our Patient: MRI Spine Our Patient: Clinical OutcomePott Disease: EpidemiologyPott Disease: PathophysiologyPott Disease: ComplicationsPott Disease: DiagnosisPott Disease: PathologyPott Disease: ImagingPott Disease: Additional ImagingRadiographs: General FeaturesRadiographs: Erosions Radiographs: Endplate DestructionRadiographs: OsteosclerosisRadiographs: Atypical FeaturesCT: FeaturesCT: CalcificationCT: Bony DestructionMRI: FeaturesMRI: Spinal Cord InvolvementPott Disease: TreatmentConservative TreatmentSurgical InterventionsSummaryReferencesAcknowledgements