Pott Disease (Spinal Tuberculosis)
Pott disease is the most common form of spinal tuberculosis, developing when the bacterium Mycobacterium tuberculosis infects the vertebrae. It usually arises from hematogenous spread of pulmonary tuberculosis to the spine and most often involves the thoracolumbar region. Its characteristic features are vertebral collapse (gibbus deformity), paravertebral cold abscesses and neurological compression. Treatment is anti-tuberculosis drug therapy lasting 12-18 months, with surgery added in selected cases.
Ultimo aggiornamento: 2026-06-07
Definition and Pathogenesis
Pott disease is vertebral osteomyelitis and discitis caused by Mycobacterium tuberculosis. The infection usually reaches the anterior part of the vertebral body from a primary focus in the lungs via the bloodstream; from there it spreads to the disc space and the adjacent vertebra. Typically two adjacent vertebrae and the intervening disc are involved together. The disease begins in the early phase with granulomatous inflammation and end-plate destruction; in the advancing phase caseous necrosis, vertebral collapse and paravertebral cold abscess develop; and in the chronic phase gibbus deformity, spinal canal narrowing and instability occur.
Risk Factors and Cold Abscess
The main risk factors are HIV/AIDS, malnutrition and low socioeconomic status, immunosuppressive treatments, diabetes mellitus, chronic renal failure and a history of active pulmonary tuberculosis. The cold abscess is the characteristic feature of Pott disease: a collection of caseous material and granulation tissue that does not show signs of inflammation (redness, warmth). Under the effect of gravity it can spread to distant regions; for example, in lumbar involvement a psoas abscess extending to the groin and thigh may be seen.
Symptoms
The disease begins slowly and insidiously; the interval to diagnosis is usually on the order of months. The most common symptom is chronic back or neck pain that is deep, persistent and continues at night. The general features of tuberculosis (low-grade fever rising in the evening, night sweats, loss of appetite, weight loss, fatigue) are present in a proportion of patients. As it progresses, gibbus (angular kyphosis, a hunched appearance), radicular pain and, in the late phase, neurological deficit (leg weakness, sensory loss, sphincter dysfunction) may develop. In cervical involvement, difficulty swallowing and respiratory compromise may occur.
Diagnosis
Diagnosis, in the presence of chronic back pain and systemic findings, is supported by an elevated sedimentation rate and tuberculin/IGRA tests. Plain radiography may be normal in the early phase; in the advancing phase disc space narrowing and vertebral collapse are seen. Contrast-enhanced magnetic resonance imaging (MRI) is the gold standard, showing anterior involvement of the vertebral body, paravertebral/epidural cold abscess and cord compression. The definitive diagnosis is made by image-guided biopsy or microbiological and histopathological examination of a surgical specimen; GeneXpert MTB/RIF provides rapid diagnosis and detection of rifampicin resistance, while culture demonstrates drug susceptibility.
Anti-Tuberculosis Treatment
The basis of treatment is anti-tuberculosis drug therapy lasting 12-18 months. In the first two months (intensive phase), isoniazid, rifampicin, pyrazinamide and ethambutol are given; in the subsequent period (continuation phase), isoniazid and rifampicin. In the presence of drug resistance (especially multidrug-resistant tuberculosis), treatment duration is extended and second-line drugs are required. Monitoring of drug side effects is important: liver enzymes for isoniazid and other agents, and the eyes (color vision and visual acuity) for ethambutol, are checked regularly; vitamin B6 is added to prevent isoniazid-related peripheral neuropathy.
Surgery, Supportive Care and Prognosis
Surgery is indicated in the presence of progressive neurological deficit, cord compression, spinal instability, severe kyphosis or a large cold abscess resistant to treatment. Anterior debridement-fusion, posterior instrumentation or combined approaches may be used. In all patients, a spinal orthosis, nutritional support and physiotherapy accompany treatment. The chance of recovery is high with early diagnosis and mild neurological involvement; adherence to treatment is vital. Some treated patients may be left with permanent deformity or neurological sequelae. Pott disease itself is not directly contagious, but accompanying active pulmonary tuberculosis should be evaluated as it may be contagious. Outcomes are individual and cannot be guaranteed.
Riferimenti
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:380-397.
- Rajasekaran S, Soundararajan DCR, Shetty AP, Kanna RM. Spinal tuberculosis: current concepts. Global Spine J. 2018;8(4 Suppl):96S-108S.
- World Health Organization. WHO Consolidated Guidelines on Tuberculosis: Module 4: Treatment - Drug-Susceptible Tuberculosis Treatment. WHO; 2022.
- Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med. 2011;34(5):440-454.
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