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Orthopaedics & Traumatology: Surgery & Research 100 (2014) 233–239

Available online at

ScienceDirectwww.sciencedirect.com

eview article

pdate on the surgical management of Pott’s disease

. Varatharajaha,c, Y.-P. Charlesa,∗,c, X. Buyb,c, A. Waltera,c, J.-P. Steiba,c

Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, FranceService de radiologie interventionnelle, hôpitaux universitaires de Strasbourg, hopitaux universitaires de Strasbourg, 1, place de l’Hôpital,P 426, 67091 Strasbourg cedex, FranceFédération de médecine translationnelle (FMTS), université de Strasbourg, 4, rue Blaise-Pascal, 67400 Strasbourg, France

a r t i c l e i n f o

rticle history:ccepted 27 September 2013

eywords:

a b s t r a c t

One-third of the world’s population is infected with Mycobacterium tuberculosis. Data reported in 2011indicate, for the first time, a decline in cases of tuberculosis, despite persistent inequalities across geo-graphic areas and increasing rates of drug resistance. Osteo-articular tuberculosis affects the spine in

ott’s diseasepinal tuberculosisbscessyphosisurgical treatmentpondylitis

half the cases. Pharmacotherapy must be combined with surgery in patients with spinal cord or nerveroot compression, large abscesses, or marked anterior column osteolysis with kyphosis and instability.The quality of debridement and bony fusion is optimal when the anterior approach is used. Posteriorfixation is the best means of achieving reduction followed by stable sagittal alignment over time. Newtreatment strategies combine conventional surgical methods, closed interventional radiology proceduresfor drainage and spinal cord decompression, and percutaneous fixation.

. Introduction

Tuberculosis of the bones and joints remains rare, accountingor only about 1 to 3% of all cases of tuberculosis [1,2], with simi-ar incidence time trends. The latest report from the World Healthrganisation (WHO) on tuberculosis control indicates that tuber-ulosis cases have started to decline worldwide for the first time3]. Similarly, the WHO Tuberculosis Surveillance and Monitoringeport issued in 2012 indicates a decrease in the incidence of tuber-ulosis in recent years [4].

Spinal tuberculosis, known as Pott’s disease, accounts for halfhe cases of osteo-articular tuberculosis [1]. Vertebral inoculationccurs via the haematogenous route and the process then spreadso the intervertebral disk and, in some cases, to the adjacent ver-ebra. Para-spinal abscesses may develop by direct spread fromhe vertebral lesion. The thoracic spine is predominantly involved5]. Pain is the most common presenting manifestation. How-ver, the limited symptoms and absence of specific radiologicalhanges early in the course of the infection often result in diag-ostic delays. Computed tomography (CT) and magnetic resonance

maging (MRI) are valuable diagnostic tools. Confirmation of theiagnosis is obtained by identification of the tubercle bacillus in

espiratory specimens and/or in samples obtained by abscess aspi-ation or bone biopsy.

∗ Corresponding author. Tel.: +33 388 116 826; fax: +33 388 115 233.E-mail address: yann.philippe.charles@chru-strasbourg.fr (Y.-P. Charles).

877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved.ttp://dx.doi.org/10.1016/j.otsr.2013.09.013

© 2014 Elsevier Masson SAS. All rights reserved.

The treatment of spinal tuberculosis usually relies onnon-surgical means, namely, the administration of four anti-tuberculosis drugs and bracing. Two situations may require surgicaltreatment: loss of sagittal alignment of the spine due to extensiveosteolysis and spread of an abscess into the para-spinal tissuesand spinal canal. In a 1960 report on the surgical treatment ofcervical, thoracic, and lumbar spinal tuberculosis in 412 patients,Hodgson et al. [6] described the anterior approach with debride-ment as of fundamental importance. This principle is still appliedto some extent in contemporary surgical strategies. Major advanceshave been achieved in recent years, however, with the use of openinternal fixation combined with anti-tuberculosis drugs, the intro-duction of percutaneous internal fixation, and the development ofinterventional radiology techniques.

Here, our objective was to review recent epidemiological data,diagnostic criteria, and medical and surgical treatments for spinaltuberculosis.

2. Epidemiology

The 2011 WHO report indicates a stabilisation in the inci-dence of newly diagnosed tuberculosis, in contrast to the steadyincrease noted earlier. In 2010, the incidence of tuberculosiswas 8.8 million and the mortality rate 1.4 million. Nevertheless,tuberculosis-related deaths decreased by 40% between 1990 and

2010 [2,7].

Considerable differences exist across geographic regions. InEurope, these differences are ascribable to HIV/AIDS, increasingpoverty, inequalities in government funding of tuberculosis control

dx.doi.org/10.1016/j.otsr.2013.09.013http://www.sciencedirect.com/science/journal/18770568http://crossmark.crossref.org/dialog/?doi=10.1016/j.otsr.2013.09.013&domain=pdfmailto:yann.philippe.charles@chru-strasbourg.frdx.doi.org/10.1016/j.otsr.2013.09.013

2 atology: Surgery & Research 100 (2014) 233–239

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fforts, increased tubercle bacillus resistance to anti-tuberculosisrugs, and immigration from endemic areas. Although the inci-ence of tuberculosis remains low in France, a few geographicegions and populations are at higher risk: tuberculosis is chieflyeen in large cities and the risk is greatest among intravenous sub-tance users, the homeless, and immigrants [8–10].

Tubercle bacillus identification in sputum samples is thecreening test currently used in the WHO tuberculosis control pro-ramme but detects only individuals with pulmonary tuberculosis.ne-third of the world’s population is believed to harbour the

ubercle bacillus. When the test is positive, short-term treatmentith anti-tuberculosis drugs is given under direct observation byealthcare providers. The effectiveness of this control programme

s obviously limited in patients with non-pulmonary tuberculosis.hus, the first problem raised by spinal tuberculosis is the fre-uently long time to diagnosis [11,12].

. Diagnosis

In France, the intradermal tuberculin test is still used to diag-ose latent tuberculosis. This test may be positive in individualsaving received the Bacillus Calmette-Guérin (BCG) vaccine, who

ig. 1. Computed tomography, coronal and sagittal views: osteolysis in a 40-year-ld patient with T11-T12 spinal tuberculosis.

ig. 2. Magnetic resonance imaging, T2 STIR sagittal view: abscess lying behind theorta from T8 to L2 (same patient as in Fig. 1).

Fig. 3. Drainage of the abscess via a video-assisted minimally invasive right anteriorapproach. Note the osteolysis after debridement (same patient as in Fig. 1).

Fig. 4. Post-operative radiographs showing preservation of sagittal alignment bythe T8-L1 posterior fusion (same patient as in Fig. 1).

S. Varatharajah et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 233–239 235

Fig. 5. Computed tomography of the neck, coronal and sagittal views: osteolysis and retropharyngeal abscess in a 79-year-old patient with C3-C4 spinal tuberculosis.

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ig. 6. Percutaneous drainage of the abscess via a pre-sterno-cleido-mastoidpproach (same patient as in Fig. 5).

ust therefore be tested using in vitro assays that measure thenterferon gamma released into venous blood by infected T cells.he French National Authority for Health (HAS) recognizes the roleor these in vitro assays as an alternative to intradermal tuberculin

Fig. 8. Computed tomography, sagittal and axial views: osteolys

Fig. 7. Post-operative radiographs of the cervical spine showing the fusion achievedvia a combined posterior and anterior approach (same patient as in Fig. 5).

testing for the diagnosis of extra-pulmonary tuberculosis. Inaddition, microscopic examination of a variety of specimens (spu-tum; gastric aspirate, particularly in children; abscess samples,and urine) for presence of the tubercle bacillus can assist in the

is in a 53-year-old patient with T8-T9 spinal tuberculosis.

236 S. Varatharajah et al. / Orthopaedics & Traumatolo

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ig. 9. Magnetic resonance imaging, T2-weighted sagittal and axial images showingn abscess within the spinal canal (same patient as in Fig. 8).

iagnosis. Molecular biology techniques may play an adjunctiveole in patients with a strong suspicion of clinical tuberculosisut should not be performed routinely, as their sensitivity andpecificity are lower than those of cultures [13]. All tissue samples

Fig. 10. Percutaneous drainage of the caseous necrosis under radiograph

gy: Surgery & Research 100 (2014) 233–239

should be subjected to histological examination for an epithelioidand giant-cell granuloma [14–16].

Spinal lesions that suggest tuberculosis are vertebral body oste-olysis and kyphosis caused by bone destruction. These lesions canbe evaluated on standing lateral radiographs and assessed in detailby CT (Fig. 1). Among currently available techniques, MRI has thebest sensitivity and offers acceptable specificity for spinal lesions[17]. T2 STIR images can ensure the early detection of inflammatoryoedema. In addition, MRI shows the extent of tuberculous abscessesand visualises spinal cord lesions (Fig. 2), allowing their detectionbefore the onset of clinical manifestations. The diagnosis of tuber-culous infection cannot be established based on imaging studiesalone. Nevertheless, imaging studies are useful to assess the extentof the lesions, guide the collection of samples for tubercle bacillusidentification, and assist in defining the best treatment strategy.

4. Medical treatment

Anti-tuberculosis drug treatment must be monitored closelyto prevent the emergence of multi-resistant strains. From 2005to 2010, Europe was among the regions with the lowest treat-ment success rates, i.e., 69% among new patients and 48% amongpreviously treated patients [18]. The recommended treatmentstarts with four drugs given for 2 months: isoniazid, 5–15 mg/kg;rifampicin, 10–20 mg/kg; ethambutol, 15–25 mg/kg; and pyraz-inamide, 30–40 mg/kg. Isoniazid and rifampicin are then givenfor the next 4 months. Fluoroquinolones are alternative first-line

drugs. The latest recommendations indicate that spinal tuberculo-sis should be treated in the same way as pulmonary tuberculosis(with a longer treatment duration of 1 year in children accordingto 2010 WHO guidelines). However, when the clinical, laboratory,

ic and computed tomography guidance (same patient as in Fig. 8).

S. Varatharajah et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 233–239 237

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ig. 11. Post-operative radiographs showing the posterior T6-T11 fusion (sameatient as in Fig. 8).

nd imaging study findings suggest persistent inflammation, mosthysicians prefer longer treatment duration of 9 months [16,19,20].

. Surgical treatment

In 1960, at a time when the surgical treatment of spinal tubercu-osis was still controversial, Hodgson et al. [6] described the routinese of debridement via the anterior approach, with a 93% fusionate. In 1961, the French Society for Orthopaedic Surgery and Trau-atology (SOFCOT) emphasised the predominant role for medical

reatment while acknowledging the existence of two strategies,amely, routine local surgery and medical treatment alone with

our anti-tuberculosis drugs and a brace [21,22]. However, pub-ished studies indicate widespread use of combined medical andurgical treatment: thus, in a review of case-series published

ig. 12. Computed tomography, sagittal view: anterior T7-T10 fibular graft (sameatient as in Fig. 8).

Fig. 13. Computed tomography of the thoraco-lumbar spine, sagittal view: osteol-ysis and kyphosis in a 48-year-old patient with T11-T12 spinal tuberculosis.

between 1980 and 2011, surgery was performed in 75% of patients[5].

At present, the need for surgery is recognised [23–25] in patientswith evidence of spinal cord or nerve root compression, exten-sive abscess formation, spinal instability due to osteolysis withkyphosis, and failure of medical treatment. In patients withoutevidence of neurological compromise, the treatment consists inanti-tuberculosis drugs and bracing, provided the sagittal align-ment of the spine is preserved [26]. Imaging studies must beobtained at regular intervals throughout the treatment to look forworsening of the kyphosis. If vertebral body osteolysis results inanterior column collapse, the need for instrumental correction andfusion should be discussed. The rate of neurological complicationsis estimated at 10 to 40% [27]. Emergency surgical decompression isindicated only in patients with evidence of spinal cord compressionand usually involves laminectomy followed by internal fixation andposterior fusion at the thoraco-lumbar spine or by corporectomyat the cervical spine.

In patients with extensive abscess formation but no neu-rological deficit, the anterior approach remains the referencestandard [28–31]. This approach allows direct debridement of thepre-vertebral and intra-spinal focus of infection (Fig. 3). Phar-macokinetic studies have established that surgery improves theeffectiveness of anti-tuberculosis drugs when debridement is opti-mal [32,33]. In addition, same-stage anterior grafting plays a keyrole in filling the lytic defect and strengthening the anterior col-umn [34,35]. At the thoraco-lumbar spine, posterior fixation mustbe performed also to correct the kyphosis and ensure long-termstability of the spine in the sagittal plane (Fig. 4). Garg et al. [36]and Kumar et al. [37] advocated using the posterior approach aloneto perform spinal canal decompression and abscess drainage dur-ing the same stage as internal fixation and fusion. Zhang et al.[38] described a similar technique involving the addition of abony graft implanted into the anterior lytic defect via the pos-terior approach in order to stabilise the entire spinal segment,thereby preventing loss of correction with kyphosis. At the cer-vical spine, abscess drainage, corporectomy, and internal fixation

are usually performed via the anterior approach alone. Additionalposterior stabilisation is required only in patients with extensivebone destruction (Figs. 5–7). In sum, the surgical management of

238 S. Varatharajah et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 233–239

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Fig. 14. Magnetic resonance imaging, T2-weighted sagittal and axial v

ypical spinal tuberculosis rests on two principles: debridementith spinal cord decompression and stabilisation of the spine.

hese principles are also followed in some developing countries,here surgical treatment can prevent the long-term development

f severe kyphosis [39].An alternative that may deserve consideration in some cases is

ercutaneous needle aspiration of the caseous necrosis to ensureecompression [40]. This procedure may be of value in patientsith severe osteolysis responsible for spinal instability, a situation

hat requires posterior fixation as the first surgical step (Fig. 8).pinal canal decompression by laminectomy must be performedith the patient in the prone position, which can increase the

ension on the spinal cord. Furthermore, the introduction of Keris-on forceps into the tight space of the canal increases the risk ofpinal cord compression (Fig. 9). Aspiration of the caseous necrosisnder CT guidance decreases the size of the collection and obviateshe need for laminectomy (Fig. 10). In addition, posterior spinaltabilisation can be achieved with less risk of propagation of the

nfection along the internal fixation material (Fig. 11). A secondtage of video-assisted surgery via a minimally invasive anteriorpproach is then performed to ensure debridement and bony graft-ng (Fig. 12). Finally, Wimmer described a percutaneous fixation

ig. 15. Post-operative radiographs showing reduction of the sagittal malalignmenty percutaneous T8-L2 fixation and anterior grafting with a Harms cage (sameatient as in Fig. 13).

extension of the abscess about the spine (same patient as in Fig. 13).

technique [41] that might constitute a less invasive alternative. Thistechnique may deserve evaluation in high-risk patients with spinaltuberculosis (Figs. 13–15).

6. Conclusion

Spinal tuberculosis (Pott’s disease) predominantly affects thethoracic spine and is often diagnosed late. Worldwide surveil-lance data published since 2011 point to stabilisation of theincidence of active tuberculosis. The treatment relies chieflyon anti-tuberculosis drugs with the same regimens as for pul-monary tuberculosis, although a treatment-duration of 9 monthsis often used in everyday practice. In the absence of a neurolog-ical emergency, surgery is indicated to prevent secondary spinalcord compression in patients with extensive abscess formationand/or sagittal spinal collapse. Both the anterior and the posteriorapproaches can be used. For thoraco-lumbar lesions, we usuallystart with the posterior approach to stabilise the spine. Decompres-sion by percutaneous aspiration of the caseous necrosis decreasesthe risk of intra-operative neurological complications in high-riskpatients. A minimally invasive anterior approach is then used toperform optimal debridement and to implant a bony graft designedto achieve long-term stability of the spine. At the cervical level,debridement and spinal stabilisation are performed via the ante-rior approach alone. Additional posterior fusion is required only inpatients with marked osteolysis responsible for severe instability.

Declaration of interest

The authors declare that they have no conflicts of interest con-cerning this article.

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Update on the surgical management of Pott's disease1 Introduction2 Epidemiology3 Diagnosis4 Medical treatment5 Surgical treatment6 ConclusionDeclaration of interestReferences