Pott's Disease Imaging PPP

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Pott’s Disease:

Pott’s Disease Lauren Mott Brett Steininger Stephen Worrel 10/07/12

Various Types:

Various Types Categorized based on type of infection: - Pyogenic (Staph Aureus usually) 2 -Parasitic 2 - Granulomatus (TB, fungal, etc) 2

Vertebral Osteomyelitis:

Vertebral Osteomyelitis Also known as Tuberculous Osteomyelitis , Tuberculous Spondylitis , and Pott’s Disease 3 Occurs secondary to tuberculous lesions that have spread and infected the spine. 3 While TB is most common cause in the spine, pyogenic infection secondary to Staph Aureus is the second most common. 2

Common Sites:

Common Sites L ower thoracic spine Upper Lumbar Spine

Pathogenesis:

Pathogenesis Infection of the bone via TB Slow deterioration of vertebral body, usually the anterior aspect 3 Penetrates the vertebral body and forms an abscess that spans several vertebrae, thus spreading the infection. 3

Incidence:

Incidence Pott’s Disease is usually found in individuals <20 years of age beginning in early childhood. 2,3

Signs and Symptoms:

Signs and Symptoms Back pain 3 Sitting or standing is painful 3 Forward bending is painful 3 Muscle guarding in the local area 2,3 Tenderness in local area 2,3 Gibbus Formation/ Kyphotic posture 3,5 Possible neurological deficits 2

Signs and Symptoms:

Signs and Symptoms Vary greatly depending on stage of infection, damage to vertebral bodies, and extent of deformity already present.

Lab Results:

Lab Results Specificity for this disease is difficult to obtain through lab work C-reactive Protein is thought to be the best marker for infection 2 WBC count is actually the least reliable lab result with only one half to a third of the population showing elevation in lab results. 2

Physical Exam:

Physical Exam Tenderness over affected area 2,3 Increased muscle guarding over area of discomfort 3 Pain with active movement, namely, forward bending 3 Forward bending kyphotic posture 3,5

Imaging:

Imaging Radiography- Often used to screen but can show early degeneration as well as bone destruction in the latter stages. 2,3 MRI- The best option for imaging with Pott’s Disease. Provides best overall detail of anatomy within the spine. 1,2 CT Scan- Distant second to MRI but still useful. 2

Radiograph:

Radiograph A. A/P view of lumbar spine 6 B. Lateral view of lumbar spine 6 C. Lateral view of thoracic spine 6 (Next Slide)

Radiograph:

Radiograph

Alignment:

Alignment Thoracic Spine- Approximately T5/T6 destruction causing severe anterior deviation of thoracic kyphosis , vertebral bodies above T5/6 show wedged shape and are no longer horizontal but veritcal until about T7 where extreme cervical extension brings all spinous processes in contact. 6 Lumbar spine- Destruction of L2 causing decreased space of L1/2 and L2/3. Minimal SBR with compensation of L rotation at L1-L4. 6

Bone Density:

Bone Density Thoracic Spine- Obvious decrease in density of the cervical and thoracic vertebrae down to approximately T10 and possibly further. Total destruction of the T6 vertabrae . Noted increase in radiodensity of vertebral endplates from T10-12. 6 Lumbar spine- Decreased density throughout lumbar spine most notable in L2 with collapse of the L2 vertabrae. 6

Cartilage Space:

Cartilage Space Thoracic Spine- Abnormal and deceased intervertebral space at T5/6 and surrounding segments T4/5 and T6/7. Anterior fanning of vertebral bodies from C6-T4 with noted decreased space between spinous processes at those segments. 6 Lumbar Spine- deceased intervertebral space of L2/3 and L3/4 and noted erosion of the lower anterior portion of L3. 6

Soft Tissue:

Soft Tissue Thoracic Spine- Nothing notable Lumbar Spine- Areas of increased radiodensity anterior to the lumbar and lower thoracic vertebrae possibly indicative of inflammation. Increased radiodensity of periosteum indicating osteomyelitis .

MRI:

MRI *

Findings:

Findings T1 weighted image Destruction and collapse of the L3 and L4 vertbral bodies Possble nerological issues secondary to impingement of the cauda equina Inflammation surround the L3/L4 segments noted as change in radiodensity . Periosteal reaction of the posterior aspects of the lumbar spine. Axial view showing changes within the vertebral body indicating possible abcesses .

PowerPoint Presentation:

References Jha P, Alsalam H, et al. Pott Disease. Radiopaedia.org Web site. http://radiopaedia.org/articles/pott-disease . Accessed October 3, 2012. Gouliouris T, Aliyu SH, Brown Nicholas. Spondylodiscitis : update on diagnosis and management. Journal of Antimicrobial Chemotherapy. 2010;65(3): iii11-iii24. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System: 3 rd Edition. Baltimore, Maryland: Lippincott Williams & Wilkins; 1999. David Werner. Tuberculosis of the backbone. Disablity Information Resources Web site. http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00223.html . Accessed October 3, 2012. Patla CE. Musculoskeletal I: Orthopaedics . University of St. Augustine: Course Note Packet. 2011. Benzagmout M, Boujraf S, Chakour K, Chaoui M. Pott’s Disease in Children. Surgical Neurology International Web site. http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2011;volume=2;issue=1;spage=1;epage=1;aulast=Benzagmout . Published January 11, 2011; Accessed October 5, 2012. Questions Which image, radiograph or MRI, do you find more beneficial from the view point of a physical therapist and why? What role would physical therapy play in treating a patient with this condition?

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