Potts

Bassam Ronaldj

Disease*
Challenge
M. D. M.D.,
;

A Resurgent
Oman, Nelson,

to the Thoracic
Robertson, M. D.
,

Surgeon
F.C.C.P

John

M.

F. C. C. P; M.D.,

F.C.C.P;andLee

C. Chiu,

were treated at the Los Angeles County Medical Center between 1971 and 1986 for tuberculosis of the spine. Fourteen were immigrants, a high-risk group. A high index of suspicion is required for Polls disease, which occurs in fewer than 1 percent of patients with tuberculosis, often presents with nonspecific symptoms, and may result in permanent deformity or neurologic impairment. CT scan, the most useful diagnostic test, showed abnormal results in 11 of 11 patients. MRI, a newer modality, may provide even more information. Eight patients required operation in addition to antimicrobial
Harbor/UCLA

Nineteen

patients

therapy. Four had lesions between spinal canal is narrow, of whom neurologic involvement. All four
proach (thoracotomy) for decompression,

T3 and T10, where three (75 percent underwent anterior

debridement,

the had apand

spinal Three

fusion. Fifteen had lesions between Ti 1 and 52. (20 percent) had neurologic involvement but responded to medical treatment alone. Four underwent drainage of abscess or spinal fusion for deformity. Combined surgical and medical treatment gave excellent results in this series. (Chest 1989;95:145-50)

Ithough

the

incidence

of tuberculosis

has

declined

caseation

necrosis the and involved

ten patients

or

granuloma site
the

on in nine

histopathologic of the was based

examination In presenthe on clinical

steadily United morbidity increased occurs in tuberculosis, particularly patients symptoms high index States,

during

the

past

several

decades with

in significant

the

from
remaining

spinal

19 patients.

it is still

associated

diagnosis

tation

response

to therapy. RESULTS

and mortality, immigration. approximately

especially in areas Skeletal tuberculosis, 1 percent of patients to the treating is involved,

with which with

is a challenge when the spine with that

physician, because: (1)

spinal tuberculosis can result in delay is not occurs if not

have nonspecific in the diagnosis if a maintained, and (2) of these promptly

Fourteen ofthe 19 patients were immigrants, mainly from Asia and Central America. There were 38 vertebrae involved in the 19 patients (mean, two vertebrae per patient). The distribution of involved involvement to the second vertebrae varied sacral the is shown from the vertebra, in Figure third the 1 The
.

of suspicion

site vertebra lumbar

of

thoracic upper

neural involvement patients,25 which, treated, can our experience where the the role place

in 10 to 47 percent adequately and damage. tuberculosis treated,

cause irreversible with spinal are frequently imaging

We present at a center emphasizing in diagnosis and

vertebrae being The presenting 19 patients tation. The were

most common symptoms are of symptoms

site of involvement. listed in Table 1 All

.

symptomatic

at the

time before

of presendiagnosis

immigrants of newer ofsurgery

duration

techniques

in management.
AND METHODS

ranged from two the most common in 17 of 19 patients percent) complained percent) percent) patient, to have had

weeks to seven years. Back pain was symptom at presentation, occurring (90 percent). Eight of weight loss. Five extremity weakness, patients patients and five (42 (26 (26

MATERIALS The tuberculosis Angeles The signs film, study, outcome. There of 6 to positive *From were 80 smear the eight or females (mean mycobacterial and 36.5). following CT scan, medical County at presentation, medical treatment, records (Polls

of 19 patients between Medical was PPD obtained: tuberculin cultures and duration,

diagnosed 1971 age, skin and test smear, surgical with or by and and Center sex,

as having 1986 were status, at the

spinal Los and x-ray and

disease) Harbor/UCLA

lower

reviewed. chest

information mycobactenial

symptoms histopathologic treatment,

had numbness at presentation. One who complained only ofback pain, a complete block of the subarachnoid

additional was found space.

1 1 males, The diagnosis culture

an age was the

distribution by of presence

Table

years

established

1-Presenting Symptoms with Tuberculosis ofthe

in 19 Patients Spine
No. 17
8

Symptom Division of Cardiothoracic Surgery Department of Back pain of lower or groin mass extremities

% 90
42

Radiology, Los Angeles County Harbor/UCLA Medical Center, Torrance, CA. Manuscript received December 10, 1987; revision accepted May 31. Reprint requests: Di Nelson, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509

Weightloss

Weakness Numbness Flank

5 5 4

26 26 21

CHEST

I 95 I 1 I JANUARY,

1989

145

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lomas seven CT culosis

institution

were

present

on histopathologic (64 percent).

examination suspected available

positive findings

in tuberat our
in

of 11 patients

was used for all patients with of the spine after it became
in 1979. CT revealed

all 11 patients or paraspinous

on

whom

it was were

done seen

(Table in ten

3). Psoas patients,

abscesses

[1

I
1

with calcification in two of destruction in ten, intervertebral in six, and pedicle fracture enhanced
I . ..--

these, vertebral body disk space narrowing in two. Metrizamideof an extradural

CT helped

in the

diagnosis

:
i
Lw,-

-----,

mass blocking All patients the diagnosis

the subarachnoid space in one patient. received medical treatment as soon as was suspected. This treatment consisted

of at least two of the following drugs: isoniazid, ethambutol, rifampin, and streptomycin. Eight patients required surgical treatment in addition to the medical cations in two sponse treatment, for surgery summarized were progressive in Table 4. The mdineurologic in three, two, and The fusion of psoas patients
in five

deficits poor reenlarging procedures

patients,

patients, spinal deformity to medical treatment in abscesses

were

psoas
performed

in

three

patients.
spinal
.

anterior

fusion

two of whom stabilization

.

also required of the spine in three

posterior Drainage All

for better abscesses survived

was I 13 14 II 11 U

done

patients.

tUII?IITi2I

tertebrie u*voIed
FIGuRE

operation and were free of symptoms One patient had recurrence of his
requiring

on follow-up. psoas abscess and did well

tuberculosis

1 . Distribution of the spine.

of involved

vertebra

in

19 patients

with

another

drainage

procedure had These

A flank

or groin

mass of the PPD were

was

present

in four procedures

patients is given

(21 in was

afterward. Six patients of 19 (32 percent) or spinal cord involvement. treatment and outcome Four patients had lesions overall series. Three

neurologic deficit cases with their

percent). A summary Table patients; abnormal inactive tuberculosis right pleural mycobacteria whom Table they 2. The two

diagnostic skin anergic. test was The

are summarized in Table 5. between T3 and T10 in the (75 percent) had neuroAll four of left of the

positive chest percent), in three,

in 17 of 19 x-ray film including miliary and for on

of these

in eight pulmonary in three,

patients (42 tuberculosis diffuse

logic symptoms or spinal cord involvement. required surgical intervention, which consisted posterolateral thoracotomy and mobilization aorta and intercostal surgery, followed racic pedic toms spinal fusion by branches for exposure debridement and either neurosurgery cured and free to four years). in the series with anterior

infiltrates

in one,

effusion in one. Smear were positive in eight were done. Caseation

and/or culture of 15 patients necrosis

by thoracic thoor orthoof symplesions

by

or granuwith

surgery. All four were on follow-up (six months were Til 15 patients and S2. Three symptoms (see 3-CT
Findings Tuberculosis

2-Diagnostk Procedures Tuberculosis ofthe

in 19 Patients
Spine No. Positive! No. 11/11 Done

There between neurologic

% 100 90 42 64 40 27 53 Vertebral Psoas
Intervertebral

of these (20 percent) had Table 5) but were treated

in 11 Patients ofthe Spine with

Procedure CTscar PPD Chest Caseation Culture Smear Smear skin x-ray test film
granulomas

Total

Table

17/19 8/19 on 7/11 6/15 4/15 for 8/15

examination

CT body

Finding destruction abscess space the narrowing abscess

disk

No. 10 10 6 2
2

histopathologic

or paraspinous within
fracture

for mycobacteria for mycobacteria anchor culture

Calcification

Pedicle
Facet

mycobacteria

joint

sclerosis

146

Potts

Disease

(Oman

et a!)

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Table
Age, yr/Sex 26/F Vertebrae T3-T4-T5 Indication Paraparesis kyphotic T4-T5 For and deformity

4-Patients

with

Surgical

Treatment Procedures Medical INH, RIF, Treatment EMB Outcome Cured

Surgery 1. of 2.

Surgical Left

thoracotomy, spinal T3-T5 spinal fusion anterior T5-Th

anterior fusion Posterior T3-T6 thoracotomy, fusion

(24 mo)

57/F

T6-17

Kyphosis gibbus T6-17; block

myelogram

with

marked at on

Left

INH,

RIF,

EMB

Cured

deformity complete at T6-T7 pain, and not spine

spinal

(7 mo)

59/F

L3-L4
a

Increasing disability deformity responsive treatment

1. 2.

Posterior Anterior

fusion fusion

L3-L5 L3-L4

INH,

RIF

(18 mo)

Cured

to medical Left thoracotomy, fusion anterior T3-T5 anterior T9-T10 INH, BIF, EMB Strep (6 Cured Cured

54/F

T4

Paraparesis

spinal 45/M T9-T10 Collapse

continued

(5 mo);

wk)
ofT9 with mass;
severe

Left

thoracotomy, fusion

INH, Strep

EMB

(12 mo)

paravertebral back pain not

spinal

(2 wk)

responsive treatment 47/F T11-T12 Enlarging abscess left

to medical psoas Drainage through

retroperitoneal

ofabscess a

INH,

RIF,

EMB Strep.

Cured

(28 ma);
(3 mo)

approach 20/M T12-L1 Enlarging psoas abscess T12-L1 costotransversectomy.

Drainage of abscess

INH, RIF, (6 mo)

EMB

Recurrence of psoas
abscess->

Incision drainage 20/M L5 Enlarging psoas bilateral abscesses Drainage of abscesses INH, RIF, EMB Strep Cured (8 mo); (2 mo) INH, isoniazid; RIF, rifampin; EMB, ethambutol; Strep, streptomycin.

and

medically

and

did had

Two

of them

not require surgical marked improvement

intervention. in their symp-

rior spinal for spinal sive

fusion through deformity, with treatment.

a transabdominal increasing pain

not

approach respon-

toms, with (14 to 28 tuberculosis 15 patients had drainage went posterior

.

minimal months), five days underwent ofpsoas lumbar

residual back pain on follow-up and the third died of miliary after admission.
. .

to medical

Four

of these Tuberculosis United States. were

with
Treatment fusion fusion spinal spinal T3-T5 T2-Th INH, Strep fusion INH, INH, PL* INH, INH, RIF, RIF, RIF, EMB EMB,

DISCUSSION

an operation abscesses, and spinal fusion

(Table 4). Three the fourth underfollowed Table 5

-

is still a major In 1985, 22,201 to the Center for

health cases Disease

problem in the of tuberculosis Control, for

by antePatients

reported
Involvement

Neurologic

Age,

yr/Sex 26/F 54/F 57/F 18/F 80/F 621M

Vertebrae T3-T4-T5 T4 T6-T7 L4-L5 L2-L3 L1,L2,L4

Surgical 1. Anterior 2. Posterior T3-T5 Anterior T5T8 None None None Anterior

Medical INH, RIF,

Treatment EMB EMB EMB EMB, (14 mo) Strep (1 wk) (24 mo) (5 mo) (7 mo)

Outcome Cured Cured Cured Improved Improved Died of sepsis

fusion

(6 wk)

(24 mo)

*PZA,

pyrazmnamide

CHEST

I 95 I 1 I JANUARY,

1989

147

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FIGURE

CT scan following

2A (left). showing therapy.

CT scan healing

showing multiple lytic lesions ofthe and sclerosis of the bony lesions

second of the

lumbar second

vertebra. lumbar

2B (right). vertebra 18

Repeat months

a rate

of9.3/100,000

U.S.

population.6

This

rate

is 8.7

who not
58

were

anergic.

Normal

chest

x-ray

film

findings

do as film tool most

times higher for the Asian/Pacific Islanders than for the white population in the United States.7 A large proportion of the Asian/Pacific Islander population in the United from areas
7

rule out the diagnosis percent of our patients

of skeletal had normal

tuberculosis, chest x-ray diagnostic is the extent

revealed

States with

today a high
spine

are immigrants prevalence

is an

of

or refugees tuberculous
form of

findings. CT has become when Potts disease thorough modality

In our disease)2

a very important is suspected for

series,

and the

imaging
CT scan

of
positive

the

Tuberculosis

of the

uncommon

tuberculosis patients kept

because

occurring with tuberculosis,5 especially delay in

in

fewer but

than it should

1 percent always population, result

of he in

findings 3). Some vertebral rowing Calcification

in all 11 patients of the typical

in whom CT

it was 2A), disk abscesses patients

done are

(Table anterior

findings

in mind,
any

in the immigrant the diagnosis The pain

can

body destruction (Fig and psoas or paraspinous within

10

space nar(Fig 3). of 4). CT (Fig

irreversible neurologic tation is nonspecific, common nation motor

positive

damage. with back

clinical being

presenthe most

the

abscess of our

is pathognomonic

seen

in two

symptom.9#{176} A thorough neurologic examishould be performed to reveal any sensory or deficits.

PPD
it

We
skin test

have
is the

found,
most

as patients

others,9 except

that
diagnostic

important

clue;

was

positive

in all our

in

two,

FICuRE
posterior

3. CT

scan

showing
muscles.

right

psoas

abscess

extending

into

the

FIGURE pathognomonic

4. CT

scan

showing

calcification
of the spine.

within

left

psoas

abscess,

abdominal

of tuberculosis

148

PoCs Disease

(Oman et a!)

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percutaneous mined,6 and being operative

seems

aspiration and biopsy its role in the postoperative because

it

is not yet period distinguish

deteris still post-

evaluated,

cannot

disease defined. The with rologic dence, disability diagnosis Neurologic disease In our
FIGURE 5. MR image showing left psoas abscess. This weighted image (TR 2,000 msec; TE 100 msec) where psoas muscle is of low signal intensity (arrows); whereas psoas abscess is of increased signal intensity

scar from to have great of the spine, incidence Potts disease percent involvement combined

recurrent disease.3 Thus, MRI potential for the evaluation of but its overall role is yet to be involvement from patients 10 to had
47

ofneurologic varies of our

in patients
percent.2-5

Thirty-two

signs This high damage

of neumciand

at presentation. with the irreversible

if the diagnosis is delayed, make early and initiation oftherapy ofgreat importance. complications are more frequent when the involves series
75

the upper and percent of the neurologic percent with

midthoracic spine.23 patients with disease et

is a T2the right the left

in this location al8 reported impairment in spine. thoracic

had a 90

impairment. Lifeso incidence of neurologic lesions spinal in the upper of 100 tuberculosis

(arrowheads).

patients In a series

scan

is also

very

helpful

in localization

of the

disease of the and as this

for percutaneous culture specimens. response to therapy

needle biopsy and aspiration It is also useful to evaluate showing the degree ofhealing as well during
important

patients with neurologic complications, Tuli2 showed that 76 had lesions of the thoracic spine. This predilection to neurologic involvement may be due to the narrow, into spinal thoracic cervical which canal spinal early rounded the spinal cord and canal nerve between that spine. intervention must be considPotts disease involving the recommended surgical procefusion.258 This anterior apthis slower in the T3 is than thoracic fit and Tb, that because region
1

sclerosis of the diseased vertebrae the resorption of the paraspinous MRI

series.

(Fig 2B) abscess. institution

a very

roots

The and the

was

not tool

available
it is now

at our
becoming

is narrowest theorized canal operative with The spinal grows

However,

Schwarz#{176} has

radiologic malities The obtain

in the

diagnostic

evaluation
13.15

of abnorthe the ability sagittal area the of the to

of the

involving advantages direct

the spinal axis. of MRI include, images the relationship sac and neural

or lumbosacral

first, whereby

Thus,

multiplanar

image outlines with the thecal coronal

disease.

of the involved structures, while the

require

ered in patients thoracic spine.418 dure is anterior

and
Second,

axial

images
MRI does

define
not

extent

intrathecal

proach, which is done through a left posterolateral thoracotomy permits direct access to the diseased vertebral pression spine. perform ing aorta
pathology.

contrast material to visualize roots. Studies have shown

the spinal cord and nerve that MRI is as accurate as level and In the case space, MRI can
4

CT and myelography in demonstrating degree of obstruction of the spinal ofcomplete block ofthe subarachnoid
identify

the

bodies allowing effective of the spinal canal and The thoracic surgeon is the and
All

mechanical stabilization often called from the below

decomof the on to

thoracotomy intercostal
unhealthy

and
tissue

to mobilize
in front

the descendunderlying
theca is of the

branches above

without material not utilize

the the above

cranial and caudal need for intrathecal and below the radiation, any ionizing

level of obstruction injection of contrast block. Third, which MRI makes does it safe

removed,

the

vertebrae

and

the

lesion graft is bony

are adequately debrided, inserted between these fusion. allowed long-term Early aggressive a prompt and results.

and autologous bone vertebrae to promote surgical approach full recovery and

especially in patients who require multiple follow-up studies. MRI is positive early in the course of disk space infection and with therapy and resolution of the infection, the signal intensity of the vertebral body and intervertebral using different differentiate musclel6 Despite It cannot pathognomonic (Fig soft 5). advantages, soft tissue of MRI still has calcifications,
17

in this series gave excellent

disk return pulse sequences, tissue abscess

to

normal.3 Finally, MRI can better from normal psoas

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Med

1970;

these identify

limitations. which are use in

Bone

51A:680-92

Tuberculosis Boeke EJ,

20:92-110 S Afr

its

routine

CHEST

I 95 I 1 I JANUARY,

1989

149

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J 1987; 71:427-28 5 Hodgson of 42:295-310 6 CDC. 35:699-703 7 CDC. 36:77-80 8 Gorse dylitis. 9 Shivaram
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Paushter of the Modic resonance North Am Weinreb study 40 deRoos Lifeso adults. Epstein spine: Febiger, Schwarz vertebra 81

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JC, of normal

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anatomy Meerden spondylitis.

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Med

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A, Van RM,

ELVP, AJR [Am] of and of

Blueman

U, Wollschlager

oftuberculous

1985;

Weaver Joint Herniation

P, Harder Surg text width reference

10 11

Marcq

M , Sharma

OP

Tuberculosis

Bone BS.

Chest 1973; 63:403-08 LaBerge JM, Brant-Zawadzki

intervertebral

a radiological 1976:632-77 GS. with The special

with
12 Gropper

computed GR, disease. MT, spine.

tomography. Acken JD, Neurosurgery T, Paushter Clin Radiol

in Potts 13 Modic of the

to the

sacrum.

Masaryk

D. Magnetic

150

Potts

Disease (Oman et a!)

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