Abstract Tuberculosis (TB) of the spine (Potts disease)

is both the most common and most dangerous form of

TB infection. Delay in establishing diagnosis and man-
agement cause spinal cord compression and spinal defor-
mity. This study investigated the data on all cases of
Potts disease reported in Turkey from 1985 to 1996. A
total of 694 cases were included. Out of the patients
evaluated, 19% were reported in the first half of the
period (19851990) and 81% in the second half
(19911996). Tuberculosis affecting the spine was com-
monly localized in the thoracic region and involved the
vertebral body. The presenting symptoms were leg weak-
ness (69%), gibbus (46%), pain (21%), and palpable
mass (10%). Decompressive surgery plus anti-TB che-
motherapy remains the best mode of therapy for Potts
disease. Follow-up information was available in 414 of
the 694 patients and there were ten deaths (2%), one oc-
curring intraoperatively and the other nine postoperative-
ly. This meta-analysis demonstrates that in Turkey Potts
disease remains a serious problem, causing paraplegia. It
should be considered when patients present with neuro-
logical findings suggesting spinal cord compression and
spinal deformity. In the present study, it was concluded
that the neurological involvement due to Potts disease is
relatively benign if urgent decompression is performed
at the onset of the disease.
Keywords Potts disease Spinal tuberculosis Surgery
Turkey
Introduction
At present, tuberculosis (TB) is much less common in
the United States and western Europe, but approximately
8 million persons develop TB each year and about 3 mil-
lion die of this disease [31]. Unfortunately, it is still a se-
rious public health problem in Turkey and has shown a
trend of increasing rather than decreasing since the early
1970s, becoming pronounced after 1978 [1, 3, 14, 19,
46, 48]. In Turkey, there is an immigration movement
from Southeast and East Anatolia to other regions of
Turkey. Furthermore, many factors such as poor nutrition
and poor living facilities play a role in the resurgence in
TB.
Although spinal involvement occurs in less than 1%
of patients with TB [1, 10, 14, 35, 37, 39, 44], it is both
the most common and the most dangerous form of TB
infection. Even today, TB of the spine (Potts disease) is
still a life-threatening condition in spite of all the ad-
vances in diagnostic procedures, surgical techniques, and
effective tuberculostatic drugs. Delay in establishing the
diagnosis and surgically relieving the spinal cord com-
pression can lead to the progression of neurological defi-
cit and spinal deformity, thereby diminishing the likeli-
hood of recovery.
This retrospective review deals with 694 patients
treated for Potts disease. The purpose of this article is to
present the cases from Turkey and discuss data from the
literature on the management of this disease with the aim
of assessing the role in its management of new radiologi-
cal modalities in diagnosis and surgery.
Patients and methods
The study covers the period of 12 calendar years from
1985 to 1996 for the whole country. Information on all
cases of Potts disease in Turkey were collected from
published studies. If a group appeared in more than one
paper on this subject and their data were also included in
the later publication(s), the earlier reports were omitted.
M. Turgut (

)
Cumhuriyet Mahallesi, Cumhuriyet Caddesi,
No:2/D Daire:7, 09020 Aydn, Turkey
Department of Neurosurgery,
Adnan Menderes University School of Medicine,
Aydn, Turkey
Fax: +90-256-212-0146
Neurosurg Rev (2001) 24:813 Springer-Verlag 2001
ORI GI NAL ARTI CLE
Mehmet Turgut
Spinal tuberculosis (Potts disease): its clinical presentation,
surgical management, and outcome. A survey study on 694 patients
Received: 11 March 1999 / Accepted: 4 September 2000
9
Publications regarding TB of other organs were exclud-
ed. Overall, 24 reports giving sufficient information on
694 patients were selected from a total of 33 reports,
with a total of 950 cases recorded in the Turkish litera-
ture. Data regarding clinical presentation, extent of dis-
ease, method of management, follow-up period, and re-
sults were evaluated.
Results
Three hundred forty-nine of the patients were female
(50%) and 345 male (50%), with a mean age of 32.4
years. The distribution of Potts disease is shown accord-
ing to year of publication in Table 1 [1, 2, 46, 9, 1219,
21, 22, 2629, 32, 4042, 45, 46, 49]. Motor deficits of
variable severity and gibbus were the most common ini-
tial complaints. The presenting symptoms of the 694
cases with Potts disease are presented in Table 2. Rou-
tine x-ray studies were performed in all cases, but new di-
agnostic studies such as CT and MRI became available in
the second half of the last decade. There was bone in-
volvement seen on X-ray in the majority of the patients
with Potts disease. Three hundred twelve patients had
detailed data suggestive of location of the infection focus
in the spine. Distribution of localization in these patients
is shown in Table 3. It involved the thoracic portion of
the spine in 55.8% of cases, the lumbar region in 22.8%,
Table 1 List of patients with tuberculosis of the spine (Potts disease) in the literature from Turkey during the last decade
Author(s) Year Patients (n) Location
Ptn et al. [42] 1985 9 1 cervical, 8 thoracic
oskun et al. [19] 1987 29 1 cervical, 11 thoracic, 17 lumbar
Pasaoglu et al. [41] 1988 18 2 cervical, 14 thoracic, 2 lumbar
Biimoglu, Agaoglu [14] 1990 30 26 thoracic, 4 lumbar
Akgn et al. [2] 1990 12 6 thoracic, 6 lumbar
Caniklioglu et al. [17] 1990 3 1 thoracic, 2 lumbar
Domani et al. [22] 1990 33 16 thoracic, 9 thoracolumbar, 8 lumbar
Akgz et al. [1] 1991 20 2 cervical, 14 thoracic, 4 lumbar
Surat et al. 46] 1991 100 Not stated
Caniklioglu et al. [16]
a
1992 17 (+3) Not stated, (1 thoracic, 2 lumbar)
Gven et al. [27] 1992 2 2 lumbar
Korkusuz et al. [32] 1992 185 Not stated
elik et al. [18] 1992 13 3 thoracic, 7 thoracolumbar, 3 lumbar
Altnmakas et al. [6] 1994 11 Not stated
Demirhan et al. [21] 1994 4 4 cervical
Aydn et al. [19] 1994 24 Not stated
Alc et al. [4] 1994 30 Not stated
Alparslan et al. [5] 1994 44 32 thoracic, 12 thoracolumbar
Gven et al. [26]
b
1994 8 (+2) 5 thoracic, 3 lumbar, (2 lumbar)
zbarlas et al. [40] 1994 33 3 cervical, 8 thoracic, 14 thoracolumbar, 8 lumbar
Berkel et al. [13]
c
1994 10 3 thoracic, 2 thoracolumbar, 4 lumbar, 1 thoracic/lumbar
Sesli et al. [45] 1994 18 18 thoracic
Gven et al. [28] 1995 2 1 lumbar
Kapcoglu et al. [29] 1996 26 10 thoracic, 8 thoracolumbar, 8 lumbar
Benli et al. [12] 1996 9 Not stated
Yalnz et al. [49] 1996 1 1 thoracolumbar
Bilsel et al. [15]
c
1996 5 Not stated
a
Because three of 20 cases reported by the author had already
been described by same author before [14], I considered 17 cases
to avoid an overlap
b
Because two of ten cases reported by the authors had been de-
scribed by same authors in this list before [19, 32], I took into con-
sideration the remaining eight cases
c
Out of ten cases, one had noncontagious lesions in the thoracic
and lumbar regions
the thoracolumbar region in 16.9%, and the cervical re-
gion in 4.2%. One case had noncontagious lesions in the
thoracic and lumbar regions. Thirty-three patients in this
series had posterior element TB without vertebral body
involvement. In the present study, multifocal TB was
present in 35 of 694 patients with Potts disease (Table 4).
Six hundred eighty-two cases were treated surgically.
the surgical indications were spinal deformity in 399,
neurological deficit in 257, intractable pain in 20, and
abscess enlargement unresponsive to medications in 18.
In all series, anti-TB chemotherapy protocols consisting
of combinations of rifampin, isoniazid, pyrazinamide,
and either ethambutol or streptomycin were administered
for 26 months, followed by rifampin and either isoniaz-
id or ethambutol for a total of 618 months. As seen in
Table 5, 678 patients received chemotherapy after the
operation, 11 had chemotherapy alone, and four had only
surgical treatment. The kinds of surgical procedure per-
formed are stated in 424 of 682 cases, as seen in Table 6.
In the majority of cases, decompression was performed
(corpectomy or drainage) with or without fusion proce-
dures. Out of 285 cases treated with an anterolateral ap-
proach, 203 underwent decompression plus fusion and
82 had decompression alone. Fusion procedure was per-
formed in 203 patients; the removed rib, iliac crest, or
fibula was used in 123, 49, and two cases, respectively.
In the remaining 29 cases, both the removed rib and iliac
crest were used for bone grafting.
10
Follow-up information was available in 414 of the
694 patients. There were nine deaths in the postoperative
period and one during the surgical intervention, resulting
in a mortality rate of 2%. The duration of the follow-up
varied from 1 month to 21 years. Thirty-four percent of
the cases had resolved, 41% improved, 14% remained
unchanged, and 9% deteriorated by the last control ex-
amination (Table 7).
Discussion
Although TB is rarely seen in developed countries, it is
still common in underdeveloped countries as a cause of
vertebral infection. The rising trend of TB after 1970 has
been observed in Turkey, where a control program based
on the construction of dispensaries for TB was started af-
ter foundation of the republic in 1923 [31]. In 1984, a
mean prevalence of 3.58 per 1000 was estimated from
the reports of TB dispensaries in Turkey [48]. High pop-
ulation growth and mobility, inflation, and unemploy-
ment after the early 1970s resulted in the recent increase
in TB in this country [3, 14, 23, 48].
The causative organism of TB is Mycobacterium tu-
berculosis, which is rarely seen in organs other than the
lung. Of course, neurosurgeons are primarily concerned
with tuberculous paraplegia, a syndrome commonly
called Potts paraplegia after Percivall Pott (17141788),
one of the leading surgeons in London in the eighteenth
century [24]. In Turkey, the resurgence in TB has been
associated with a concomitant rise in Potts disease, as
seen in this survey study [1, 3, 14, 23, 48]. Here, patients
Table 2 Initial complaints
Complaints Patients (n) Percentage of total
a
Leg weakness 480 69.2
Gibbus 322 46.4
Pain 148 21.3
Palpable mass 68 9.8
Numbness 34 4.9
Incontinence 14 2.0
Fever 11 1.6
Fistula 10 1.4
Stiffness 1 0.1
Dysphagia 1 0.1
a
Some patients had more than one sign or symptom of Potts dis-
ease
Table 3 Distribution of lesions (n=312)
Localization Patients (n) Percentage of total
Cervical spine 13 4.2
Thoracic spine 174 55.8
Thoracolumbar spine 53 16.9
Lumbar spine 71 22.8
Thoracic and lumbar spine
a
1 0.3
a
One patient had two noncontagious lesions in the thoracic and
lumbar regions
Table 6 Surgical procedures performed (n=455)
Surgical procedure Patients Percentage
(n) of total
Transoral approach 1 0.2
Posterior approach
Fusion 98 21.5
Laminectomy 18 4.1
Posterolateral approach
Transpedicular drainage 2 0.4
Biopsy 1 0.2
Lateral approach
Costotransversectomy 4 0.9
Anterolateral approach
Decompression and anterior fusion
a
285 62.6
Combined approach
Posterolateral decompression 2 0.4
and posterior fusion
Anterolateral decompression 44 9.7
and fusion and posterior fusion
Not stated 258 56
a
Out of 285 patients, decompression plus fusion procedures were
performed in 203 and only decompressive procedures in 82
Table 4 Distribution of 35 patients with multifocal tuberculosis
(TB) among 694 patients with Potts disease
Location other than spine Patients (n) Percentage of total
Lung 16 45
Spinal cord 8 23
Pleura 7 20
Rib 2 6
Uterus 1 3
Table 5 Different forms of treatment in 694 patients with Potts
disease
Treatment Patients (n) Percentage of total
Only surgery 4 0.6
Only chemotherapy 11 1.6
Surgery and chemotherapy 678 17.7
None
a
1 0.1
a
One of 694 cases died during the surgical intervention
Table 7 Final results (n=414)
Result Patients (n) Percentage of total
Resolved 140 34
Improved 169 41
Unchanged 59 14
Deteriorated 36 9
Deaths
a
10 2
a
Out Of ten deaths, one occurred in the intraoperative period
11
with Potts disease are treated surgically by neurosur-
geons or orthopedic surgeons and receive chemotherapy
under the control of internal medicine clinics or dispen-
saries built by the National Society for Fighting Tuber-
culosis. In a majority of cases, the lesions involve the
vertebral body [10, 28, 30, 41, 42]. The incidence of
neurological deficit in Potts disease varies from series to
series: 5% to 100% [1, 2, 19, 22, 30, 40, 42, 44, 46, 47]
and 69% in the present study. The high incidence of ky-
phoscoliosis and motor weakness in the Turkish popula-
tion is probably due to the advanced stage of the disease
in most patients.
Tuberculosis infection typically affects the vertebral
body itself in the lower thoracic and upper lumbar re-
gions, and the posterior elements are rarely affected [8,
10, 33, 43, 44]. It is now generally believed that the dis-
ease spreads to the spine from a primary focus by way
of the vertebral venous system described by Batson
[11]. Atypical spinal TB, in which only the posterior
vertebral elements (i.e., lamina, spinous process, and
pedicle) are involved, sparing the vertebral bodies and
intervertebral discs, is an uncommon entity [33, 43].
Clinically, the majority of patients with posterior ele-
ment involvement present with severe neurological defi-
cit. Various incidences of this deficit in the literature are
shown in Table 8 [8, 10, 33, 43, 44]. In some patients,
infection is brought to the extradural space by the inter-
nal vertebral venous plexus, which surrounds the dura
mater of the spinal cord [7]. Although it could produce
an extradural abscess without bony involvement, in our
experience it was frequently associated with bony defor-
mities caused by vertebral body collapse. According to
Martin [35], abscess formation is more frequently seen
in third world nations than economically advanced
countries. Although, in general, TB has become less
widespread globally, it is still responsible for 25% of
cases of spinal extradural abscess and is usually associ-
ated with vertebral osteomyelitis [10, 30, 33, 43, 47].
Today, CT and MRI have become the radiological mo-
dalities of choice in the diagnosis of Potts disease.
Computed tomographic scan can strongly suggest a di-
agnosis of Potts disease of the spine and demonstrate
its extension [25]. Spinal MRI has proved to be a very
useful noninvasive diagnostic tool [20]. In Potts para-
plegia, accurate diagnosis can only be obtained by the
isolation of M. tuberculosis in the materials taken dur-
ing surgical intervention. Bacteriological diagnosis is
easy in untreated cases, but it is impossible to identify
this organism in cases receiving anti-TB treatment in the
preoperative period. In such cases, mycobacterial cul-
tures are relatively reliable for diagnosing TB [34].
In Potts paraplegia, an important point is the question
of which type of surgical procedure is more appropriate.
Surgery achieves early decompression of the spinal cord,
histological verification of the diagnosis, and prompt re-
lief of most symptoms. So far, different treatment meth-
ods have been used, but there is still debate on the treat-
ment modalities. It has been stated that the success of
chemotherapy alone has reduced the importance of sur-
gery [1, 14, 29, 36, 39, 44]. Surat et al. [46] also reported
that outcomes showed no differences when different
types of treatment modalities were compared. I believe,
in agreement with Akgz et al. [1], that standard lami-
nectomy is a method to decompress the cord in cases
with only a tuberculous abscess [1, 44]. Recently, Gven
et al. [26] described single-stage posterior instrumenta-
tion and fusion in selected patients with Potts disease.
This proved quite adequate in decompressing the spinal
cord and provides an effective route for draining the as-
sociated anterior or anterolateral cold abscess. I also be-
lieve that simple posterior decompressive laminectomy,
as opposed to anterior radical surgery, is the surgical ap-
proach of choice, especially in patients with posterior el-
ement involvement. Neurological involvement and bony
deformity are also important factors in deciding surgical
procedure [2, 4, 15, 22, 32, 38]. Many authors advocate
early anterior radical debridement and grafting (Hong
Kong operation) to prevent kyphosis and progressive
paraplegia, together with anti-TB chemotherapy [2, 14,
32]. On the other hand, some surgeons think this is best
done in the presence of multiple level involvement (more
than two vertebral bodies) and in children [14, 37, 40]
with a combined fusion procedure. In Turkey, unfortu-
nately, most of the patients with Potts disease have large
abscesses, neurological involvement, and multisegmental
involvement when admitted. In these patients, undoubt-
edly the best results can be obtained with a combined ap-
proach. But even today, such an approach for the thorac-
ic spine is problematic because of the watershed blood
supply and the tighter space between the cord and the ca-
nal than in the cervical and lumbar regions. For this rea-
son, Aikgz et al. [1] prefer costotransversectomy for
lower thoracic lesions as an alternative approach. How-
ever, anterior debridement and grafting must be per-
Table 8 Studies on spinal TB
with posterior element involve-
ment
Authors Year Patients (n) Patients with neurological deficit
(n) (%)
Rahman [43] 1980 11 5 45
Kumar [33] 1985 27 9 33
Azzam, Tammawy [10] 1988 1 1 100
Arthornthurasook, 1990 9 4 44
Chongpieboonpatana [8]
Rezai et al. [44] 1995 8 5 62
Present series 1998 33 16 48
12
formed in patients with pathology in the midthoracic re-
gion.
Unfortunately, even today TB still remains a source of
socioeconomic and follow-up problems in many devel-
oping nations, despite the availability of effective che-
motherapeutical agents and World Health Organization
(WHO) efforts to improve public health [36]. In control
examinations, 34% of the cases were found to be normal
and in 41% there was some improvement in the neuro-
logical state. In light of this study, surgery and chemo-
therapy provide satisfactory results in Potts disease.
Moreover, the importance of long-term anti-TB medica-
tion after discharge should be kept in mind, as some pa-
tients may erroneously discontinue to take the recom-
mended chemotherapeutical agents due to early improve-
ment in their clinical status.
Conclusions
This study is a meta-analysis of the Turkish literature on
Potts disease over the last decade. It provides an over-
view on clinical symptoms, diagnostic studies, and surgi-
cal treatments in 694 cases with Potts disease. In this se-
ries, most of the subjects had bony deformities causing
neurological complications or severe pain. Therefore, I
think that Potts disease should be treated by chemother-
apy combined with surgery because of the advanced
stage of the disease in most patients, as commonly seen
in our country [1, 5, 2628, 41, 42, 46]. It was concluded
that:
1. Turkey is one of the nations where TB is still encoun-
tered as an important cause of paraplegia.
2. Potts disease should be suspected when patients pres-
ent with neurological findings suggesting cord com-
pression or back pain.
3. Potts disease usually affects the body of vertebrae
and causes spinal deformity, and sole lesions in the
posterior element without vertebral body involvement
are extremely rare.
4. New radiological modalities such as CT and MRI
have added detailed osseous information and in-
creased soft tissue discrimination in the diagnosis of
Potts disease.
5. Surgical intervention must be undergone in patients
with progressive paraplegia.
6. All patients should receive full chemotherapy beside
surgical treatment.
7. The neurological involvement due to Potts disease is
relatively benign if urgent decompression is per-
formed at the onset of disease.
Acknowledgements My thanks go to Mrs. A. Madran for secre-
tarial assistance and Dr. F. Turgut for her helpful suggestions. I
had useful discussions with Drs. . Savk and E. ullu.
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