A 23-year-old female patient presented with low back pain for the last 7 to 8 months.
The patient was a refugee from neighbouring Myanmar, presented with low back pain for the last 7 to 8 months. Gradual onset weakness of lower limbs was also noted for a few months. No history of trauma or fever. On examination the patient's posture was slightly kyphotic. Routine blood examination revealed elevated ESR at 113 mm after first hour and raised white blood cell count of 20,000/ milliliter. X ray of thoraco-lumbar spine revealed D11 and D12 collapse along with narrowing of the intervening disc. Psoas shadows were not well outlined, especially on the right side. MR imaging of spine was done using 1.5T GE machine both before and after contrast administration. Study revealed collapse of D11 and D 12 with narrowing of intervening disc space. Paravertebral swelling with epidural extension, which appeared isointense on T1 and heterogeneously hyperintense on T2 was seen. The swelling showed heterogeneous post gadolinium enhancement, a feature suggestive of inflammatory swelling or abscess. Extension of inflammation into the right psoas was also noted. Compression over the cord by the epidural abscess was also noted at that level. MR features are suggestive of tuberculous infection of thoracic spine.
Surgical intervention was a must in this case and evacuation of the collection was done followed by anti-tubercular therapy.
Pott's disease is named after a surgeon from London, Percival Pott (1714-1788). Pott's disease is tuberculosis of the spine .The commonest area affected are T10 to L1.The lower thoracic region is the most common area of involvement at 40 to 50% followed closely by lumbar spine at 35 to 45%.The cervical spine accounts for about 10%.
The source of infection is usually from the lungs via the blood. There is a combination of osteomyelitis and infective arthritis. Usually more than one vertebra is involved. The area most affected is the anterior part of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to the adjacent intervertebral discs. In adults, disc disease is secondary to the spread of infection from the vertebral body but in children it can be a primary site, as the disc is vascular in children. The infection spreads from two adjacent vertebrae into the adjoining disc space. If only one vertebra is affected, the disc is normal, but if two are involved the disc between them collapses as it is avascular and cannot receive nutrients. Caseation occurs with vertebral narrowing and eventually damage the cord or the conus.
Pott's disease is rare in developed countries. Over 90% of tuberculosis occurs in poorer countries, but recently there has been a marked increase in the number of cases in developed countries with the spread of HIV.
Risk factors include poor socio-economic conditions, HIV infection, alcoholics, undernourished, post-gastrectomy patients and the elderly.
Presentation is usually nonspecific, gradual and can present as back pain, fever, night sweats, anorexia and weight loss etc .Signs may include kyphosis (common) and/or a paravertebral swelling. If there is neural involvement there will be neurological signs. A psoas abscess may present as a lump in the groin or resemble a hernia.
Differential diagnosis includes pyogenic osteitis of the spine and spinal tumours.
Routine blood investigations revealed elevated ESR and total WBC counts. Mantoux skin test shows strong positivity. Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space. MRI can depict the lesion much better and is the modality of choice. Scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy.
Surgical evacuation of paravertebral and epidural abscess and follow up with tuberculostatics is the treatment of choice.
Complications include progressive bone destruction with vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses; can lead to spinal cord compression and neurological signs (Pott's paralysis).
Preventive measures include BCG vaccination, improvement of socio-economic conditions and prevention of HIV and AIDS. Prognosis is better if diagnosed and treated early.
Tuberculosis of thoracic spine
Based on the provided spinal MRI images, the following key features can be observed:
1. In certain lumbar and lower thoracic vertebral bodies (possibly involving T12-L1), abnormal signals are noted. On T1-weighted images, they appear as low signal intensity, while on T2-weighted and fat-suppression sequences, they present high signal intensity, suggesting the presence of inflammatory or infectious infiltration.
2. The adjacent intervertebral disc spaces are narrowed, with marked destruction at the anterior vertebral margins and partial collapse in some areas, indicating possible combined disc and vertebral infection.
3. Significant soft tissue swelling or abscess is visible around the vertebrae, especially in the anterior or paravertebral regions (such as the psoas muscle area). The T2 signal appears high and T1 signal low, with an irregular shape, suggesting the presence of a paravertebral or intraspinal abscess.
4. No obvious acute compression fracture morphology is observed, but the bone continuity in the infected area may appear locally defective or destroyed.
Considering the patient’s age (23 years), the 7–8-month history of chronic low back pain, significantly elevated ESR, a strongly positive Mantoux test, and the imaging features of multiple vertebral destructions, narrowing of adjacent disc spaces, and a clearly visible paravertebral abscess, the most likely diagnosis is: Spinal Tuberculosis (Pott’s Disease).
Once the acute infection is under control and pain and inflammatory markers have significantly improved, phased rehabilitation training should begin to gradually restore spinal function and prevent muscle atrophy or joint stiffness. Any exercise program should be tailored to the individual and follow the FITT-VP (Frequency, Intensity, Time, Type, Volume & Progression) principles.
During exercise, be alert for any new onset of pain, lower extremity numbness, or other neurological symptoms. If these occur, reduce the intensity or discontinue activity and consult with a physician or rehabilitation specialist.
Disclaimer: This report is intended for reference only based on the provided information and does not replace an in-person consultation or professional medical advice. The specific diagnosis and treatment plan should be determined by qualified medical professionals after a comprehensive evaluation of the patient’s condition.
Tuberculosis of thoracic spine
