CASE 2889 Published on 19.04.2007

Pott's disease of upper thoracic spine

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

Syed T, Macnamara M

Patient

37 years, female

Categories
No Area of Interest ; Imaging Technique CT, MR, MR, MR, MR, MR, MR, MR
Clinical History
A 37-year-old patient presented with bilateral leg weakness with no sensory level. The patient previously had back pain in the lumbar region that had shifted to the inter-scapular thoracic region over the last four months.
Imaging Findings
The patient presented with bilateral leg weakness with no sensory level. She previously had back pain in the lumbar region that shifted to the inter-scapular thoracic region over the last four months. An MRI was performed that showed T1/2 vertebral collapse with pre-vertebral abscess (as shown in Figs. 1,2,3,4,5,6,7 & 8). She underwent CT guided aspiration, which yielded smear positive fully sensitive mycobacterium tuberculosis. She was started on anti-tuberculosis therapy. An open drainage of the abscess was performed. She had made full recovery with anti-tuberculosis treatment.
Discussion
The spine is the most common site of skeletal tuberculosis (1% of TB patients and > 25% of patients with skeletal TB). It is more predominant among males. The risk factors for the disease include older debilitated patients, IV drug abusers (pseudomonas) and immune-compromised patients including those suffering from AIDS. The concomitant risk of having pulmonary lesion is about 50% which changes the mortality rate by up to 30%. The disease is mostly blood-borne, which settles in the anterior part of the vertebral body. The lower thoracic spines are the most commonly affected. The development of the disease involves bone destruction, sequestrum formation, large abscess and pus. The intervertebral discs are preserved until late in the disease. An anterior vertebral body collapse causes sharp kyphosis. The progression of kyphosis leads to an increased risk of cord compression, a condition called Pott’s paraplegia. Clinically, the disease has an insidious course, with fever, night sweats, anorexia, weight loss, and back pain with tenderness, developing over a period of 1–3 months. The incidence of neurological deficit may be as high as 40%, which suggests an epidural extension of the abscess. Radiology plays an invaluable role in the diagnosis and management of this disease. X-rays of the entire spine should be taken ( to detect skip lesions). The earliest sign is local osteoporosis of two adjacent vertebrae, which later collapse into each other. The paraspinal soft tissue shadows help in the diagnosis of paravertebral abscesses. Bone scans give a high false negative rate. An MRI is the gold standard which accurately describes the involved spine, the site and size of the abscesses, and assesses the extent of cord compression. Antituberculous drugs are the basis of the treatment (not surgery). A spinal orthosis can be used to prevent deformity. The indications for surgery are a large abscess, neurology, instability, unresponsiveness to medical therapy and in patients younger than 15 years, kyphosis greater than 30º(high risk of progression of kyphosis).
Differential Diagnosis List
Pott's disease of upper thoracic spine due to TB.
Final Diagnosis
Pott's disease of upper thoracic spine due to TB.
Case information
URL: https://eurorad.org/case/2889
DOI: 10.1594/EURORAD/CASE.2889
ISSN: 1563-4086