Spinal tuberculosis, also known as Pott’s disease, is an infection of the spine by the bacterium that causes TB. It is the most common form of TB affecting bones and joints. In South Africa, where TB and HIV are common, it is an important and treatable cause of back pain, spinal deformity and paralysis.
At a glance
- About half of all TB affecting bones involves the spine, most often the thoracic and upper lumbar regions.
- It develops slowly over weeks to months, often without high fever.
- It is usually cured with 9 to 12 months of TB medication.
- Surgery is needed for paralysis that does not improve, severe or progressive deformity, instability, or large abscesses.
How TB affects the spine
TB bacteria spread through the bloodstream, usually from the lungs, and settle in the front part of the vertebral bodies. The infection slowly destroys bone and spreads beneath the ligaments to neighbouring vertebrae. As the front of the spine collapses, a sharp forward angulation called a gibbus develops. Pus can collect in a “cold” abscess (cold because it causes little redness or heat), which may track along the muscles to the groin or chest wall.
Symptoms
- Persistent back pain, often present for weeks or months.
- Night sweats, weight loss, loss of appetite, tiredness and low-grade fever.
- A visible hump or angulation of the spine.
- A swelling in the groin, flank or back from a cold abscess.
- Leg weakness, stiffness, numbness or difficulty walking, and bladder problems, if the spinal cord is compressed (Pott’s paraplegia).
- Cough or other symptoms of TB elsewhere in the body may or may not be present.
Risk factors
- Living in or coming from an area with high rates of TB, including South Africa.
- HIV infection.
- Close contact with someone who has active TB.
- Diabetes, malnutrition, kidney disease and immune-suppressing medication.
- Overcrowded living conditions.
- Children and young adults are commonly affected, which makes early treatment important to prevent lifelong deformity.
How is it diagnosed?
- MRI shows the extent of bone destruction, abscesses and any spinal cord compression. TB typically involves several vertebrae with relative preservation of the discs in early disease, and large abscesses beneath the ligaments.
- Biopsy: a CT-guided or surgical biopsy is sent for GeneXpert (rapid DNA testing that also detects drug resistance), culture and histology.
- Chest X-ray, HIV test and blood tests.
Non-surgical treatment
- Anti-TB medication: a combination of four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) for the first 2 months, followed by two drugs to complete 9 to 12 months. Drug-resistant TB requires specialised regimens.
- Taking every dose is essential to cure the infection and prevent resistance.
- HIV treatment where relevant, with careful coordination of medication.
- Bracing to support the spine and reduce pain while healing.
- Nutrition and rehabilitation.
What the evidence says: Medication cures most patients
The British Medical Research Council conducted a series of landmark trials on spinal TB in Korea, Hong Kong, India and Rhodesia (now Zimbabwe). These showed that ambulatory treatment with modern anti-TB drugs cures the large majority of patients without surgery, and that bed rest and plaster casts are unnecessary. In the Hong Kong trials, radical surgery combined with medication reduced the progression of kyphosis.
Surgical options
Surgery is recommended for:
- paralysis or weakness that does not improve, or worsens, on medication;
- severe kyphosis, or a spine at risk of progressive collapse, especially in children;
- instability;
- large abscesses that do not respond to medication;
- an uncertain diagnosis requiring tissue.
Minimally invasive drainage and biopsy
Abscesses can sometimes be drained with a needle under CT guidance or through small endoscopic incisions.
Decompression and debridement
Infected bone and abscess are removed to relieve pressure on the spinal cord. This can be done from the front (through the chest or abdomen) or the back.
Fusion and deformity correction
The spine is stabilised with screws and rods, and the defect left by destroyed bone is reconstructed with a bone graft or cage. In established, severe deformity, more complex osteotomies may be needed to straighten the spine and relieve pressure on the cord.
Spinal TB can also be managed with anterior-only surgery. Here the destroyed vertebrae are removed from the front and the spine is reconstructed with a structural allograft shaft (a strut of donor bone) held with screws and a rod.
What the evidence says: Predicting deformity
Studies of children with spinal TB (Rajasekaran, JBJS Br 2001) identified radiological “spine-at-risk” signs that predict progressive kyphosis after healing. Recognising these early allows surgery before a severe deformity develops.
Outlook
With early diagnosis and a full course of treatment, spinal TB is curable, and most patients with weakness recover function. Late diagnosis can result in permanent deformity and paralysis, which is why persistent back pain with weight loss or night sweats should always be investigated, particularly in South Africa.
Talk to Prof Kruger
If you are living with this condition and would like an opinion on your options, you are welcome to book a consultation. Please bring any recent scans and reports.
References and key studies
- Medical Research Council Working Party on Tuberculosis of the Spine. A 15-year assessment of controlled trials of the management of tuberculosis of the spine in Korea and Hong Kong. J Bone Joint Surg Br. 1998;80(3):456–462.
- Rajasekaran S. The natural history of post-tubercular kyphosis in children: radiological signs which predict late increase in deformity. J Bone Joint Surg Br. 2001;83(7):954–962.
- Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010;92(7):905–913.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 4: treatment. Geneva: WHO; 2022.
- Dunn RN, Ben Husien M. Spinal tuberculosis: review of current management. Bone Joint J. 2018;100-B(4):425–431.
This page is general patient education based on published research and is not a substitute for a personal consultation. Treatment is always tailored to the individual.