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Year : 2010  |  Volume : 58  |  Issue : 1  |  Page : 125-127

Vertebral body hyperostosis as a presentation of Pott's disease: A report of two cases and literature review

Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Acceptance23-Oct-2009
Date of Web Publication8-Mar-2010

Correspondence Address:
Alok Umredkar
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.60426

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 » Abstract 

Vertebral body tuberculosis has numerous forms of presentations. We present two patients of Pott's disease, in whom vertebral body hyperostosis was the radiological presentation. Both the patients had massive hyperostosis of vertebral bodies leading to the obliteration of the spinal canal and neurological deficits. The first case had associated lupus vulgaris, while the second patient had milliary mottling of lungs and calcified bilateral psoas muscles. Surgical decompression, followed by full-dose chemotherapy, remains the hallmark of management of this disease.

Keywords: Pott′s disease, hyperostosis, lupus vulgaris, tuberculosis

How to cite this article:
Umredkar A, Mohindra S, Chhabra R, Gupta R. Vertebral body hyperostosis as a presentation of Pott's disease: A report of two cases and literature review. Neurol India 2010;58:125-7

How to cite this URL:
Umredkar A, Mohindra S, Chhabra R, Gupta R. Vertebral body hyperostosis as a presentation of Pott's disease: A report of two cases and literature review. Neurol India [serial online] 2010 [cited 2023 Dec 2];58:125-7. Available from:

 » Introduction Top

Tuberculosis of spine has shown resurgence in the recent past in parallel with organ transplantation, cancer chemotherapy and immunodeficiency diseases. [1],[2] Spinal tuberculosis may produce serious neurological deficits; [3],[4] cervical involvement is rare, about 0.03%. [5] Numerous patterns of vertebral body tuberculosis include fragmentary, osteolytic, subperiosteal and localized/sclerotic. [3],[6],[7] Radiological presentation like that of malignancy has also been reported. [1],[8] Magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) studies are helpful in detecting the disease early and in accurate anatomic localization. [9],[10]

 » Case Reports Top

Case 1

A nine-year-old female child, from a poor economic background, presented with gradually progressive spastic quadriparesis of three years duration. Power in upper limbs was grade 2/5, while in the lower limbs with severe spasticity. There were multiple eruptions on nose and hands, the biopsy of which revealed lupus vulgaris. Plain skiagram of cervical spine suggested a bony mass lesion involving third vertebral body. Computerized tomography (CT) scan showed a dense bony hyperostosis of vertebral body, grossly chinking the spinal canal [Figure 1]a. Gadolinium-enhanced MRI showed rim-enhancing mass, compressing the cord [Figure 1]b. There was no extraspinal collection. Fine needle aspiration cytology of the spinal lesion was unsuccessful due to its bony hard texture. With the provisional diagnosis of chordoma, the patient underwent decompression of cervical spine from anterior cervical approach and placement of an iliac bone graft. Plating was not done. Post-operatively, the spine was immobilized for three months with HALO. Histopathology revealed areas of destruction, with necrosis and calcification, consistent with tuberculosis. Culture was not done. Four-drug chemotherapy (isoniazid 5 mg/kg; rifampicine 10 mg/ kg; ethambutol 15 mg/kg and pyrizinamide 25 mg/kg ) was administered for 18 months. At the two-year follow-up, the patient was asymptomatic with no residual neurological deficit.

Case 2

A 32-year-old female presented with a history of gibbus formation at mid back for 19 years. The patient never asked for medical help, as there was no neurological deficit. Before this admissin the patient developed paraparesis and bladder hesitancy. On examination, both limbs had power grade 4/5, with a normal tone. Plain radiograph of dorso-lumbar spine showed kyphotic thoracic spine and massive calcification, spilling all around in paraspinal region [Figure 2]a, while chest radiograph revealed calcified hilar nodes. CT scan revealed hyperostosis of vertebral body [Figure 2]b. MRI showed spinal deformity and hypodense lesion, with minimal contrast enhancement occupying the entire vertebral body [Figure 2]c. After four weeks of four-drug chemotherapy administration, the bladder symptoms improved and patient could walk normally . Four-drug chemotherapy (isoniazid 5 mg/kg; rifampicine 10 mg/ kg; ethambutol 15 mg/kg and pyrizinamide 25 mg/kg) was administered for 18 months. At the two-year follow-up, the patient remained asymptomatic.

 » Discussion Top

Classical presentation of spinal tuberculosis is of four types; fragmentary, osteolytic, subperiosteal and localized/sclerotic. [1],[3] Unusual forms occur in 30% of cases, which include destruction of posterior arch, [11] isolated neural arch, [12] single vertebral body, or Pott's disease without bony involvement. [4] Other uncommon variants are centrosomatic, suboccipital, subligamentar. [13] "Sclerosis" as a presentation of Pott's spine is noted in more than half the patients, which progresses for over a year and returns to normal after two-and-a-half years of treatment. [14] Calcification within the paraspinal soft-tissue has also been reported. [15] The radiological diagnosis is important as radiographic changes are significant when final diagnosis is reached. [2] Associated extraspinal collections, identifiable on contrast MRI, are the hallmark of spinal tuberculosis, [7],[11],[13] providing a site for establishing the diagnosis. [5] British Infection Society has given specific guidelines for the diagnosis and treatment of CNS tuberculosis. [16]

Pott's disease, associated with lupus vulgaris, has been reported earlier. [17] Vertebral body hyperostosis as a presentation of Pott's disease has not been reported earlier. Differential diagnosis of such a lesion includes osteochondroma, chondromyxoid fibroma, [18] giant cell tumor, metastases especially from prostate, locally malignant osteoblastoma, [19] chordoma, chondrosarcoma and chondroblastoma. Plain X-rays and CT scan may not differentiate between inflammatory and neoplastic pathologies, but MRI may highlight contrast-enhancing rim, suggestive of tuberculosis (as in our case), while uniformly enhancing lesion is well-demonstrated in osteochondroma. Absence of paraspinal fluid collections may further make such a differentiation difficult as in both of our cases. Non-neoplastic pathologies, which need to be differentiated, are multiple hereditary exostoses, [20] Paget's disease and fibrous dysplasia.

Pathophysiology causing vertebral hyperostosis in tuberculosis in not known. It may be a form of metastatic calcification. Such a widespread calcification may be an example of metastatic calcification, but kyphosis is rarely associated. Moreover, blood vessels, kidneys, lungs and gastric mucosa are likely involved, instead of muscles and vertebral body, with deranged calcium metabolism. In the first case, cervical vertebra and in the second case, dorsal vertebra may be examples of dystrophic calcification, where the calcium salts have deposited in non-viable bony matrix of vertebral bodies which were presented as vertebral hyperostosis. The psoas muscles were like that of 'heterotopic bone,' where calcification had occurred in viable tissues.

 » Conclusion Top

Bony hyperostosis of vertebral body may be a rare presentation of Pott's disease. Tuberculosis, being a systemic disease, should always be kept among the differential diagnoses of any unusual radiographic spinal abnormality, especially when some other organ is involved. Fine needle aspiration cytology may provide the correct diagnosis. Surgical decompression, followed by full-dose chemotherapy remains the management of choice, even today.

 » References Top

1.Lindahl S, Nyman RS, Brismar J, Hugosson C, Lundstedt C. Imaging of tuberculosis IV. Spinal manifestations in 63 patients. Acta Radiol 1996;37:506-11.  Back to cited text no. 1  [PUBMED]    
2.Shanley DJ. Tuberculosis of the spine: Imaging features. AJR Am J Roentgenol 1995;164:659-64.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: Patterns of bone destruction. Clin Radiol 1993;47:196-9.  Back to cited text no. 3  [PUBMED]    
4.Naim-Ur-Rahman, Al-Arabi KM, Khan FA. Atypical forms of spinal tuberculosis. Acta Neurochir (Wien) 1987;88:26-33.  Back to cited text no. 4  [PUBMED]    
5.Wurtz R, Quader Z, Simon D, Langer B. Cervical tuberculous vertebral osteomyelitis: Case report and discussion of the literature. Clin Infect Dis 1993;16:806-8.  Back to cited text no. 5  [PUBMED]    
6.Cotten A, Flipo RM, Drouot MH, Maury F, Chastanet P, Duquesnoy B, et al. Spinal tuberculosis. Study of clinical and radiological aspects from a series of 82 cases. J Radiol 1996;77:419-26.  Back to cited text no. 6  [PUBMED]    
7.Sinan T, Al-Khawari H, Ismail M, Ben-Nakhi A, Sheikh M. Spinal Tuberculosis: CT and MRI feature. Ann Saudi Med 2004;24:437-41.  Back to cited text no. 7  [PUBMED]    
8.Abdelwahab IF, Norman A, Hermann G, Santini L, Klein MJ. Atypical radiographic appearances of tuberculous granulomas of bone. Can Assoc Radiol J 1990;41:72-5.  Back to cited text no. 8  [PUBMED]    
9.Gnanasegaran G, Barwick T, Milburn H, Vijayanathan S, Fogelman I. Tuberculosis of the spine on Tc-99m MDP bone scan: Additional role of SPECT-CT. Clin Nucl Med 2009;34:271-4.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Yusof MI, Hassan E, Rahmat N, Yunus R. Spinal tuberculosis: The association between pedicle involvement and anterior column damage and kyphotic deformity. Spine (Phila Pa 1976) 2009;34:713-7.  Back to cited text no. 10      
11.Narlawar RS, Shah JR, Pimple MK, Patkar DP, Patankar T, Castillo M. Isolated tuberculosis of posterior elements of spine: Magnetic resonance imaging findings in 33 patients. Spine 2002;27:275-81.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Lin-Greenberg A, Cholankeril J. Vertebral arch destruction in tuberculosis: CT features. J Comput Assist Tomogr 1990;14:300-2.  Back to cited text no. 12  [PUBMED]    
13.Ousehal A, Gharbi A, Zamiati W, Saidi A, Kadiri R. Imaging findings in 122 cases of Pott's disease [Article in French] Neurochirurgie 2002;48:409-18.  Back to cited text no. 13      
14.Boxer DI, Pratt C, Hine AL, McNicol M. Radiological features during and following treatment of spinal tuberculosis. Br J Radiol 1992;65:476-9.  Back to cited text no. 14  [PUBMED]    
15.Pantongrag-Brown L, Suwanwela N. CT findings in tuberculous spondylitis. Australas Radiol 1992;36:4-7.  Back to cited text no. 15  [PUBMED]    
16.Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect 2009;59:167-87.  Back to cited text no. 16      
17.Aggarwal A, Aneja S, Taluja V, Anand R. Multifocal cystic bone tuberculosis with lupus vulgaris and lymphadenitis. Indian Pediatr 1997;34:443-6.  Back to cited text no. 17  [PUBMED]    
18.Lopez-Ben R, Siegal GP, Hadley MN. Chondromyxoid fibroma of the cervical spine: Case report. Neurosurgery 2002;50:409-11.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Schneider M, Sabo D, Gerner HJ, Bernd L. Destructive osteoblastoma of the cervical spine with complete neurologic recovery. Spinal Cord 2002;40:248-52.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Tully RJ, Pickens J, Oro J, Levine C. Hereditary multiple exostoses and cervical cord compression: CT and MR studies. J Comput Assist Tomogr 1989;13:330-3.  Back to cited text no. 20  [PUBMED]    


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