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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 8  |  Page : 200-205

A Comparative Study of Diagnosis and Treatment of Pott's Spine Amongst Specialists and Super Specialists in India


Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India

Date of Submission16-Jun-2020
Date of Decision15-Sep-2020
Date of Acceptance27-Nov-2021
Date of Web Publication11-Nov-2022

Correspondence Address:
Usha K Misra
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh - 226 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.360937

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 » Abstract 


Background and Objective: There is a paucity of guidelines about the diagnosis and management of Pott's spine. In this study, we report the pattern of practice of diagnosis and treatment of Pott's spine among the specialists and super-specialists in India.
Subject and Methods: Response to a 22-item questionnaire regarding the diagnosis and treatment of Pott's spine has been reported. The responses were compared between medical and surgical specialists, residents and consultants, and specialists and super-specialists. There were 84 responders: 42 physicians and 42 surgeons; 48 residents and 36 faculty or consultants; 53 specialists and 31 super-specialists.
Results: Thirty-eight responders rarely recommended biopsy whereas others recommended biopsy more frequently, especially the surgeons (P < 0.007). Twenty-five responders recommended immobilization even in an asymptomatic patient whereas 38 would immobilize those with neurological involvement only. All but 4 responders would repeat imaging at different time points. The response of medical treatment was judged at 1 month by 53, and 3 months by 26 responders. Surgery was recommended in a minority of patients—in those with neurological involvement or abscess. Surgeons more frequently biopsied, immobilized the patients, and recommended surgery compared to the physicians. The residents also recommended biopsy and recommended immobilization more frequently compared to consultants or faculty members. Super-specialists more frequently recommended biopsy compared to specialists.
Conclusion: There is marked variation in investigations and treatment of Pott's spine patients, suggesting the need for consensus or evidence-based guidelines.


Keywords: Immobilization, paraplegia, Pott's spine, spinal tuberculosis, surgery, treatment
Key Message: There is variability about the decision of biopsy, immobilization and surgery amongst residents and faculties. Surgeons and residents were more proponent for biopsy and immobilization, and surgeons also preferred surgery compared to physician. A consensus guideline is needed for treatment decision of Pott's spine.


How to cite this article:
Warrier S, Chaudhary SK, Kalita J, Tripathi A, Misra UK. A Comparative Study of Diagnosis and Treatment of Pott's Spine Amongst Specialists and Super Specialists in India. Neurol India 2022;70, Suppl S2:200-5

How to cite this URL:
Warrier S, Chaudhary SK, Kalita J, Tripathi A, Misra UK. A Comparative Study of Diagnosis and Treatment of Pott's Spine Amongst Specialists and Super Specialists in India. Neurol India [serial online] 2022 [cited 2022 Dec 3];70, Suppl S2:200-5. Available from: https://www.neurologyindia.com/text.asp?2022/70/8/200/360937




Approximately 10% extrapulmonary tuberculosis affects the bones and joints, of which spinal tuberculosis is the commonest.[1] There is a paucity of epidemiological studies on spinal tuberculosis. A study from the United Kingdom reported that 61 out of 729 patients with tuberculosis had skeletal tuberculosis and half of them had spinal tuberculosis. The majority of these patients were Indian migrants.[2] There is a paucity of guidelines about the diagnosis and management of spinal tuberculosis compared to TB meningitis.[3],[4],[5] There is variability in the recommendation of medical treatment ranging from 6 months,[6],[7] 9 months,[7] and 12 months in children.[7],[8] Many experts recommend the treatment of Pott's spine for 12–24 months or till the radiological evidence of regression is seen.[9],[10],[11],[12],[24] In spinal TB, the role of corticosteroids is not proven but these are recommended in arachnoiditis or non-osseous tuberculosis.[13],[14],[25],[26] However, corticosteroids are often prescribed to patients with Pott's spine. Moreover, there is no clear guideline regarding the duration of therapeutic trial before surgery is considered. The extent and vigor of investigations may also vary because of the availability of imaging, microbiological and molecular diagnostic facilities, and the cost of these investigations. The extent and duration of immobilization of the spine and duration of rest are also not well established. Neither all the patients with spinal tuberculosis require surgery nor can they all be managed conservatively. A middle path regime has been proposed for the management of Pott's spine.[15],[27],[28] In the absence of evidence-based guidelines, the patients may be investigated and treated depending on the opinion and experience of the treating doctor. There is no report on the prevalent practice of diagnosis and treatment of Pott's spine in India. The knowledge and practice patterns emerging from teaching hospitals and variation among the doctors of teaching hospitals may be an indicator of variation of practice in the community. Understanding of pattern of practice in different regions may help in planning resource allocation and defining educational and research needs in Pott's spine. The present study has been undertaken to evaluate the prevalent practices in the diagnosis and treatment of Pott's spine among specialists and super specialists in India.


 » Methods and Materials Top


This is a questionnaire-based study including specialists (MD, MS) or super-specialists (MCh, DM) from 20 institutions who practiced in teaching or tertiary care hospitals in North India (Uttar Pradesh SGPGI, KGMU BRD Medical college Gorakhpur, New Delhi Spinal cord injury center Delhi), West India (KEM hospital, Bombay, BJ hospital Pune, Surat Medical college, Gujarat), or South India (Sri Chitra Tirunal Institute Trivandrum, NIMHANS Bangalore, Karnataka).

Specialist was defined as one who after 5 years of medical training had undergone 3 years of specialized training and passed the examination of MD medicine, MD pediatrics, MS general surgery, or MS orthopedic surgery. Super-specialist was defined as one who had acquired or was undergoing further 3-year training in Neurology or Neurosurgery after obtaining abovementioned MD or MS degrees.

The questionnaire comprised 25 items [Appendix 1]: 1–7 items were on the training and experience of the participant, including the number of cases of Pott's spine seen in a month. The next section 8–19 was on the details of spinal tuberculosis: type of specialist or super-specialist managing spinal tuberculosis, requirement of biopsy, policy of empirical treatment, indications of surgery, details of immobilization of spine (indication, timing, and duration), duration of anti-tubercular regimen, its composition, duration of conservative treatment before considering surgery, and role of corticosteroids. The next section (questions 20–25) focused on the need and timing of repeat imaging, the decision to allow mobilization, and the decision to stop anti-tubercular treatment. In total, 123 physicians or surgeons were selected from different regions of the country and they were posted the questionnaire. If there was no response in 10 days, it was followed by a telephone call. Some of the responses were also collected during various national and international conferences. The responses were compared between various groups of responders.

Statistical analysis

The categorical data were presented as median and range, and the continuous variables as mean and SD. The comparisons were made using Fisher Exact, Chi-square, or Mann–Whitney u test for categorical data and Students t test for continuous variables. The statistical analysis was done using SPSS version 20 software and a two-tailed P value < 0.05 was considered significant.


 » Results Top


Characteristics of the responders: Eighty-four responded whose median age was 32 (range: 26–60) years, and 76 (90%) were males and only 5 children below 15 years of age. The responses were from North, West, and South India; there was no response from East India [Figure 1]. There was variation in the specialist treating Pott's spine; in north India, mainly the neurologist and neurosurgeon (66%), in West Orthopedics surgeon (67%), and in South, it was evenly distributed between neurologist, neurosurgeon, and orthopedic surgeon managing Pott's spine patients [Figure 2]. The number of patients seen per month was quite variable: less than 1 in 21, 1–4 in 46, 5–19 by 10, 11–15 by 4, and 16–20 by 1. Many specialists managed spinal TB and included orthopedic surgeons, neurosurgeons, neurologists, general physicians, pediatricians, and general surgeons. An equal number of physicians and surgeons (42 each), and 48 residents and 36 faculty members or consultants participated in this study.
Figure 1: The distribution of responders from different regions of India

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Figure 2: The relative frequency of specialists and super-specialists treating Pott's spine in different regions

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Responses: The diagnosis of Pott's spine was generally made on clinical examination and imaging findings; however, there was great variation in the need for pathological and or microbiological confirmation. Biopsy was rarely recommended (<10%) by 28 (33%) responders whereas 23 (27%) responders commonly depended on biopsy confirmation (>50% cases). Demand for biopsy was more common amongst surgeons than physicians (40% vs. 14%; P = 0.007). Ultrasonography or CT-guided biopsy was considered in less than 10% cases by 28 and in 11%–30% cases by 19 and 31%–75% by 33 responders and more than 75% by 4 responders [Table 1]. Repeat MRI was required by most (78 subjects) and only 4 responders did not consider repeating MRI. Spinal MRI was to be repeated after 3 months by 7 responders, 6 months by 33 responders, on worsening of the clinical picture by 25, and at the end of treatment by 7 responders. Ten responders would repeat MRI both on worsening and at the end of treatment.
Table 1: Comparison of frequency of biopsy in the diagnosis of Pott's spine by different groups of participants

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Management details: Twenty-five responders would immobilize even an asymptomatic patient whereas 38 would recommend immobilization if there were neurological signs and 2 responders would immobilize if there was subluxation and 4 if there was a cold abscess. Six responders would immobilize if both abscess and subluxation were present and 8 would immobilize if there was pain. The duration of immobilization was variable and r was 1 month (9), 3 months (25), 6 months (5) till neurological deficit persist (11), and till radiological clearance (9). There was variation in the method of immobilization, which included brace by 29, corset by 19, and bed rest by 37 subjects. Comparing the indication for immobilization between medical and surgical specialists, surgeons more frequently immobilized even asymptomatic patients (21% vs. 42%; P = 0.02).

The medical treatment (RHZE) for 9–12 months was recommended by all responders. The duration of the therapeutic trial for deciding the response of treatment was variable and was 1 month by 54 responders, 3 months by 26 responders, 6 months by 1, and 1 year by 2 responders. Corticosteroid was prescribed by 40 and not by 44 subjects, with no significant difference among medical (23/42) and surgical specialists (17/42) [P = 0.19].

Second-line anti-tubercular drugs were considered in less than 10% by 46 responders, in 10%–30% by 28, 31%–50% by 7, and more than 50% by 3 responders. Most of the responders (82) felt that four-drug anti-tubercular treatment should precede surgery by the majority, but surgery was considered the initial treatment by 2 responders.

Thirty-six responders had the opinion that surgery was needed in a minority of patients (<10% cases); 30 responders felt that surgery was needed in 10%–30% patients, in 31%–50% by 15 responders, and in more than 50% by 3 responders. The commonest indication of surgery was neurological deficit by 20, abscess by 3, subluxation by 16, bladder involvement by 10, and any combination of the above indications by 33 responders.

The majority of medical respondents (22/42, 52.4%) believed surgery was rarely needed, 15 (35.7%) believed it was needed occasionally (in 10%–30% cases), and 5 responders (11.9%) regarded surgery as standard treatment.

Analysis: Comparison of pattern of practice in Pott's spine in physicians and surgeons revealed that surgeons more frequently recommended biopsy (P = 0.007), more frequently immobilized the spine (P = 0.02), and more commonly recommended surgery (P = 0.02). However, corticosteroid usage was not different in physicians and surgeons [Table 2].
Table 2: Comparison of management of Pott's spine by medical physicians and surgeons

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Comparison of responses between residents and consultants revealed that residents were insignificantly more likely to recommend biopsy than consultants (75% vs. 55.6%, P = 0.06) and there was no difference in the use of corticosteroids (50% vs. 44%), immobilization of spine (33.3% each), indication for surgery (16.5% vs. 27.7%), and duration of immobilization (41.6% vs. 36.8%) [Table 3]. The comparison of biopsy policy (P = 0.43), steroid use (P = 0.41), immobilizing (P = 0.60), and recommendation for surgery (P = 0.43) were not different in those below and above 40 years of age.
Table 3: Comparison of management of Pott's spine by residents and consultants

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Comparing responses of super-specialists and specialists revealed that super-specialists more frequently recommended biopsy (P = 0.001) but immobilization, need of surgery, and use of second-line drugs were not significantly different [Table 4].
Table 4: Comparison of management of Pott's spine by specialists and super-specialists

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 » Discussion Top


There was marked variation in the investigations and management of Pott's spine in different regions in India. In West India, the patients were generally treated by orthopedic surgeons; in North, by neurologists and neurosurgeons; and in South India, by neurologists, neurosurgeons, and orthopedic surgeons. Most responders relied on clinical pictures and imaging characteristics and the majority managed patients without biopsy. Many of the responders would recommend immobilization even in an asymptomatic patient (25), whereas others would immobilize those with neurological involvement (30). Most responders wanted to repeat the imaging at 1–3 months and surgery was considered to be needed in a minority of patients, especially those with neurological involvement, subluxation, or abscess.[35] Subgroup analysis of responders revealed that surgeons wanted biopsy confirmation, wanted more frequent immobilization, and recommended surgery more frequently than physicians. Resident and consultants did not reveal significant differences and super-specialists recommended biopsy more frequently. This is the first study documenting the practice pattern in the diagnosis and management of Pott's spine in India. There is a paucity of trials on different aspects of management, and the available trials mainly focus on the comparison of medical versus. surgical treatment. The guidelines regarding the management Pott's spine are based on category 1 anti-tubercular treatment, which includes two months of intensive therapy (HRZE) followed by a continuation phase (HR) of 4 months.[6] Because of the risk of disability and deformity, the WHO recommends 9 months of treatment,[6] the American Thoracic Society recommends 6 months in adults and 12 months in children,[7] and the British Thoracic Society recommends 6 months of treatment.[16] Although six months of ATT is considered adequate but 18–24 months of treatment is given till the pathological and or radiological evidence of TB persists.[9],[10],[12]

The majority of patients with Pott's spine, including those with cord compression, respond to medical treatment, and the recovery of symptoms occurs in the reverse order as these appeared, that is, bladder dysfunction weakness and pain (unpublished observations). After starting anti-tubercular treatment, there may be transient worsening (paradoxical response) due to the release of tubercular protein following anti-tuberculosis treatment. There is no report of paradoxical response in Pott's spine; however, in intracranial tuberculoma paradoxical worsening, new or enlargement of tuberculoma in 22/34 (65.7%) and only half of these patients are symptomatic.[17],[29],[30],[31],[32]

Patients with Pott's spine have limited mobility because of pain and weakness. However, the majority of responders, especially the surgeons and residents, would immobilize and recommend rest even to the asymptomatic patients with Pott's spine. If there is a neurological disability, pain, significant radiological damage, or instability, rest and immobilization are recommended; however, the majority of patients are treated with ambulatory care without prolonged recumbence. Rest, cast, and brace were the classic form of immobilization but have not been found to be useful and are generally not recommended,[18] although 28 responders were willing to immobilize even the asymptomatic patients which may be because of the paucity of evidence-based recommendation or an over-cautious approach. Prolonged immobilization and bed rest has multiple problems such as pressure sore, pneumonia, pulmonary embolism, bone loss, and deconditioning. Immobilization in Pott's spine is recommended in special cases such as instability and atlantoaxial tuberculosis severe bone loss, which are generally associated with pain and weakness and preclude ambulation.

In our study, corticosteroids were recommended by both physicians and surgeons. There is no definite evidence favoring the use of corticosteroids except arachnoiditis and non-osseous tuberculosis.[14],[18],[33],[34] However, in impending cord compression, high CSF protein and acute paraplegia corticosteroids are prescribed.[19] In TBM, corticosteroids have been proven to result in favorable outcome in randomized controlled trials[4] and Cochrane review.[20]

The majority of responders felt that less than 10% of Pott's spine patients need surgery (42.8%); however, a higher proportion of surgeons (39.9%) and faculty members (27.7%) recommended surgery, which may be due to a referral bias—more advance cases reaching the surgeons and consultants or faculty members. The difference between medical and surgical specialists in the perceived need for surgery was statistically significant (P = 0.03). This may be due to greater willingness among physicians to attempt conservative management. It has been reported that 40% of Pott's paraplegia respond to respond to ATT. A middle path recommended by Tuli et al.[15] suggested that conservative treatment with ATT and surgery being reserved for specific indications In MRC trial, ATT was effective, and as per the Cochrane database, there was not sufficient evidence to recommend routine use of surgery in Pott's spine.[21] Myelopathy with or without functional impairment most often responds to medical treatment;[22] medical treatment was also found to be effective in a Korean trial.[23]

The diversity in the practice of diagnosis and treatment in the present study. Can be attributed to the difference in infrastructure, economic conditions, and training availability of experts. In South and West of India, Pott's spine patients are commonly managed by orthopedics whereas in North India, they are managed by neurologists and neurosurgeons, which may account for the differing practice. Tuberculosis is more common in poor socioeconomic groups and hence has the limitation of resources influences treatment decisions.

This study has several limitations such as a small sample size, but we focused on specialists super specialists and have not included the primary doctors to whom these patients approach first. However, the opinions and practice are determined by the specialist or super-specialist. We had no representations of East India, which may be due to fewer neurologists and neurosurgeons in this region and paucity of contacts The responses from different regions of India were also variable and the results should be considered with these limitations. However, this study provides information about the spectrum of diagnosis and treatment of Pott's spine in India.

Acknowledgements

We thank Mr. Shakti Kumar for his secretarial help.

Ethical approval

This study was approved by Institutional Ethics Committee, SGPGIMS, Lucknow INDIA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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