Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Skeletal tuberculosis

Malcolm McDonald, PhD, FRACP, FRCPA
Daniel J Sexton, MD
Section Editor
C Fordham von Reyn, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints. It is an ancient disease; features of spinal TB have been identified in Egyptian mummies dating back to 9000 years ago [1,2], and analysis of 483 pre-Columbian skeletons in Chile showed lesions consistent with bony tuberculosis in 2 percent of cases [3]. Subsequently, molecular studies have established the presence of Mycobacterium tuberculosis complex DNA in ancient bony specimens [2,4].

Clinical issues related to skeletal TB will be reviewed here. Other aspects of TB are discussed separately. (See related topics.)


Skeletal tuberculosis (TB) accounts for 10 to 35 percent of cases of extrapulmonary tuberculosis (10.8 percent of United States extrapulmonary cases in 2013) and, overall, 2.3 percent of all United States TB cases reported in 2013 [5-9]. Reported rates of extrapulmonary TB are higher among immigrants from endemic areas to developed countries; this may be due in part to immigration screening procedures for pulmonary TB [10]. One retrospective review of skeletal TB between 1980 and 1994 in France noted 103 cases of spinal TB; 68 percent of patients were foreign born, the majority from Africa [11]. The proportion of skeletal TB among HIV-infected individuals is comparable with the proportion of skeletal TB among HIV-uninfected individuals [12,13].

The most common form of skeletal TB is Pott’s disease, a disease of the spine; this entity comprises approximately half of musculoskeletal TB cases. The next most common form of musculoskeletal TB is tuberculous arthritis, followed in frequency by extraspinal tuberculous osteomyelitis [14].


During primary M. tuberculosis infection, bacillemia may lead to seeding of organisms in bone and/or synovial tissue. In most cases, small foci of infection are confined by local adaptive immune processes, and infection is subclinical. Following primary infection, reactivating foci may be contained by the cellular immune response. CD4 and CD8 lymphocytes play important roles, as does interferon-gamma [15]. Reactivation of infection with progression to clinically apparent disease may occur when local immune defenses fail, as in the setting of malnutrition, advancing age, HIV infection, or renal failure [16].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 14, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Daniel TM, Bates JH, Downes KA. History of tuberculosis. In: Tuberculosis: Pathogenesis, Protection, and Control, Bloom BR (Ed), American Society for Microbiology, Washington 1994. p.13.
  2. Hershkovitz I, Donoghue HD, Minnikin DE, et al. Detection and molecular characterization of 9,000-year-old Mycobacterium tuberculosis from a Neolithic settlement in the Eastern Mediterranean. PLoS One 2008; 3:e3426.
  3. Arriaza BT, Salo W, Aufderheide AC, Holcomb TA. Pre-Columbian tuberculosis in northern Chile: molecular and skeletal evidence. Am J Phys Anthropol 1995; 98:37.
  4. Donoghue HD, Lee OY, Minnikin DE, et al. Tuberculosis in Dr Granville's mummy: a molecular re-examination of the earliest known Egyptian mummy to be scientifically examined and given a medical diagnosis. Proc Biol Sci 2010; 277:51.
  5. Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am 1996; 78:288.
  6. Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004; 120:316.
  7. Teo HE, Peh WC. Skeletal tuberculosis in children. Pediatr Radiol 2004; 34:853.
  8. Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999; 160:1597.
  9. Peto HM, Pratt RH, Harrington TA, et al. Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006. Clin Infect Dis 2009; 49:1350.
  10. Johansen IS, Nielsen SL, Hove M, et al. Characteristics and Clinical Outcome of Bone and Joint Tuberculosis From 1994 to 2011: A Retrospective Register-based Study in Denmark. Clin Infect Dis 2015; 61:554.
  11. Pertuiset E, Beaudreuil J, Lioté F, et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994. Medicine (Baltimore) 1999; 78:309.
  12. Fuentes Ferrer M, Gutiérrez Torres L, Ayala Ramírez O, et al. Tuberculosis of the spine. A systematic review of case series. Int Orthop 2012; 36:221.
  13. Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. Eur Rev Med Pharmacol Sci 2012; 16 Suppl 2:58.
  14. Vohra R, Kang HS, Dogra S, et al. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997; 79:562.
  15. Kaufmann SH, Cole ST, Mizrahi V, et al. Mycobacterium tuberculosis and the host response. J Exp Med 2005; 201:1693.
  16. Ellner JJ. Review: the immune response in human tuberculosis--implications for tuberculosis control. J Infect Dis 1997; 176:1351.
  17. Tuli SM. Tuberculosis of the Skeletal System, Jaypee Brothers Medical Publishers, New Delhi 2016.
  18. Lenaerts A, Barry CE 3rd, Dartois V. Heterogeneity in tuberculosis pathology, microenvironments and therapeutic responses. Immunol Rev 2015; 264:288.
  19. Lifeso R. Atlanto-axial tuberculosis in adults. J Bone Joint Surg Br 1987; 69:183.
  20. Nussbaum ES, Rockswold GL, Bergman TA, et al. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg 1995; 83:243.
  21. Turgut M. Spinal tuberculosis (Pott's disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurg Rev 2001; 24:8.
  22. Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol 1984; 12:178.
  23. Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am 1985; 67:1405.
  24. Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine. Spine J 2003; 3:130.
  25. Polley P, Dunn R. Noncontiguous spinal tuberculosis: incidence and management. Eur Spine J 2009; 18:1096.
  26. Girdlestone GR, Somerville EW. Tuberculosis of Bone and Joint, 2nd ed, Oxford University Press, London 1952.
  27. Hodgson SP, Ormerod LP. Ten-year experience of bone and joint tuberculosis in Blackburn 1978-1987. J R Coll Surg Edinb 1990; 35:259.
  28. Hopewell PC. Overview of clinical tuberculosis. In: Tuberculosis: Pathogenesis, Protection and Control, Bloom BR (Ed), American Society for Microbiology Press, Washington, DC 1994. p.25.
  29. Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J 2013; 22 Suppl 4:556.
  30. Hsu LC, Leong JC. Tuberculosis of the lower cervical spine (C2 to C7). A report on 40 cases. J Bone Joint Surg Br 1984; 66:1.
  31. Kamara E, Mehta S, Brust JC, Jain AK. Effect of delayed diagnosis on severity of Pott's disease. Int Orthop 2012; 36:245.
  32. Kumar K, Saxena MB. Multifocal osteoarticular tuberculosis. Int Orthop 1988; 12:135.
  33. Kim SJ, Postigo R, Koo S, Kim JH. Total hip replacement for patients with active tuberculosis of the hip: a systematic review and pooled analysis. Bone Joint J 2013; 95-B:578.
  34. Isaacs AJ, Sturrock RD. Poncet's disease--fact or fiction? A re-appraisal of tuberculous rheumatism. Tubercle 1974; 55:135.
  35. Sood R, Wali JP, Handa R. Poncet's disease in a north Indian hospital. Trop Doct 1999; 29:33.
  36. Dall L, Long L, Stanford J. Poncet's disease: tuberculous rheumatism. Rev Infect Dis 1989; 11:105.
  37. Arora S, Prakash TV, Carey RA, Hansdak SG. Poncet's disease: unusual presentation of a common disease. Lancet 2016; 387:617.
  38. Kawsar M, D'Cruz D, Nathan M, Murphy M. Poncet's disease in a patient with AIDS. Rheumatology (Oxford) 2001; 40:346.
  39. Cuende E, Almeida V, Portu J, et al. Poncet's disease and papulonecrotic tuberculid in a patient infected with the human immunodeficiency virus. Arthritis Rheum 1998; 41:1884.
  40. Kroot EJ, Hazes JM, Colin EM, Dolhain RJ. Poncet's disease: reactive arthritis accompanying tuberculosis. Two case reports and a review of the literature. Rheumatology (Oxford) 2007; 46:484.
  41. Spinner RJ, Sexton DJ, Goldner RD, Levin LS. Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosis. J Arthroplasty 1996; 11:217.
  42. Zahraa J, Johnson D, Lim-Dunham JE, Herold BC. Unusual features of osteoarticular tuberculosis in children. J Pediatr 1996; 129:597.
  43. Rubinstien EM, Lehmann T. Sternal osteomyelitis due to Mycobacterium tuberculosis following coronary artery bypass surgery. Clin Infect Dis 1996; 23:202.
  44. Gondal GM, Mushtaq S, Masood R, et al. Mediastinal tuberculosis presenting with sternal osteomyelitis and discharging sinus. J Postgrad Med Inst 2011; 25:379.
  45. Platt MA, Ziegler K. Primary sternal osteomyelitis with bacteremia and distal seeding. J Emerg Med 2012; 43:e93.
  46. Frouge C, Miquel A, Cochan-Priollet B, et al. Breast mass due to rib tuberculosis. Eur J Radiol 1995; 19:118.
  47. Kim YT, Han KN, Kang CH, et al. Complete resection is mandatory for tubercular cold abscess of the chest wall. Ann Thorac Surg 2008; 85:273.
  48. Karanas YL, Yim KK. Mycobacterium tuberculosis infection of the hand: a case report and review of the literature. Ann Plast Surg 1998; 40:65.
  49. Hadfield PJ, Shah BK, Glover GW. Facial palsy due to tuberculosis: the value of CT. J Laryngol Otol 1995; 109:1010.
  50. Gothwal S, Varshney P, Mathur S, Songra B. Tuberculosis of the pubic symphysis. BMJ Case Rep 2014; 2014.
  51. Ormerod LP, Grundy M, Rahman MA. Multiple tuberculous bone lesions simulating metastatic disease. Tubercle 1989; 70:305.
  52. Muradali D, Gold WL, Vellend H, Becker E. Multifocal osteoarticular tuberculosis: report of four cases and review of management. Clin Infect Dis 1993; 17:204.
  53. Lynn MM, Kukanesen JR, Khan AW. Troublesome Tuberculosis: A Case Report on Multi-focal Tuberculous Osteomyelitis in An Immunocompetent Patient. J Clin Med Res 2012; 4:73.
  54. Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am 1995; 33:679.
  55. Phemister, DB, Hatcher, CH. Correlation of pathological and roentgenological findings in the diagnosis of tuberculous arthritis. Am J Roentgenol 1933; 29:736.
  56. Choi JA, Koh SH, Hong SH, et al. Rheumatoid arthritis and tuberculous arthritis: differentiating MRI features. AJR Am J Roentgenol 2009; 193:1347.
  57. Shanley DJ. Tuberculosis of the spine: imaging features. AJR Am J Roentgenol 1995; 164:659.
  58. Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of bone destruction. Clin Radiol 1993; 47:196.
  59. Kim NH, Lee HM, Suh JS. Magnetic resonance imaging for the diagnosis of tuberculous spondylitis. Spine (Phila Pa 1976) 1994; 19:2451.
  60. Desai SS. Early diagnosis of spinal tuberculosis by MRI. J Bone Joint Surg Br 1994; 76:863.
  61. Pui MH, Mitha A, Rae WI, Corr P. Diffusion-weighted magnetic resonance imaging of spinal infection and malignancy. J Neuroimaging 2005; 15:164.
  62. Jung NY, Jee WH, Ha KY, et al. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol 2004; 182:1405.
  63. Davidson PT, Horowitz I. Skeletal tuberculosis. A review with patient presentations and discussion. Am J Med 1970; 48:77.
  64. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med 2000; 161:1376.
  65. Colmenero JD, Ruiz-Mesa JD, Sanjuan-Jimenez R, et al. Establishing the diagnosis of tuberculous vertebral osteomyelitis. Eur Spine J 2013; 22 Suppl 4:579.
  66. Merino P, Candel FJ, Gestoso I, et al. Microbiological diagnosis of spinal tuberculosis. Int Orthop 2012; 36:233.
  67. Mondal A. Cytological diagnosis of vertebral tuberculosis with fine-needle aspiration biopsy. J Bone Joint Surg Am 1994; 76:181.
  68. Versfeld GA, Solomon A. A diagnostic approach to tuberculosis of bones and joints. J Bone Joint Surg Br 1982; 64:446.
  69. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2017; 64:e1.
  70. Allali F, Mahfoud-Filali S, Hajjaj-Hassouni N. Lymphocytic joint fluid in tuberculous arthritis. A review of 30 cases. Joint Bone Spine 2005; 72:319.
  71. Patwardhan SA, Joshi S. Laboratory diagnosis of spinal tuberculosis: Past and present. ArgoSpine News & Journal 2011; 23:120.
  72. Held M, Laubscher M, Mears S, et al. Diagnostic Accuracy of the Xpert MTB/RIF Assay for Extrapulmonary Tuberculosis in Children With Musculoskeletal Infections. Pediatr Infect Dis J 2016; 35:1165.
  73. Sikalengo G, Ramirez A, Faini D, et al. Tuberculous spondylitis diagnosed through Xpert MTB/RIF assay in urine: a case report. BMC Infect Dis 2016; 16:514.
  74. Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147.
  75. Blumberg HM, Leonard MK Jr, Jasmer RM. Update on the treatment of tuberculosis and latent tuberculosis infection. JAMA 2005; 293:2776.
  76. Suárez-García I, Noguerado A. Drug treatment of multidrug-resistant osteoarticular tuberculosis: a systematic literature review. Int J Infect Dis 2012; 16:e774.
  77. A controlled trial of six-month and nine-month regimens of chemotherapy in patients undergoing radical surgery for tuberculosis of the spine in Hong Kong. Tenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. Tubercle 1986; 67:243.
  78. Upadhyay SS, Saji MJ, Yau AC. Duration of antituberculosis chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis. Spine (Phila Pa 1976) 1996; 21:1898.
  79. A controlled trial of anterior spinal fusion and débridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy: a study in two centres in South Africa. Seventh Report of the Medical Research Council Working Party on tuberculosis of the spine. Tubercle 1978; 59:79.
  80. Five-year assessment of controlled trials of short-course chemotherapy regimens of 6, 9 or 18 months' duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery. Fourteenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. Int Orthop 1999; 23:73.
  81. Controlled trial of short-course regimens of chemotherapy in the ambulatory treatment of spinal tuberculosis. Results at three years of a study in Korea. Twelfth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg Br 1993; 75:240.
  82. Ramachandran S, Clifton IJ, Collyns TA, et al. The treatment of spinal tuberculosis: a retrospective study. Int J Tuberc Lung Dis 2005; 9:541.
  83. Wang Z, Shi J, Geng G, Qiu H. Ultra-short-course chemotherapy for spinal tuberculosis: five years of observation. Eur Spine J 2013; 22:274.
  84. Nene A, Bhojraj S. Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 2005; 5:79.
  85. Upadhyay SS, Sell P, Saji MJ, et al. Surgical management of spinal tuberculosis in adults. Hong Kong operation compared with debridement surgery for short and long term outcome of deformity. Clin Orthop Relat Res 1994; :173.
  86. Wang LJ, Zhang HQ, Tang MX, et al. Comparison of Three Surgical Approaches for Thoracic Spinal Tuberculosis in Adult: Minimum 5-Year Follow-Up. Spine (Phila Pa 1976) 2016.
  87. Wang ST, Ma HL, Lin CP, et al. Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults: a retrospective study. Bone Joint J 2016; 98-B:834.
  88. Alam MS, Phan K, Karim R, et al. Surgery for spinal tuberculosis: a multi-center experience of 582 cases. J Spine Surg 2015; 1:65.
  89. Oguz E, Sehirlioglu A, Altinmakas M, et al. A new classification and guide for surgical treatment of spinal tuberculosis. Int Orthop 2008; 32:127.
  90. Garg N, Vohra R. Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine. Clin Orthop Relat Res 2014; 472:1855.
  91. Jutte PC, Van Loenhout-Rooyackers JH. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Database Syst Rev 2006; :CD004532.
  92. Zhang X, Ji J, Liu B. Management of spinal tuberculosis: a systematic review and meta-analysis. J Int Med Res 2013; 41:1395.
  93. Hoffman EB, Allin J, Campbell JA, Leisegang FM. Tuberculosis of the knee. Clin Orthop Relat Res 2002; :100.
  94. Boxer DI, Pratt C, Hine AL, McNicol M. Radiological features during and following treatment of spinal tuberculosis. Br J Radiol 1992; 65:476.
  95. Kalita J, Misra UK, Mandal SK, Srivastava M. Prognosis of conservatively treated patients with Pott's paraplegia: logistic regression analysis. J Neurol Neurosurg Psychiatry 2005; 76:866.