Post-tubercular Kyphosis Research Articles

Global realignment after posterior vertebral column resection in severe thoracolumbar post-tubercular kyphosis: correlation with patient-reported outcomes.

To investigate spinal realignment in patients with severe post-tubercular kyphosis (PTK) who underwent posterior vertebral column resection (PVCR) and its correlation with patient-reported outcomes (PROs). Eighty-two patients were included in this study. Spinopelvic parameters (focal scoliosis (FS), coronal balance (CB), sagittal vertical axis (SVA), focal kyphosis (FK), C2-7 lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and pelvic incidence minus lumbar lordosis (PI-LL)) and PROs (Visual Analog Scale (VAS) and Oswestry Disability Index (ODI)) were analyzed. The correlation between spinopelvic parameters and PROs was evaluated. FK, FS, CL, TK, LL, and PI-LL significantly changed after surgery. FK decreased from pre-operative 108.5 ± 16.4° to 31.8 ± 4.5° at threemonths after surgery and increased to 38.7 ± 6.6° at final follow-up (P < 0.001). FS decreased from pre-operative 20.9 ± 2.2° to 5.1 ± 2.2° at final follow-up (P < 0.001). CL decreased from pre-operative 7.2 ± 7.3° to 3.3 ± 8.3° at final follow-up (P = 0.002). TK improved from pre-operative - 5.6 ± 7.1° to 12.9 ± 8.2° at final follow-up (P < 0.001). LL decreased from pre-operative 75.5 ± 12.6° to 45.5 ± 7.9° at final follow-up (P < 0.001). PI-LL improved from pre-operative - 24.8 ± 13.4° to 4.8 ± 9.9° at final follow-up (P < 0.001). The improvement of PROs was found to be significantly correlated with the variations of FK, CL, TK, LL, and PI-LL. The multiple regression analysis revealed that FK was an independent predictor for the improvement of VAS and ODI. PVCR is effective in treating severe PTK, which can significantly improve patients' clinical and radiographic outcomes. Spine surgeons should pay more attention to reducing the residual kyphosis.

Retrospective analysis of deformed complex vertebral osteotomy in children with severe thoracic post-tubercular angular kyphosis

BackgroundMany surgical options have been described to manage post-tubercular kyphosis, but the standard approach for treating severe post-tubercular angular kyphosis in children has not been established yet. The present study was performed to evaluate the safety and efficacy of deformed complex vertebral osteotomy (DCVO) for the treatment of severe thoracic post-tubercular angular kyphosis (> 70°) in children.MethodsDeformed complex vertebrae indicated that multiple deformed and fused vertebrae were usually involved with two or more vertebral bodies and the partial or total fusion of many segments' facet joints and intervertebral discs. Thus, DCVO indicated that a wider posterior wedge-shaped and three-column osteotomy was performed within deformed complex vertebrae to correct a more extensive range of angles. From 2010 to 2017, 15 children who suffered from severe thoracic post-tubercular angular kyphosis underwent DCVO. Deformed complex vertebrae involved two vertebral bodies in 9 patients and three vertebral bodies in 6 patients. The Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were assessed preoperatively and at the final follow up. This was a retrospective study analysing the outcome after grade 4/5 spinal osteotomies in deformed complex vertebrae.ResultsThe mean duration of surgery was 239 ± 37.81 min. The average period of follow-up was 31.6 ± 6.98 months. The preoperative mean kyphosis of deformed complex vertebrae was 83.39° ± 9.04°; the mean thoracic kyphosis (TK) and lumbar lordosis (LL) were 81.09° ± 8.51° and 80.51° ± 7.64°, respectively; the mean sagittal vertical axis (SVA) was 3.83 cm ± 1.43 cm. The postoperative mean kyphosis of deformed complex vertebrae was reduced to 19.98° ± 2.47° (P < 0.001) with a mean kyphosis correction of 63.41°; at the final follow up, it was 18.4° ± 2.29° (P < 0.001) without obvious loss of correction. The postoperative mean TK, LL, and SVA were reduced to 24.05° ± 3.84°, 46.9° ± 3.53°, and 0.6 cm ± 0.34 cm, respectively (P < 0.001 for all); and there was no obvious loss of sagittal alignment and balance at the final follow up (p = 0.982, p = 0.604, p = 0.754). Complicated with neural dysfunction preoperatively, 5 Frankel's grade D cases showed complete neurological recovery at final follow up. VAS score reduced from 3.6 ± 1.18 to 0.87 ± 0.64 (P < 0.001); and ODI score reduced from 22.21 ± 6.93 to 5.02 ± 2.6 (P < 0.001) at the final follow up.ConclusionsDCVO was an individualized osteotomy for treating severe thoracic post-tubercular angular kyphosis in children and could be safe and effective in reducing the incidence of complications and significantly improving kyphosis correction.

The Outcome of Pedicle Subtraction Osteotomy (PSO) For the Correction of Post-Traumatic and Post-Tubercular Kyphotic Deformity

Introduction: Pedicle subtraction osteotomy (PSO) is one of the well-established and well-known techniques for kyphosis correction. Objective: Objective of our study is to analyze the clinical and radiological outcomes of PSO in terms of VAS to access the pain relief, ODI to assess the functional outcome, and the ASIA impairment scale for preoperative and postoperative assessment of neurology. The per-operative and postoperative complications related to surgery, access radiological correction of deformity in terms of kyphosis angle, and postoperative fusion status. Method: Ten patients with dorso-lumbar kyphosis (5 post-tubercular and 5 post-traumatic) were followed up for an average of 2 years after PSO. They were assessed prospectively for clinico-radiological and functional outcomes. The neurological deficit, cosmetic deformity &amp; back pain were the major complaints among the study population. Result: For the post-tubercular kyphosis group, the mean pre-operative kyphosis angle was 67.5°±10.4° and 14.9°±6.1° postoperatively, with significant improvement (p&lt;0.001) at a mean follow-up of 24 months. The mean ODI improved from 44.1±12.4 pre-operatively to 21.1±7.1 at the latest follow-up. Pre-operative VAS was 8.9±2.5, with a significant improvement of 1.5±1 in the final follow-up. For the post-traumatic kyphosis group, the mean pre-operative kyphosis angle was 33.7°±4.5° and 3.8°±3.4° postoperatively, with a significant improvement (p&lt;0.001). Here the mean ODI improved from 37±2.5 pre-operatively to 6.0±1.9 at the latest follow-up. Pre-operative VAS was 8.4±1 with a significant improvement of 1.25±1 in the last postoperative follow-up. Fusion was achieved in all cases. Transient neurological deficit was found in 1 patient who became normal after 3 months. All patients had ASIA grade “E” at last follow-up. There were no significant intraoperative major complications in this group either, except a few minor complications. Conclusion: A greater degree of kyphotic correction (&gt;40°) can be obtained with a single pedicle subtraction osteotomy at the dorso-lumbar level with minimal neurological complications.

Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes.

To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK). The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24months. Patients in Group CK (median: 13years, range: 4-30years) presented earlier than those in Group PTK (median: 16years, range: 6-45years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group. Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up.

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy. The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded. The median age of the study population was 16years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5min and the mean operative blood loss was 701 ± 312ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9mm v/s postoperative: 5.5 ± 16.3mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient. Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Sagittal Balance, Pulmonary Function, and Spinopelvic Parameters in Severe Post-Tubercular Thoracic Kyphosis.

Study DesignCross-sectional study.PurposeTo evaluate sagittal balance, pulmonary function, and spinopelvic parameters in patients with healed spinal tuberculosis with severe thoracic kyphosis.Overview of LiteratureDeterioration of neurological function is an absolute indication of surgical intervention in severe post-tubercular kyphosis, but the relationship of compromise in lung function and spinal alignment with severity of kyphosis is still unclear.MethodsTwenty patients (age, 14–60 years) with healed spinal tuberculosis with thoracic kyphosis >50° were included. Lateral-view radiography of the whole spine, including both hips, was performed for assessment of kyphotic angle (K angle), sagittal balance, lumbar lordosis, and spinopelvic parameters. Pulmonary function was assessed by measuring the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and their ratio (FEV1/FVC) by spirometry.ResultsA positive correlation between severity of kyphosis and sagittal imbalance was noted, with compensatory mechanisms maintaining the sagittal balance in only up to 80° of dorsal kyphosis. In >80° of kyphosis, FVC was found to be markedly decreased (mean FVC=50.6%). The mean K angle was lower in subjects with lower thoracic kyphosis. In lower thoracic kyphosis, due to short lordotic and long kyphotic curves, both lumbar lordosis and pelvic retroversion worked at compensation, whereas, in middle thoracic kyphosis, due to long lordotic curve, only lumbar lordosis was required. Normal pulmonary function (mean FVC, 83.0%) and lesser kyphotic deformity (mean K angle in adolescents, 69.8°; in adults, 94.4°) were found in adolescents.ConclusionsIn >80° of thoracic kyphosis, there is sagittal imbalance and a markedly affected pulmonary function. Such patients should be offered corrective surgery if they are symptomatic and medically fit to undergo the procedure. However, whether the surgical procedure would result in improved pulmonary function and sagittal balance needs to be evaluated by a follow-up study.

Safety and Feasibility of Cervical Pedicle Screw Insertion in Pediatric Subaxial Cervical Spine Without Navigation: A Retrospective Cohort Study.

The use of cervical pedicle screws (CPSs) in pediatric subaxial cervical spine has been scarcely reported in the literature. The biomechanical superiority of CPS over other methods of fixation is beneficial in surgery for correcting severe, rigid cervical/cervicothoracic deformity. Our study aims to assess the safety, efficacy, and feasibility of CPS fixation in pediatric subaxial cervical spine without intraoperative navigation. Eight pediatric patients requiring rigid subaxial cervical spine fixation for complex cervical deformities were operated at a single center between 2014 and 2016. Their hospital records and imaging were retrospectively studied. The feasibility of inserting CPS was assessed by studying pedicle morphometry on preoperative computed tomography (CT) scans. Aberrant vertebral artery anatomy was ruled out using CT angiography. CPS were inserted into selected pedicles without navigation. Postoperative CT scans were studied to look for screw containment within pedicles. Complications were noted and clinicoradiologic follow-up was for a minimum of 36 months. Thirty-seven CPS were inserted in 8 pediatric patients with a mean age of 9.2 years (range: 5 to 13 y). Surgery was done for complex cervical deformities due to various causes-neglected cervical spine trauma (n=3), posttubercular kyphosis (n=2), cervicothoracic scoliosis (n=2), and cervicothoracic osteoblastoma (n=1). The level-wise distribution of the inserted CPS was: C3=4, C4=6, C5=10, C6=10, and C7=7. Postoperative CT scans showed grade-1 medial cortical breach in 5/37 screws and grade-2 medial cortical breach in a single screw (16%). No perioperative complications were noted. At a mean follow-up of 3.6 years (range: 3 to 4.33 y), no patient had implant failure or deformity progression. CPS insertion in pediatric subaxial cervical spine without neuronavigation is safe, feasible, and effective in carefully selected cases. Biomechanical advantages of CPS can be extended to the pediatric subaxial cervical spine. Level IV-retrospective cohort.

Apical Vertebral Column Resection with Sagittal Rotation and Controlled Anterior Opening and Posterior Closing Maneuver for the Treatment of Severe Post-Tubercular Kyphosis: Case Series and Literature Review.

Study DesignRetrospective case series.PurposeDescribe the technique and evaluate the outcome of apical vertebral column resection (VCR) with sagittal rotation and anterior opening and posterior closing (AOPC) maneuver for correction of severe post-tubercular kyphosis (PTK).Overview of LiteratureThe surgical procedures described for the correction of PTK are VCR, pedicle subtraction osteotomy, transpedicular decancellation osteotomy, and closing-opening osteotomy.MethodsWe retrospectively evaluated 21 patients who had been operated on with single stage apical VCR with AOPC maneuver. Radiographs were obtained before surgery and at regular follow-up intervals. These were used to calculate the angle of kyphosis. Back pain was rated using the Visual Analog Scale (VAS) and neurological status was graded using Frankel grading. Radiological outcome was assessed by the improvement in the angle of kyphosis and fusion following surgery. Neurological status was assessed using Frankel grading.ResultsThe study included eight males and 13 females with a mean age of 21.9 and average follow-up time of 30.4 months. The average number of vertebral bodies destroyed was 2.57. Kyphosis was improved from a mean of 68.42°±13.23° preoperative to 8.71°±4.58° postoperative. The average correction achieved was 87.10%. Preoperative VAS score improved from a mean of 6.38±0.92 preoperative to 1.38±0.49 postoperative. No patients had any sign of neurological deterioration. Seven out of eight patients with a preoperative neurological deficit improved following surgery. Two patients developed superficial wound maceration, one had persistent postoperative hypotension, and the other developed hemothorax. All patients recovered fully without a need for additional surgery.ConclusionsSingle stage simultaneous anterior column lengthening and posterior column shortening is an effective method for surgical correction of severe PTK.

Incidence and risk factors of neurological complications during posterior vertebral column resection to correct severe post-tubercular kyphosis with late-onset neurological deficits: case series and review of the literature

BackgroundSevere post-tubercular kyphosis with late-onset neurological deficits is difficult to treat, with high risk of neurological complications. This study retrospectively evaluates the efficacy and safety of posterior vertebral column resection (PVCR) for treating severe post-tubercular kyphosis with late-onset neurological deficits.MethodsFrom January 2012 to December 2015, 13 patients with severe post-tubercular kyphosis underwent PVCR. All these patients were of late-onset neurological deficits. The operative time, blood loss, preoperative and postoperative kyphotic angles, sagittal vertical axis (SVA), neurological status, and complications were recorded. The preoperative and postoperative Oswestry Disability Index (ODI) scores and visual analog scale (VAS) scores for back pain were compared. The American Spinal Injury Association (ASIA) grading system was used to evaluate neurological function.ResultsThe mean postoperative follow-up period was 28.6 months. The mean operative time was 388 ± 46 min. The mean blood loss was 2554 ± 1459 ml. The mean preoperative and postoperative kyphotic angles were 93.7 ± 14.4° and 31.7 ± 7.3°, respectively, with a mean correction of 62.0 ± 13.8°. The mean preoperative and postoperative SVA were 43.2 ± 44.4 mm and 17.8 ± 16.2 mm, respectively. The mean ODI score improved from 56.3 ± 5.1 preoperatively to 18.3 ± 18.5 at last follow-up. The mean VAS score improved from 6.4 ± 1.8 preoperatively to 1.8 ± 0.8 at last follow-up. Two cases had spinal cord injuries, including one complete paraplegia and one incomplete paraplegia, and a total neurological complication rate of 15.4%. The risk factors for neurological complications were summarized.ConclusionsSevere post-tubercular kyphosis with late-onset neurological deficits can be corrected by PVCR carefully and properly to prevent neurological complications. In many cases with stenosis adjacent to the angular kyphosis, sufficient decompression of the spinal cord at the segments with stenosis is necessary before correcting the kyphosis.

Outcome and safety analysis of 3D-printed patient-specific pedicle screw jigs for complex spinal deformities: a comparative study

Background ContextSpinal deformities are very challenging to treat and have a great risk of neurologic complications because of hardware placement during corrective surgery. Various techniques have been introduced to ensure safe and accurate placement of pedicle screws. Patient-specific screw guides with predrawn and prevalidated trajectory seem to be an attractive option. PurposeWe have focused on developing three-dimensional (3D) printing technique for complex spinal deformities in India. This study also aimed to compare the placement of pedicle screw with 3D printing and freehand technique. Study Design/SettingsThis is a retrospective comparative clinical study in an academic institutional setting. Patient SampleA total of 20 patients were enrolled during the study: 10 were operated on with the help of 3D printing (Group 1) and 10 were operated on with freehand technique (Group 2). Group 1 included six patients with congenital scoliosis, three patients with adolescent idiopathic scoliosis (AIS), and one patient with post-tubercular kyphosis, and Group 2 included five patients with congenital scoliosis, four patients with AIS, and one patient with post-tubercular kyphosis. Outcome MeasuresPrimary outcomes were measured in terms of screw violation, and secondary outcomes were measured in terms of surgical time, blood loss, radiation exposure (number of shoots required), and complications. Materials and MethodsMIMICS Base v18.0 software was used for 3D reconstruction from computed tomography scan images of all the patients. 3-Matic software was used to create a drill guide. A 3D printer from Stratasys Mojo with ABS P430 model material cartilage (a thermoplastic material) was used for the printing of the vertebra model and jigs. A two-sample test of proportion was used to compare correctly and wrongly placed pedicle screws with 3D printing and freehand technique. t Test with equal variance was used for operating surgical time and blood loss. ResultsNo superior or inferior screw violation was observed in any of our patients in either group. We found a significant difference (p=.03) between the two groups regarding perfect screw placement in favor of 3D printing. There were 13 Grade 2 medial perforations in the freehand group and 3 in the 3D printing group. There was no Grade 3 medial perforation in either group. Six Grade 2 lateral perforations in the freehand group and seven in the 3D printing group were observed. Three Grade 3 lateral perforations in the freehand group and two in 3D printing group were observed. Analysis showed a statistically significant (p=.005) medial violation in the freehand group. Surgical time was significantly less (p=.03) in the 3D printing group compared with the freehand group. Mean blood loss was higher in the freehand group but was not statistically significant (p=.3) in the 3D printing group. Fluoroscopic shots required were less in number in the 3D printing group compared with the freehand group. There was no neurologic deficit in any of the patients in the two groups. ConclusionsIn our study, focusing on spinal deformities with statistically significant higher rates of accurate screw positioning and higher numbers of inserted screws with 3D printing was possible because of enhanced safety, particularly at apical levels. As such, spinal deformities are difficult to treat worldwide. In India, these deformities are often neglected and present at a very late and a much more deformed state when their treatment becomes even more challenging. Developing these patient-specific drill templates will enable an average spine surgeon to treat these patients with much ease and safety.

Corrective spine reconstruction surgery for post-tubercular kyphosis: A case report

Corrective spine reconstruction surgery for post-tubercular kyphosis: A case report

Posterior Vertebral Column Resection With Intraoperative Manual Retraction for the Treatment of Posttubercular Kyphosis in Upper Thoracic Spine or Cervicothoracic Junction.

This is a case-series. To evaluate the clinical and radiologic outcomes of posterior vertebral column resection (PVCR) for treatment of posttubercular kyphosis in upper thoracic spine and cervicothoracic junction (CTJ). Surgical management of severe posttubercular kyphosis in upper thoracic spine or CTJ is challenging. A new technique that combines PVCR and intraoperative manual traction in a single procedure, was developed to maximize the correction rate and minimize the risk of dural buckling and spinal cord injury. However, the safety and effectiveness of the procedure is yet to be established. Ten patients with upper thoracic or CTJ posttubercular kyphosis, who underwent PVCR with intraoperative manual traction between December 2008 and 2013, were studied retrospectively. Data pertaining to operation time, blood loss, and perioperative complications were collected. Outcomes were evaluated using the visual analog scale; the 12-Item Short Form Health Survey (SF-12), Mental Component Summary, and SF-12 Physical Component Summary. Neurological status was assessed using American Spinal Injury Association (ASIA) impairment scale. Radiologic outcomes including fusion and deformity correction were assessed using plain radiography and computed tomography. The average duration of follow-up was 53.6±7.2 months. Average operating time and blood loss were 263±35.3 minutes and 2490±569 mL, respectively. Visual analog scale score for back pain, SF-12 Mental Component Summary, and Physical Component Summary showed significant improvement postoperatively. Kyphosis improved from a preoperative average of 73.6±13.1 degrees to an average of 37.9±8.7 degrees at final follow-up (correction rate: 48.5%). No postoperative neurological deterioration was observed based on the ASIA score. As of the last follow-up, solid fusion was not achieved only in 1 patient. PVCR with intraoperative manual traction is a safe and effective procedure for treatment of upper thoracic or CTJ posttubercular kyphosis. Level 4.

Utilization of ring-shaped bone allograft for surgical treatment of adolescent post-tubercular kyphosis: A retrospective study.

This study aimed to investigate the mid-term outcome of ring-shaped bone allografts in the surgical treatment of adolescent post-tubercular kyphosis secondary to spinal tuberculosis.The records of adolescent patients diagnosed with spinal tuberculosis who received treatment in our department between 2009 and 2013 were retrospectively reviewed. The anterior approach was used in cases of cervical kyphosis and the posterior approach was used in cases of thoracic and lumbar kyphosis. During the surgery, the ring-shaped bone was used as a structural bone graft associated with the cancellous bone filing in the center portion of the ring shape. Cobb's angle, signs of spinal infusion on computed tomography, and complications were followed up.A total of 25 patients were included in our study. Among them, 3 involved the cervical region, 5 involved the thoracic region, 8 involved the thoracolumbar region, and 9 involved the lumbar region. The preoperative kyphosis deformity was a mean 65° Cobb's angle (40°–97°) compared to the postoperative 14° Cobb's angle (10°–21°) for an average correction of 51°. All wounds healed well without graft rejection. All patients achieved bone fusion 3 months postoperative for a 100% fusion rate.Our results show that the ring-shaped allograft bone is an effective option for the treatment of adolescent kyphosis. The ring-shaped allograft bone demonstrated satisfactory mechanical strength and vertebral fusion without mid-term metallic toxicity.

Review article: Surgical approaches for correction of post-tubercular kyphosis.

This study reviewed the literature regarding the pros and cons of various surgical approaches (anterior, anterolateral, combined, and posterior) for correction of post-tubercular kyphosis. The anterior and anterolateral approaches are effective in improving neurological deficit but not in correcting kyphosis. The combined anterior and posterior approach and the posterior approach combined with 3-column osteotomy achieve good neurological improvement and kyphosis correction. The latter is superior when expertise and facilities are available.

Modified pedicle subtraction osteotomies (mPSO) for thoracolumbar post-tubercular kyphosis in pediatric patients: retrospective clinical cases and review of the literature.

The purpose of this study was to evaluate the clinical and radiographic outcomes of modified pedicle subtraction osteotomy (mPSO) for thoracolumbar post-tubercular kyphosis in pediatric patients. From January 2008 to August 2012, 26 consecutive pediatric patients with thoracolumbar post-tubercular kyphosis underwent modified pedicle subtraction osteotomy (mPSO). The clinical and radiologic outcomes were analyzed preoperatively, postoperatively, and at the last follow-up. Twenty-six patients with thoracolumbar post-tubercular kyphosis underwent mPSO. The average operation time was 256 min (188~314 min). The mean follow-up was 41 months (18~56 months). The mean estimated blood loss was 870 ml (620 ~ 1020 ml). The thoracolumbar kyphotic angle ranged from 51° to 79° before operation, 60.6° in average. The mean thoracolumbar kyphotic Cobb angle was 19.7° after operation, with a mean correction of 40.9°. The C7 sagittal plumb line was 3.8 cm after operation, comparing to the 10.5 cm preoperative. The mean preoperative angle of thoracic kyphosis (TK) was 9.9° ± 1.2° and increased to 11.8° ± 1.4°, postoperatively. Lumbar lordosis (LL) improved from -22.8° ± 4.9° preoperative to -17.8° ± 2.1° postoperative. Visual analogue scale (VAS) was 8.7 ± 1.1 preoperative and 1.2 ± 0.4 postoperative, respectively. The mean Oswestry Disability Index (ODI) improved from 49.2 ± 5.3 before surgery to 10.8 ± 3.3 postoperative (P < 0.01). All patients received good bone healing, no significant loss of correction angle. Most patients (24/26) considered pain and exterior was significantly improved. Modified pedicle subtraction osteotomy (mPSO) is effective and reliable for thoracolumbar post-tubercular kyphosis in pediatric patients.

Thoracolumbar spinal tuberculosis in children with severe post-tubercular kyphotic deformities treated by single-stage closing–opening wedge osteotomy: preliminary report a 4-year follow-up of 12 patients

The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multistaged with a high morbidity. In this study, we evaluated the outcomes of children who underwent single-stage closing-opening wedge osteotomy as a surgical treatment of PTK of the thoracolumbar spine. Our study group included 12 children with thoracolumbar PTK (seven boys and five girls) with an average age of 9.4 years (range 6-12 years), who were treated at our institution from January 2004 to October 2009. The American Spinal Injury Association Impairment Scale and visual analog scale score were used to classify neurologic function. All patients underwent halo-pelvic traction before surgery and were treated with single-stage closing-opening wedge osteotomy. The duration of surgery averaged 99 min (range 70-150 min). Average blood loss was 782 ml (range 560-1,200 ml), and the average length of hospital stay was 12 days (range 8-16 days). The neurological function of all patients improved significantly after the procedure. The mean preoperative kyphotic angle was 83.3° (range 59-118°), which had reduced to 27.6° (range 20-38°) at the final follow-up visit. All patients had solid fusion, and no major complications were observed through the final follow-up visit. Single-stage closing-opening wedge osteotomy is an effective method to correct severe thoracolumbar PTK. A main advantage of the procedure is that it is a posterior-only, single-staged surgery, allowing for significant correction with minimal complications.

Natural history of Pott’s kyphosis

The natural history of Pott's kyphosis is different from that of other spinal deformities. After healing of the spinal infection, the post-tubercular kyphosis in adults is static but in children variable progression of the kyphosis is seen. The changes occurring in the spine of children, after the healing of the tubercular lesion, are more significant than the changes that occur during the active stage of infection. During growth, there is a decrease in deformity in 44% of the children, an increase in deformity in 39% of the children and no change in deformity in 17% of the children. The critical factor leading to the progress of the deformity is dislocation of the facets. This can be identified on radiographs by the "Spine-at-risk" signs. Dislocation of facets at more than two levels can lead to the "Buckling collapse" of the spine, which is characteristically seen only in severe tubercular kyphosis in children. Age below 10years, vertebral body loss of more than 1-1.5 pre-treatment deformity angle of greater than 30° and involvement of cervicothoracic or thoracolumbar junction are the other risk factors for deformity progression. In children, the kyphosis can progress even after healing of the spinal infection and hence children with spinal tuberculosis must be followed-up till skeletal maturity.

Short term analysis of healed post-tubercular kyphosis in younger children based on principles of congenital kyphosis

Background:The patients with healed severe progressive tubercular kyphosis may develop late-onset paraplegia. A particular subgroup of these children (Type IB progression) may benefit from the management principles of congenital kyphosis. Self-correction may be observed by selective continued growth of anterior vertebral epiphyseal end-plates over the posterior fused mass. We report a series of cases with posterior fusion of progressive post-tubercular kyphosis with an aim to prevent further progression of kyphosis and to assess if any gradual self correction is seen in followup.Materials and Methods:Twelve children fulfilling inclusion criteria of clinicoradiological, hematological diagnosis of healed spine TB having no or <2 spine at risk signs having documented progression of kyphosis and neural deficit underwent posterior fusion in situ without instrumentation, using autogenous iliac crest grafts as well as allograft donor bone graft. They were followed up to maximum of 5 years.Results:All 12 children had a progressive increase in angle preoperatively. Mean followup was 3.6 years. Post surgery, 66% showed a clinical improvement and correction, 25% had static angle, and worsening in one patient. Thus, overall 91% have a favorable result.Conclusion:The mechanism of correction of deformity in presence of posterior fusion is continued growth of the anterior epiphyseal end plates and hence this leads to selective differential anterior column growth giving gradual correction of kyphosis. This avoids anterior, technically demanding and complex, internal gibbus surgeries. This procedure is simple, safe, and less morbid with good results, avoiding long term disability to the patients in selected group of patients.

Expert’s comment concerning Grand Rounds case entitled “Closing–Opening Wedge Osteotomy for Severe, Rigid Thoraco-Lumbar Post-tubercular Kyphosis” (by S. Rajasekaran, P. Rishimugesh Kanna and Ajoy Prasad Shetty)

Prevention or correction of severe kyphotic deformity in addition to eradication of the infective focus has become the modern standard of management of tuberculosis of the spine. Circumferential excision of the kyphus is now technically feasible with the development of rigid pedicle screw fixation system and intraoperative spinal cord monitoring in the past two decades.

Closing–opening wedge osteotomy for severe, rigid, thoracolumbar post-tubercular kyphosis

Childhood spinal tuberculosis, especially when associated with severe vertebral destruction of more than two vertebral bodies can end up in severe deformity. These children show progressive deformity throughout the period of growth and can develop severe kyphosis of >100°. Such kyphosis is severely disabling with significant risk of neurological deficit and respiratory compromise. Surgical correction of these deformities by both anterior and posterior approaches has been described but each have serious limitations of approach, correctability and safety. We describe here a technique of posterior closing-anterior opening osteotomy, which allowed us to correct a rigid post-tubercular deformity of 118° in a 13-year-old boy with neglected spinal tuberculosis. The patient was a 13-year-old boy, who had contracted spinal tuberculosis at the age of 6 years. Although the disease was cured by anti-tubercular chemotherapy, he continued to deteriorate in deformity and presented to us with severe thoracolumbar kyphosis (118°). He was neurologically intact but was beginning to show shortness of breath on exertion. Patient also had fore shortening of the trunk with impingement of the rib cage on the iliac crest. Radiographs revealed complete destruction of T12, L1 and L2 vertebral bodies with the T11 vertebra fusing with L3 anteriorly. CT scans and MRI revealed severe collapse of the vertebral column and the spinal cord being stretched over the 'internal gibbus', which was formed by the remnants of the destroyed vertebrae. A single stage closing-opening osteotomy was done by a midline posterior approach with continuous intraoperative spinal cord monitoring. The procedure involved extensive laminectomy of T11-L2, pedicle screw fixation of three levels above and three levels below the apex, a wedge osteotomy at the apex of the deformity from both sides, anterior column reconstruction by appropriate-sized titanium cage and gradual correction of deformity by closing the posterior column using the cage as a fulcrum. This allowed us to achieve a correction to 38° (68% correction). There was no intraoperative or perioperative adverse event and patient had good functional and radiological outcome at 1-year follow-up. In this Grand Rounds case presentation, we have also discussed the aetiology and evolution of severe post-tubercular kyphosis, which is the most common cause of spinal deformity in the developing world. Early identification of children at risk for severe deformity, the time and ideal methods of prevention of such deformities are discussed. The pros and cons of the available options of surgical correction of established deformity and the merits of our surgical technique are discussed.