Surgical Management Of Spinal Tuberculosis Research Articles

Conservative treatment of spinal tuberculosis in a retrospective cohort study over 20-year period: high eradication rate and successful health status can be expected.

Tuberculosis (TB) which mainly cause lung primarily TB, can also affect the musculoskeletal system. Spine involvement occurs in 50% of the cases and neurologic deficit and kyphotic deformity may occur. The choice of conservative or surgical management of spinal TB in the absence of neurologic deficits remains controversial. The aim of the present study was to investigate the outcome and the success rate of conservative treatment and to provide evidence for the timing of treatment for spinal TB in adult patients. Consecutive enrolled adult patients were conservatively treated from January 2000 to January 2020 for spinal TB in a tertiary care Orthopedic and Trauma Center-Spine Surgery Unit in Turin. Patients were conservatively treated with antibiotics and orthoses and followed up for at least 12 months. Clinical, radiological, laboratory and microbiological tests were performed for all the patients and demographic data, risk factors, comorbidity, clinical symptoms such as peripheral neurological deficit, and vertebral level involved were recorded. Treatment success was considered as no disease recurrence after 1 year of follow-up. Patients underwent successful conservative treatment were also evaluated with the self-perceived quality of life [36-Item Short Form (SF-36)] survey. A total of 132 patients (59 women and 73 men) suffering from spinal TB with a mean age at presentation of 49 years (range, 32-68 years) were treated. The mean follow-up was 43 months (range, 12-82 months). In 80 cases, there was a single vertebra involvement while multiple levels were involved in 52 cases. Sixty-nine (52%) patients presented spondylitis without involvement of the disk and 63 (48%) patients presented a spondylitis with disk involvement. Conservative treatment was effective in 113 patients (86%) which showed inter-somatic fusion with stability of the spine. The mean period of antibiotic therapy was 12 months (range, 8-15 months). Patients wear spinal orthosis for at least 12 weeks. The physical component summary (PCS)-36 (48.9±10.0) and mental component summary (MCS) (46.5±7.0) summary scores at follow-up were comparable to the normative values (P=0.652 and P=0.862, respectively). Painful deformity occurred in 25 patients (19%). Conservative treatment is effective treatment for spinal TB and may avoid surgical intervention in the absence of neurologic deficits.

Surgical Management of Spinal Tuberculosis - A Retrospective Observational Study from a Tertiary Care Center in Karnataka.

Context:Tuberculosis (TB) is a common infectious disorder in developing countries. A significant load of patients with extrapulmonary TB are diagnosed in our institute, mostly involving the spine.Aim:We aimed to present our experience in the surgical management of spinal TB.Setting and Design:This was a retrospective observational study.Materials and Methods:Seventy patients (year 2016–2018) who underwent surgical management with minimum of 1-year follow-up (17 patients lost during follow-up) were graded as per the American Spinal Injury Association (ASIA) grading system for neurological deficits. All were surgically treated with laminectomy and epidural abscess drainage/transpedicular debridement of granulation with/without spinal stabilization. Thoracic and lumbar cases were managed by posterior approach; among them, 12 patients who had no significant cord compression and good ASIA grade with facet involvement (requiring fusion) underwent minimally invasive pedicle screw fixation. Cervical cases were managed mostly by anterior approach. All patients received Anti-tubercular treatment (ATT) post operatively as per protocol postoperatively, following which magnetic resonance imaging (MRI) spine was done.Statistical Analysis:Data were analyzed using SPSS software version 18.0 (SPSS Inc. Released in 2009. PASW Statistics for Windows, version 18.0. Chicago, IL, USA: SPSS Inc.). The continuous variables were analyzed using descriptive statistics using mean and standard deviation.Results:The average age was 42.5 years. The most common location was thoracic (28 patients), followed by lumbar (20 patients), cervical (16 patients), and thoracolumbar (6 patients). Twenty patients had epidural abscess with cord compression. All patients who presented within 4 weeks of onset of symptoms showed a statistically significant improvement postsurgery. Sixteen patients with epidural abscess had good neurological recovery immediately after surgery (ASIA B to ASIA D/E). Four patients with epidural abscess with late presentation remained ASIA A after surgery. All patients had good fusion rates (follow-up X-ray) at 1 year. After ATT course completion, all patients had complete eradication of disease (MRI spine).Conclusion:Surgical treatment for spinal TB, if performed early (within 4 weeks) with good decompression, results in satisfactory clinical outcome with early improvement in the neurological deficits. Posterior approach to the spine with decompression and fixation gives good results, and minimally invasive procedures further help lessen muscle dissection, less pain, and early mobilization.

Outcome Analysis of Anterior Reconstruction with Rib Grafts in Tuberculosis of the Thoracic Spine.

Introduction:Tricortical iliac bone is the gold standard as an autograft for the reconstruction of the anterior column in tuberculosis (TB) of the thoracic spine. However, the quantity of graft needed is significant. It creates a considerable defect in the pelvic bone, causing graft site complications, including pain, pelvic instability, fractured ilium, herniated muscle, or abdominal contents. To prevent these donor site morbidities, ribs that were removed during the versatile approach were used for anterior reconstruction. The aim of this study was to assess the clinical and radiological results of the reconstruction of the anterior column of the spine with the help of an excised rib during the versatile approach.Subjects and Methods:This retrospective study was undertaken at a tertiary care center with a study duration of 14 years. Between January 2004 and December 2016, 52 patients with thoracic Koch's spine had anterior column reconstructed with multiple rib grafts. A single surgeon performed all operations. Indications for the surgery in these patients were the presence of neurologic deficit (49 patients) and vertebral column instability (3 patients). The preoperative kyphosis angle and visual analog scale (VAS) score were compared with postoperative values using a paired t-test.Results:All patients underwent a minimum follow-up of 18 months and were evaluated clinicoradiologically. Good bony fusion with neurological recovery was achieved in all cases. The VAS score for back pain improved significantly postsurgery. There was one case of graft buckling treated conservatively.Discussion:Appropriate anterior reconstruction forms the cornerstone of successful surgical management of spinal TB. The “Versatile approach” used offers anterior and posterior access in the lateral position. In these patients, we obviated the need for iliac crest graft using multiple segments of the rib for anterior column reconstruction. This meticulous rib grafting technique gives good functional outcome in terms of solid bony fusion.Conclusion:Meticulous rib grafting technique gives 360° bony fusion and good functional outcome in surgery for thoracic spinal TB. It has the advantage of avoiding the complications associated with a tricortical iliac crest graft.

Role of local streptomycin in prevention of surgical site infection in TB spine.

Surgical site infection (SSI) continues to be one of the most common post-operative complications in most spine surgeries. Patients with tuberculosis (TB) of spine are more at risk of developing this complication due to a number of reasons. This adds to significant morbidity and economic burden on patients adversely affecting the mental status and quality of life of patients. The aim of this study was to investigate the role of local streptomycin in preventing SSI in patients undergoing surgical management of spinal TB. In total, 56 patients who underwent surgical management for radiologically proven TB spine divided into two groups were included in the study. Group A included 30 patients with no local streptomycin administered intraoperatively, while group B included 26 patients operated in the later part of study with the use of local streptomycin intraoperatively. The two groups were compared and the outcome criteria analysed were SSI rate, length of hospital stay, duration of post-operative antibiotics and need for debridement. Length of hospital stay (group A: 18.4 ± 6.9days; group B: 9.7 ± 3.9days) and duration of post-operative antibiotics (group A: 8.1 ± 1.6days; group B: 6.2 ± 2.1days) were significantly higher in group A when compared with group B. SSI rate (group A: 13.34%; group B: 3.84%) and need for debridement (group A: 10%; group B: 3.84%) were higher in group A, but the difference was not statistically significant. Intraoperative administration of local streptomycin significantly reduces the length of hospital stay and duration of antibiotic administration in post-operative period in patients undergoing surgery for TB spine.

Role of Additional Coronal Magnetic Resonance Imaging in Decompression and Reconstruction with or without Segment Salvage in Thoracic Spine Tuberculosis.

Study DesignRetrospective and observational study.PurposeThe present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).Overview of LiteratureIndications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.MethodsSixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.ResultsThis method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.ConclusionsFor segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.

Standalone Instrumented Posterior Approach Used as Universal Approach for Tuberculosis Spondylodiscitis.

Background:Surgical management of spinal tuberculosis (TB) has been classically the anterior, then combined, and of late increasingly by the posterior approach. The posterior approach has been successful in early disease. There has been a paradigm shift and inquisitive to explore this approach in the more advanced and even long-segment disease. Our study is a retrospective analysis by authors in variable disease pattern of TB Spine operated at an institute using a single posterior approach.Settings and Design:A retrospective case study series in a tertiary level hospital.Aims:The aim of this study is to evaluate the functional and radiological results of an all posterior instrumented approach used as a “universal approach” in tubercular spondylodiscitis of variable presentation.Materials and Methods:The study is from January 2015 to May 2018. Twenty-four of 38 patients met the inclusion criterion with a male: female = 8:16, and mean age 44.26 years. The initial diagnosis of TB was based on clinic-radiologic basis. Their level of affection, number of vertebrae affected, and vertebral body collapse, the kyphosis (preoperative, predicted, postoperative, and final residual) and bony fusion were measured in the preoperative, postoperative, and final X rays. Functional scoring regarding visual analog scale and Frankel neurology grading was done at presentation and follow-up of patients. Histopathological data of all patients were collected and anti-tubercular therapy completed for a period of 1 year with 4 drugs (HRZE) for 2 months and 2 drugs (HR) for rest of period.Statistical Analysis Used:The descriptive data were analyzed by descriptive statistics, and other parameters were calculated using the appropriate statistical tests such as the Student paired t-test for erythrocyte sedimentation rate, visual analog scale score, and kyphosis.Results:The mean number of vertebrae involved was 3.29 ± 0.86 (2–6) with mean vertebral body destruction was 0.616. Preoperatively, the mean kyphosis angle was 22.42° ± 12.56° and was corrected postoperatively to 13.08° ± 11.34° with an average correction of 9.34° (41.66%). At the latest follow-up, there was mean loss of correction of 0.80° resulting in 13.88° of final correction. Bony fusion was achieved in 20 patients (83.33%) cases. Neurological recovery occurred in all patients (100%), and 92% could be ambulatory at 1 year follow-up. There was improvement of visual analog scale from 6.33 ± 1.05 preoperatively to 1.042 ± 0.75 at 3 months of postoperative period. Two patients had bed sore, two had urinary infection, and one had neurological worsening requiring re exploration and cage removal eventually recovering to Frankel E. Two patients died due to unrelated cause.Conclusions:The procedure in safe and has satisfactory results in variable group affection of Pott's spine including early and late disease, multisegment involvement using pedicle screw fixation with/without cage support.

The Analysis of Safety and Effectiveness Using Allograft in the Treatment of Spinal Tuberculosis-A Multicenter Retrospective Study

To evaluate the clinical efficacy and fusion characteristics of allografts in spinal tuberculosis (TB). The research reviewed 1196 patients with spinal tuberculosis who received treatment at six hospitals from January 2000 to January 2016. A total of 623 patients who had spinal tuberculosis were included in the study. All patients underwent debridement, decompression, allograft bone grafting, and instrumentation. Postoperative treatment consisted of a combination of anti-TB drug treatment for 18 months and brace fixed braking for 3–9 months. Clinical outcome, laboratory indexes, and radiological results were analysed. The average follow-up time was 34.1 months (12–60 months). Pain was relieved postoperatively in all cases, and 87.8% of patients were painless at the final follow-up. The erythrocyte sedimentation rate (ESR) significantly decreased and returned to normal at the final follow-up. The fusion rate of allografts was 30.2% and 98.4% at the 9- and 12-month follow-ups, respectively. At the final follow-up, the fusion rate was 100%. The application of allografts in the surgical management of spinal tuberculosis is safe and effective. Allografts can replace autografts in surgeries for spinal tuberculosis.

Management of Spinal Tuberculosis (TB) in Developing Country

Background: Tuberculosis on the spine is involved approximately 1 % of all tuberculosis cases. It is a lethal type of TB skeletal due to highly neurologic compromised because of adjacent medullary compression and incidence kyphotic deformity. Early diagnosis and management of this disease is mandatory to prevent serious complications. Method: Serial case report was conducted in Sanglah General Hospital from January 2014 until December 2015. All patients were diagnosed based on local protocol using appropriate imaging technique. All patients were treated by anti-tuberculosis drugs for 2 weeks followed by functional assessment by MMT, ASIA, and JOA. Result: The author reported 10 patients of spinal TB whom were treated in Sanglah Hospital, Bali between January 2014- Desember 2015. Among pts 8 male and 2 female with location of spinal TB i.e 4 in thoracal, 4 in lumbal and 2 in cervicothoracal. Preoperative ASIA scale was an average scale C and postoperative ASIA scale was in D. The average JOA pre-surgical score was 10.5 and postsurgical was 14.5. Improvement using the formula JOA achieved with an average of 21.6 %. All patients neurologically improved, no complications and surgical implant failures in this series. Conclusions: Surgical management of spinal tuberculosis, if delivered with appropriate indication, proved to be effective in correcting spinal kyphosis. Early management is mandatory in order to ensure better prognosis.

Minimally Invasive Surgical Approaches in the Management of Tuberculosis of the Thoracic and Lumbar Spine

Spinal tuberculosis is the most common form of skeletal tuberculosis. Various approaches have been described for surgical management of spinal tuberculosis, but many entail wide exposures with attendant morbidity; whether minimally invasive surgical (MIS) approaches are suitable is unknown. We evaluated (1) neurologic results, (2) radiographic results, and (3) complications in patients with thoracic and lumbar spinal tuberculosis treated with two MIS approaches. We retrospectively evaluated 22 patients with thoracic and lumbar tuberculosis managed surgically from October 2008 to February 2011 using MIS methods; one patient was lost to followup, leaving 21 patients with a minimum followup of 15 months (mean, 30 months; range, 15-59 months) for analysis. MIS approaches were used for patients with disease below D6 and minimum pedicle diameters of 4.5 mm to permit percutaneous screw placement. The MIS approach was divided into two groups depending on the extent of destruction of the vertebral body: a posterior-only group (n = 9), where posterior transpedicular decompression sufficed, and the hybrid group (n = 12), requiring anterior débridement and ventral-column reconstruction by conventional or mini-open thoracotomy. All but two patients with more than two contiguous bodies involvement underwent MIS posterior fixation by percutaneous transpedicular screws. Plain radiographs were evaluated for deformity correction and correction maintenance. Neurologic recovery and complications were ascertained by chart review. All patients with neurologic deficits recovered completely with no motor deficits at followup; 13% improved by three grades, 53% by two grades, and 33% by one grade. Mean correction was 2.5° (thoracic) and 8° (lumbar) in the posterior-only group and 4.2° in the hybrid group. Some correction loss occurred with healing (2° and 1.6° in the posterior-only and hybrid groups, respectively), but in none of those who had fixation did this progress to more than preoperative status. Two of 22 patients (9%) had complications. One had a malposition of L5 screw causing painful radiculopathy without motor deficit and required repositioning. The other had an intraoperative dural tear repaired by onlay fascial patch and cerebrospinal fluid diversion. There were no approach-related complications, neurologic deterioration, or implant fatigue at last followup. We found evidence of neurologic recovery, avoidance of deformity progression, and few complications with these MIS approaches. Comparative trials are called for between open and MIS approaches for patients with spinal tuberculosis. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Single-Stage Anterior Autogenous Bone Grafting and Instrumentation in the Surgical Management of Spinal Tuberculosis

Results of single-stage anterior autogenous bone grafting and instrumentation for spinal tuberculosis were reported. To determine the efficacy of anterior instrumentation following radical debridement and autogenous bone grafting in patients with spinal tuberculosis over a 3-year period at a single institution. Patients with spinal tuberculosis have been not always successfully treated by radical debridement and bone grafting with or without supplementary posterior instrumentation and fusion, although most surgeons use posterior instrumentation to support anterior strut grafts. In this prospective study, the authors evaluated 39 patients (22 male and 17 female; average age, 48 years) with spinal tuberculosis, who underwent single-stage anterior radical debridement, autogenous bone grafting, and instrumentation. The average follow-up period was 39.9 months (range, 30-54 months). A solid fusion was achieved in all cases; there were 2 cases of draining fistula formation. Of all 28 patients with preoperative kyphosis, the deformity was corrected from an average of 13.5 degrees on admission to an average of 1.9 degrees after surgery. No significant loss of deformity correction was noted in these patients. There was no other recurrence of the tuberculous infection. The authors think that the single-stage anterior autogenous bone grafting and instrumentation are a safe and effective method in the surgical management of spinal tuberculosis.

Surgical Management of Spinal Tuberculosis in Adults

Of 112 patients who were subjects of the Medical Research Council's prospective study, 105 (94%) were involved in a longitudinal study follow-up for a mean of 15.3 years postoperatively. Seventy-one patients had radical resection of the tuberculous lesion and bone grafting, and the remaining 34 were treated with debridement surgery at a mean age of 36.7 and 35.3 years, respectively. All these patients were aged 18 years or older at the time of surgery. The kyphosis and deformity angles were measured on lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: (1) Neurologic recovery in both radical and debridement surgical groups were equally good and no patient had pain two years after surgery. There was no incidence of reactivation or recurrence of tuberculosis in either surgical group. (2) At the six-month postoperative evaluation, patients who had radical surgery showed marginal correction in deformity, whereas those who were treated with debridement showed deterioration in both kyphosis and deformity angles. There was a statistically significant difference between the two surgical groups for the mean changes in kyphosis and deformity angles at the six-month postoperative evaluation compared with their preoperative evaluation. (3) The mean difference for kyphosis and deformity angles at final follow-up evaluation from the patients' six-month postoperative measurements were not statistically significantly different between the two surgical groups. (4) Forty percent of patients showed an improvement in deformity angle by 5 degrees or more after radical surgery at the six-months postoperative evaluation, whereas 53% of patients showed deterioration after debridement surgery. (5) All patients with tuberculosis of the lumbar spine treated with radical surgery had normal lordosis in the lumbar spine at final follow-up evaluation, compared with only 63% of patients after debridement surgery. Correction achieved after surgery at the six-month evaluation was practically maintained up to final follow-up evaluation. Radical resection and bone grafting provided better correction of deformity than did debridement surgery.