Surgical Treatment Of Spinal Tuberculosis Research Articles

Progress in surgical treatment of spinal tuberculosis.

Progress in surgical treatment of spinal tuberculosis.

Single Posterior Surgery Versus Combined Posterior–Anterior Surgery for Lumbar Tuberculosis Patients

Posterior approach of debridement, interbody graft, and instrumentation, and combined posterior-anterior approach of posterior instrumentation and anterior debridement and interbody graft are two essential surgeries for the surgical treatment of spinal tuberculosis (TB), and, until now, which one should be chosen is still controversial. This study aimed to compare the therapeutic efficacy between the single posterior surgery and combined posterior-anterior surgery for lumbar tuberculosis (LTB) patients to elucidate the role of debridement and the effects that result from posterior structure resection. One hundred and nineteen LTB patients managed with single posterior debridement, interbody graft, and instrumentation surgery (Group P, 73 cases), or combined posterior-anterior surgery of posterior instrumentation and anterior debridement and interbody graft (Group P-A, 46 cases) from January 2008 to December 2016 were retrospectively analyzed. Different indexes were compared between the two groups to evaluate the curative effect and explore the role of debridement and the effects that result from posterior structure resection: operation time, blood loss, visual analog scale (VAS), Japanese Orthopaedic Association (JOA), Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP), surgical complication type and rate, spinopelvic sagittal parameters (local kyphosis [LK], pelvic incidence [PI] and pelvic tilt [PT], lumbar lordosis [LL], and sacral slope [SS]), drainage retention duration, hospital stay, time of abscess disappearance, time of activity recovery, and time of bone graft fusion by t-test or χ2 test. The follow-up period ranged from 24 to 60months. No significant variations were detected between the two groups for age, sex ratio, BMI, disease duration, indication, and the preoperative values of VAS, JOA, ESR, CRP, and LK (p > 0.05). The VAS, JOA, ESR, and CRP significantly improved in both groups after the operation (p < 0.05), along with the LK and LL (p < 0.05). Meanwhile, the SS, PI, and PT showed minor improvement after the operation (p > 0.05). Compared to the P-A group, the P group had shorter operation time and less blood loss and hospital stay (p < 0.05). However, both groups presented similar VAS, JOA, ESR, CRP, and LK improvements (p > 0.05). Additionally, the surgical complication type and rate, postoperative spinopelvic sagittal parameters, and bone graft fusion time did not differ between the two groups (p > 0.05). On the other hand, the patients in the P-A group had a shorter time of abscess disappearance and activity recovery (p < 0.05) but a similar time of drainage retention (p > 0.05) compared to the P group. Both single posterior and combined posterior-anterior surgeries presented a good therapeutic effect for LTB patients with a low surgical complication rate and good quality of LK correction and LL reconstruction and maintenance. Moreover, single posterior surgery was less traumatic than combined posterior-anterior surgery but with slower TB lesion healing and activity recovery. Compared to debridement, stability seems to be more vital for STB healing, posterior structure resection does not affect the effect of spinopelvic realignment.

Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results.

Retrospective cohort study. To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage. Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment. The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated. Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications. CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

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.

Inpatient Outcomes of Surgical Treatment for Spinal Tuberculosis: 10-Year Results from the US National Inpatient Sample.

To evaluate the association between in-hospital outcomes of patients with spinal tuberculosis and different surgical approaches. This population-based, retrospective observational study analyzed data of hospitalized patients undergoing surgical treatment for spinal tuberculosis in the United States who were identified in the US Nationwide Inpatient Sample (NIS) between 2005 and 2014. The study cohort was stratified by posterior-only, anterior-only, and combined surgical approaches. Logistic and linear regression analyses were performed to evaluate associations between surgical approaches and patient outcomes. Significant differences were found in postoperative complications, number of instrumented levels, and comorbidity scores (all p ? 0.033) between patients who received different surgical approaches. A univariate analysis demonstrated the combined approach was associated with significantly increased odds of postoperative complications compared with the posterior-only approach. This association remained significant when following multivariate analysis after adjustments. For patients who received surgery at the lumbosacral level, the anterior-only approach and combined approach were both associated with significantly increased odds of postoperative complications compared with the posterior-only approach. Among patients who received surgery at the lumbosacral level, multivariate analysis showed that anterior-only and combined approaches were associated with significantly longer length of stay. Among patients with spinal tuberculosis who are undergoing surgical treatment, a posterior-only approach was associated with fewer complications and shorter length of stay compared with an anterior-only or combination approaches when performed at the lumbo-sacral spinal level.

Treatment of lavage drainage under spinal endoscopy on lumbar spinal tuberculosis with vertebral lesions

To investigate the efficacy and safety of the treatment of percutaneous endoscopic debridement (PED) and continuous lavage drainage (CLD) on lumbar tuberculosis. Total 31 patients diagnosed with lumbar tuberculosis, who underwent the PED and CLD from January 2012 to January 2018 in our hospital were included. The operation time, intraoperative blood loss, complications were analyzed. The recovery of local tuberculosis was evaluated by erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and visual analogue scale (VAS) before and after operation. The patients were followed up for 18 to 84 months. At the last follow-up, lumbar lordosis (LL), the Japanese Orthopaedic Association (JOA) score and imaging data were used to evaluate the recovery of spinal structure and function. There were no complications for all patients. During the follow-up of 3 to 12 months after operation, ESR and CRP returned to normal. The VAS score of local pain was significantly lower than that before operation ( p &lt; 0.05). The LL and JOA scores of the patients at the last follow-up were significantly better than those before operation ( p &lt; 0.05), and the lumbar CT and MR suggested the healing of vertebral lesions. PED and CLD might be an effective surgical treatment for spinal tuberculosis.

Extended Posterior Decompression and Instrumented Fusion for Spinal Tuberculosis.

Study DesignRetrospective cohort.PurposeTo evaluate clinical outcomes, including pain and neurologic status, and to evaluate radiographic outcomes of patients treated with extended posterior decompression, posterior fixation, and fusion in different vertebral segments.Overview of LiteratureThe standard surgical treatment of spinal tuberculosis is radical debridement via anterior approach. However, this approach may lead to several serious complications. Meanwhile, extended posterior approach, the posterior surgical approach, involving the removal of posterior elements, ribs, and pedicles, is an alternative option that can achieve the aims of treatment in this disease and may reduce the serious complications from anterior approach.MethodsThe medical records and imaging of 50 patients admitted with spinal tuberculosis from January 2010 to June 2016 were reviewed. The Visual Analog Scale (VAS), Frankel grading scale, and kyphotic Cobb angle between the pre- and postoperative periods were used to evaluate the patients.ResultsThe patients had significant improvement of VAS score in all the groups. The T/T–L, L, and L–S group scores improved from 7.2±1.5 to 1.7±1.2 (p<0.01), from 8.1±1.8 to 1.7±1.4 (p<0.01), and from 7.9±2.2 to 1.7±0.8 (p<0.01), respectively, and overall, the patient scores (n=50) improved from 7.8±1.4 to 1.7±1.3 (p<0.01). Ten patients (20%) had Frankel grade E preoperatively, which was improved to 38 patients (76%) postoperatively. A significant improvement of the kyphotic Cobb angle was observed when compared at the preoperative, early postoperative, and final follow-up period in the T/T–L, L, and L–S groups. The loss of correction angle in the LS group was 7.7°±4.3° at the final follow-up compared with the early postoperative correction angle at 9.1°±5.8°, with no statistically significant difference.ConclusionsExtended posterior decompression, posterior instrumentation, and fusion are effective methods of surgery for treatment of spinal tuberculosis involved in the thoracic, thoracolumbar, lumbar, and lumbosacral regions.

Application of transforaminal-lumbar interbody fusion technology combined with lesion clearance and chemotherapy via catheter for the treatment of spinal tuberculosis.

The aim of the present study was to analyze the clinical and radiological outcomes of active thoracolumbar spinal tuberculosis (TB) treated by application of transforaminal-lumbar interbody fusion technology combined with lesion clearance and chemotherapy via catheter (TCLC). Posterior debridement and indwelling catheterization in the lesion area were performed for direct injection of anti-TB drugs, so as to reduce the recurrence rate. The present prospective study comprised 26 patients with active thoracolumbar spinal TB who underwent TCLC at Hong Hui Hospital affiliated to Xi'an Jiaotong University (Xi'an, China). The kyphotic Cobb angle at presentation, after surgery and at the final follow-up were 22.7±9.8, 9.8±7.3 and 10.3±8.8°, respectively, with an average correction of 13.1±5.4° after surgery, and a loss of correction of 1.8±1.0° at the final follow-up. The rate of correction and loss of correction were 56.6 and 8.3%, respectively. At six months after the surgery, all abnormal erythrocyte sedimentation rates and C-reactive protein levels had returned to normal. The average time to union was ~5 months. All patients had bony union and improved neurological function, with their daily activity returning to normal. In conclusion, in the present study, application of TCLC for the treatment of spinal TB achieved satisfactory healing of lesions. The surgical treatment for spinal TB comprised the removal of the disease as far as possible, and the local administration of anti-TB chemotherapy to the lesion is key to successful treatment.

The efficiency of the posterior-only approach using shaped titanium mesh cage for the surgical treatment of spine tuberculosis in children: A preliminary study.

The study aimed to evaluate the efficiency of the posterior-only approach using shaped titanium mesh cage for surgical treatment of spinal tuberculosis (TB) in children. Between January 2011 and July 2013, 22 children with a single motion spinal segment involved, including 10 with thoracic, 4 with thoracolumbar, and 8 with lumbar, were enrolled in the study. The patients were treated by the posterior-only approach using the shaped titanium mesh cages. Their medical records and radiographs were retrospectively analyzed. The mean operating time was 163 min (ranging from 120 min to 200 min). Blood loss was 210-550 ml with an average of 300 ml. The mean follow-up period was 41.1 months. At the final follow-up, all patients showed a solid bony fusion without the infection recurrence. The average bone fusion time was 6.2 months. The average correction of the local segment kyphosis angle was 6.9° (from 9.2° preoperative to 2.3° postoperative). Minimal loss in correction angle was noted in these patients at the final follow-up (only 1.5°). Changes in erythrocyte sedimentation rate, local segment kyphosis angle, and neurological status demonstrated a significant clinical improvement in all children at their last follow-up. Children with spinal TB of a single motion spinal segment involved can be successfully treated by the posterior-only approach using shaped titanium mesh cage. It is a minimally invasive, safe, and effective surgical procedure.

A medium-term follow-up of adult lumbar tuberculosis treating with 3 surgical approaches.

Surgical intervention is an important option for treating lumbar tuberculosis. Previous studies have reported different surgical intervention procedures. To our knowledge, few studies have compared the clinical results of mid-term follow-up of 3 different surgeries in surgical treatment of spinal tuberculosis. This study's purpose is to evaluate the effectiveness of 3 different surgeries for the treatment of lumbar tuberculosis in adult and analyze the mid-term influence of the surgery on quality of life.Between June 2004 and January 2010, a total of 137 adult patients (54 women and 83 men) with lumbar tuberculosis were recruited for this study. The patients were divided into 3 groups based on administered surgeries: posterior, anterior, and combined posterior-anterior. The trauma index (operation time, blood loss, length of hospital stay, and complications), imaging parameters (segment kyphotic angle, correction rate, loss angle, and bone fusion time), and quality-of-life indicators, including Oswestry Disability Index (ODI), the Frankel grade, visual analog scale (VAS), and Macnab score, were collected.The posterior group experienced the lowest trauma index, whereas the combined group faced the highest trauma index. The anterior group's kyphosis correction rate of (52% ± 5.45%) was significantly inferior to the posterior group (74% ± 5.04%) and the combined group (69% ± 7.95%), whereas the loss of correction in the anterior group (2.5°) was higher than the losses of correction in the posterior group (0.8°) and combined group (1.1°). The mean bone fusion times of the 3 groups were similar. Postsurgery quality of life was markedly improved in all patients. The improvement rates of the ODI, VAS, and the excellent and good rate per the Macnab score were similar among the 3 groups at the final follow-up.Based on a retrospective study, for patients with lumbar tuberculosis, use of the anterior approach should be limited. Although the combined approach produced satisfactory outcomes, it remains more traumatic. Compared with the anterior surgery and the combined surgery, the posterior-only approach is safer and less invasive.

Debridement, internal fixation, and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach: a 4-year follow-up of 28 patients.

BackgroundThe standard recommended method for surgical treatment of spinal tuberculosis is an anterior approach for debridement and fusion combined with posterior instrumentation. However, the method has its disadvantages. The aim of this study was to analyze the effectiveness and safety of treating thoracic and lumbar spinal tuberculosis with debridement, internal fixation reconstruction, and using specially formed titanium mesh cages via a posterior-only approach.MethodsThe authors retrospectively reviewed the cases of 28 patients with spinal tuberculosis treated by debridement, internal fixation, and reconstruction with a specially formed titanium mesh cage via a posterior-only approach. The levels involved were less than two contiguous vertebrae: 13 thoracic vertebrae, 5 thoracolumbar vertebrae, and 10 lumbar vertebrae. All patients suffered from back pain, and nine patients had neurologic deficits (two were class C and seven were in class D according to the American Spinal Injury Association classification). All patients were followed up every 3 months after surgery, with a minimum 48-month follow-up. The clinical efficacy was evaluated based on the visual analog scale (VAS), the Oswestry Disability Index (ODI), neurological status, kyphosis angle, and erythrocyte sedimentation rate (ESR).ResultsAll patients obtained solid bony fusions without failure of fixation. The infections were resolved in all patients, as noted by normalization of their ESR. The average surgery time was 2 h and 15 min, with an average blood loss of 435 ml. The VAS scores dropped from a preoperative level of 6.31 ± 1.25 to the final follow-up level of 0.57 ± 0.14. The ODI scores dropped from 39.14 ± 12.38 preoperatively to 7.29 ± 3.09 at 1 year postoperatively and 6.77 ± 2.53 at final follow-up. The kyphosis Cobb’s angle was corrected from 22.31° ± 4.26° preoperatively to 5.86° ± 0.57° at final follow-up. No subsidence of titanium mesh cage or posterior instrumentation failure was observed postoperatively. The neurological outcome increased by 1–2 grades in the patients with neurological deficits.ConclusionsDebridement, internal fixation, and reconstruction using specially formed titanium mesh cages via a posterior-only approach is effective and safe for treating adults with thoracic and lumbar spinal tuberculosis involving less than two contiguous levels.

Surgery in Pott Disease: Experience of 582 Cases

Introduction Tuberculosis of the spine is the most common and dangerous form of TB infection accounting 50 to 60% of osseous tuberculosis. Although uncommon, spinal TB still occurs even in both developed and developing countries. The diagnosis of spinal tuberculosis is difficult and it commonly presents at an advanced stage. Delay in establishing diagnosis and management cause spinal cord compression and spinal deformity. Patients mostly present with lower limb weakness, Gibbus, pain, palpable mass, and kyphotic deformity in long standing cases. Material and Methods To evaluate the efficacy and clinical outcome of surgical treatment of spinal tuberculosis treated by different approaches consisting decompression surgery, autogenous bone grafting and anti-TB chemotherapy. Before that a strong evidence-based diagnosis must be established which can be done by clinical features, MT test, and MRI of spine. Because vertebral body collapse from TB may be misdiagnosed as compression fracture. A total of 582 patients who had tuberculosis of the cervical, thoracic, and lumbar spine with moderate-to-severe cord compression were studied. Variable degrees of neurological deficit with deformity were treated at NITOR and BSOH, Dhaka, in the period from January 2003 to July 2014. Anterolateral decompression and autogenous strut bone grafting with simultaneous fixation by screws and rods were done. Posterior decompression, posterior interbody, and posterolateral fusion by bone graft with stabilization by transpedicular screws and rods. Appropriate anti-TB drugs were given to all patients for 18 to 24 months. The postoperative follow-up period was 12 months (range, 3–21 months). Results Overall, 427 (73.4%) cases with neurological deficits recovered totally or partially. No neurological improvement had occurred in 69 (11.9%) cases with paraplegia. Overall, 56 (9.6%) cases were lost from follow-up. X-ray showing bony fusion was achieved in all cases for mean of 6 months (range, 4–8 months). There was no recurrence. Seven (5.1%) cases developed bed sore postoperatively. Excellent result was seen in 70% cases, fair in 15%, good in 10%, and poor in 5% cases. Conclusion For patients with spinal tuberculosis anterior debridement, auto graft bone fusion, anterior or posterior fixation appears to be effective in arresting disease, correcting kyphotic deformity and maintaining correction until solid spinal fusion.

Primary issues in the selection of surgical procedures for thoracic and lumbar spinal tuberculosis.

Debridement, spinal canal decompression, deformity correction, bone graft fusion and internal fixation are commonly used in the surgical treatment of spinal tuberculosis. A complete surgical plan for patients with spinal tuberculosis may include all or some of these five surgical procedures that involve both removing tuberculous lesions and re-establishing spinal stability and function. All five procedures can be carried out via an anterior or posterior approach or a combination of these two approaches. A combined posterior-anterior approach is becoming a preferred choice for treating spinal tuberculosis. However, this procedure requires two incisions and two rounds of surgeries, which the associated extensive surgical trauma. Thus, a simple anterior or posterior approach may be preferable. Each of these approaches has its own advantages and disadvantages that must be considered during the clinician's evaluation. Selection of the most appropriate of these three approaches is vital to achieving cure of spinal tuberculosis. Spinal surgeons should comprehensively consider each patient's characteristics, the manifestations of their lesions and how familiar the surgeon is with the required surgical procedure(s). The primary consideration should be the potential outcome: the effectiveness of debridement is the key determinant of the surgical outcome.

Clinical outcomes of surgical treatment of spinal tuberculosis with paraplegia

Objective To investigate the clinical outcomes of the surgical management for spinal tuberculosis with paraplegia retrospectively.Methods From March 2008 to April 2012,we retrospectively analyzed 78 patients with spinal tuberculosis combined with paraplegia.Among them,45 patients were male and 33 were female.The average age was 39.5(13 to 71) years.69 patients had focus-active paraplegia.41 patients had received chemotherapy before admissed to our hospital.They also received further standard chemotherapy for an average period of 2.3 (0 to 4) weeks after the admission.22 patients with complex complications (6 patients with active pulmonary tuberculosis,5 with tuberculous meningitis,7 with drug hepatitis,3 with kidney failure and 1 with unstable angina) received preoperative treatment for an average period of 4.5(3 to 8) weeks after the admission.6patients were managed with chemotherapy only.All 9 patients who had focus-healed paraplegia received surgical treatment after the admission immediately.Results All the patients were followed up clinically and radiologically for an average period of 31.4 (12 to 48) months.There was no recurrence of patients.At the final follow-up,all the patients had achieved rigid bony fusion.Both the VAS score and the Cobb angle had satisfactory improvement postoperatively and at the final follow-up.The neurological status began to improve 1-21 days after the operation.From 3 months postoperatively to the final follow-up,65 patients achieved complete recovery,7 partial recovery and 6 no recovery.The clinical outcomes for focus-active paraplegia were similar,while focushealed paraplegia had slower recovery and worse outcomes.Conclusion Patients with focus-active paraplegia combined with mild destruction and relative favourable neurological status could be treated conservatively.For patients with severe bony destruction and neurologic deficits (Frankel A-C,or combined with kyphosis),surgical treatment as early as possible is crucial to improve the neurologic status.If patients had contraindications,operation could be performed after the complications had been cured.However,the neurologic status improvement in focus-healed paraplegia is worse than focus-active paraplegia,suggesting that the reconstruction of spinal stability is important for initial treatment of spinal tuberculosis and children. Key words: Tuberculosis, Spinal; Paraplegia; Treatment outcome

Comment on Wang et al.: Single-stage posterior instrumentation and anterior debridement for active tuberculosis of the thoracic and lumbar spine with kyphotic deformity

Dear Sir, We read the article titled “Single-stage posterior instrumentation and anterior debridement for treatment of active spinal tuberculosis with kyphotic deformity” by Xiao-bin Wang et al. where the patients did very well both in terms of kyphosis correction and neurological improvement [1]. We congratulate them for their nice work and study. The mean pre-operative kyphotic angle noted by the authors was 53.5° which was corrected up to 12.6° post-operatively. The mean vertebral body loss (VBL) was 1.2. Rajasekaran et al. proposed the method to calculate the predicted angle of kyphosis for thoracic and thoracolumbar levels in adults as Y = 5.5 + 30.5 VBL [2]. This formula has been used widely and found to have a good correlation with the final angle. The predicted angle should be the maximum possible final kyphosis where patients are treated by conservative methods. However the initial kyphosis always remains less than this predicted angle, which has also been shown by various other studies [3, 4]. In the study by Wang et al. the mean VBL was 1.2, thus the mean predicted kyphotic angle came out to be 42.1° (5.5 + 30.5 X 1.2) using the above formula. But their initial preoperative angle (53.5°) was very much higher than the predictive angle which we found to be contrary to the previous studies [2–4]. So we request the authors to kindly explain the possible causes for such discrepancies in the values of predicted and initial observed angle. We however agree with the authors that one stage posterior fixation along with anterior debridement is a safe and effective option for surgical treatment of spinal tuberculosis with kyphosis and paraplegia.

Spinal tuberculosis: diagnosis and management

The involvement of spinal column reportedly occurs in less than 1% of all tuberculosis (TB) patients. Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit because of compression of adjacent neural structures and significant spinal deformity. Therefore, the early diagnosis and management of spinal TB has special importance to prevent these serious complications. Therefore, the present study was aimed at conducting a comprehensive narrative review and analysis of all the papers available for us published during 1990 to 2011 to extract current trends in diagnosis and medical or surgical treatment of spinal TB.. Although the development of more accurate imaging modalities such as magnetic resonance imaging (MRI) and advanced surgical techniques have made the early diagnosis and management of spinal TB much easier, these are still very challenging topics. In this review we aimed to discuss diagnosis and management of spinal TB based on the studies with acceptable design, clearly explained results and justifiable conclusions.

Spinal tuberculosis: diagnosis and management.

The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Therefore, early diagnosis and management of spinal TB has special importance in preventing these serious complications. In order to extract current trends in diagnosis and medical or surgical treatment of spinal TB we performed a narrative review with analysis of all the articles available for us which were published between 1990 and 2011. Althoug h the development of more accurate imaging modalities such as magnetic resonance imaging and advanced surgical techniques have made the early diagnosis and management of spinal TB much easier, these are still very challenging topics. In this review we aim to discuss the diagnosis and management of spinal TB based on studies with acceptable design, clearly explained results and justifiable conclusions.

Treatment of Acute Tuberculous Spondylitis by the Spinal Shortening Osteotomy: A Technical Notes and Case Illustrations

Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encountered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treatment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurological deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening osteotomy is an alternative method for the management of tuberculous spondylitis.

Comment on Oguz et al.: A new classification and guide for surgical treatment of spinal tuberculosis

Dear Editor, In their article, Oguz et al. have proposed a classification of spinal tuberculosis as a guide to surgical management [4]. They were able to classify all their 76 cases with this classification system retrospectively. I would like to make the following observations in this regard. The usual presentation of spinal tuberculosis is paradiscal involvement of two adjacent vertebrae, the intervening disc and, frequently, a paravertebral or psoas abscess. This classical picture is readily identifiable and presents no diagnostic difficulties. Posterior spinal tuberculosis, where there is isolated involvement of the neural arch, is a rare manifestation of spinal tuberculosis [1, 2]. It is the most common of the different atypical presentations and its incidence has been variously reported to be up to 10% [1]. It is of interest, therefore, that there are no cases of posterior spinal tuberculosis in their large series of patients. It must also be mentioned here that posterior spinal tuberculosis is more prevalent in certain areas, most reports of these originating from the Indian subcontinent [5]. Posterior spinal tuberculosis has many features that are different from the typical paradiscal tuberculosis. Foremost among these is the delay in diagnosis due to atypical radiographic features. Second, cases of isolated posterior spinal tuberculosis do not present with a kyphotic deformity as kyphosis is due to loss of stability of the anterior elements. Another striking feature is the early and high incidence of neurological complications [1]. But perhaps the most striking difference arises in the treatment of posterior spinal tuberculosis. While anterolateral decompression is advocated for the classical disease, decompression for posterior spinal tuberculosis with neurological deficits and cauda equina is by laminectomy. This is because cord compression is from the dorsal aspect, unlike the more common picture of pressure from the anterior aspect seen with disease of the vertebral bodies. Neural arch tuberculosis with deficits is therefore a rare indication for posterior decompression (laminectomy), which otherwise is contraindicated in the presence of anterior disease [1, 3]. Posterior spinal tuberculosis does not find a place in the classification proposed by the authors and its treatment by laminectomy is also not brought out. In this regard, the classification proposed by Mehta and Bhojraj seems more inclusive [3]. They have grouped posterior spinal tuberculosis as a separate category requiring posterior decompression. Though described for the thoracic vertebrae, its use can be extended to the lumbar vertebrae as well with modifications.

Measurement of the concentration of three antituberculosis drugs in the focus of spinal tuberculosis

This is an experimental study on the distribution of antituberculosis drugs such as rifampin, isoniazid, and pyrazinamide in pathologic vertebrae of spinal tuberculosis in order to provide the regimen of chemotherapy and surgical treatment of spinal tuberculosis. The distribution of antituberculosis drugs in pathologic vertebral tissues matters greatly to the clinical effect of spinal tuberculosis' treatment. However, few pharmacokinetic studies and clinical reports about the concentrations of antituberculosis drugs in vertebral foci have been published so far. Twenty-four patients with spinal tuberculosis were divided into sclerotic group (n = 15) or non-sclerotic group (n = 9) according to radiographic features of lesion. All patients received chemotherapy with 2HRZ/2.5H(2)R(2)Z(2) for a duration of 4.5 months. Four weeks after chemotherapy all patients underwent surgery and the specimen of serum, ilium, and pathologic vertebral tissues, including sclerotic wall, subnormal osseous tissue, and foci were obtained during operation in 120-130 and 180-190 min after oral intake in the morning, respectively. The levels of three drugs in the specimen were measured using HPLC method. The concentration levels of isoniazid, rifampin and pyrazinamide varied greatly in different tissues of spinal tuberculosis, of which the bactericidal concentration values of isoniazid and rifampin and fivefold minimal inhibitory concentration (MICs) of pyrazinamide were found in subnormal vertebral bone and self-contrast ilium, the MICs of all drugs were found in sclerotic wall outside foci, and undetected level was found in foci inside the sclerotic wall. To patients without vertebral sclerotic wall around the foci, the isoniazid in foci was of bactericidal level and rifampin and pyrazinamide in foci corresponded to the MICs respectively. The sclerotic bone of affected vertebra plays an important role in blocking the antituberculosis drug's penetration into tuberculosis focus.