The goal of this study was to assess the efficacy of one-stage surgical management for children with spinal tuberculosis by anterior decompression, bone grafting, posterior instrumentation, and fusion. Between January 2002 and December 2006, 15 cases with spinal tuberculosis were treated with one-stage posterior internal fixation and anterior debridement. All cases were followed-up for an average of 30.3 months (range 12–48 months). The average neurological recovery in the patients was 0.93 grades on the scale of Frankel et al. (Paraplegia 7:179–192, 1969). The average preoperative kyphosis was 36° (range 19–59°), and the average postoperative kyphosis was 23° (range 15–38°) at final follow-up. At final follow-up, minimal progression of kyphosis was seen, with an average kyphosis of 27° (range 16–40°). An average loss of correction of 4° was seen at final follow-up. One-stage surgical management for children with spinal tuberculosis by anterior decompression, bone grafting, posterior instrumentation, and fusion was feasible and effective.
The conventional procedure in the treatment of vertebral tuberculosis is drainage of the abscess, curettage of the devitalized vertebra and application of an antituberculous chemotherapy regimen. Posterior instrumentation results are encouraging in the prevention or treatment of late kyphosis; however, a second-stage operation is needed. Recently, posterolateral or transpedicular drainage without anterior drainage or posterior instrumentation following anterior drainage in the same session has become the preferred treatment, in order that kyphotic deformity can be avoided. Information on the use of anterior instrumentation along with radical debridement and fusion is scarce. This study reports on the surgical results of 63 patients with Pott's disease who underwent anterior radical debridement with anterior fusion and anterior instrumentation (23 patients with Z-plate and 40 patients with CDH system). Average age at the time of operation was 46.8±13.4 years. Average duration of follow-up was 50.9±12.9 months. Local kyphosis was measured preoperatively, postoperatively and at the last follow-up visit as the angle between the upper and lower end plates of the collapsed vertebrae. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed on magnetic resonance (MR) images. It was observed that the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (79.7±20.1%), and was effective in maintaining it, with an average loss of 1.1°±1.7°. Of the 25 patients (39.7%) with neurological symptoms, 20 (80%) had full and 4 (16%) partial recoveries. There were very few intraoperative and postoperative complications (major vessel complication: 3.2%; secondary non-specific infection: 3.2%). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis.
Pott's disease Surgical treatment Anterior instrumentation
Spinal deformity and paraplegia/quadriplegia are the most common complications of tuberculosis (TB) of spine. TB of dorsal spine almost always produces kyphosis while cervical and lumbar spine shows reversal of lordosis to begin with followed by kyphosis. kyphosis continues to increase in adults when patients are treated nonoperatively or by surgical decompression. In children, kyphosis continues to increase even after healing of the tubercular disease. The residual, healed kyphosis on a long follow-up produces painful costopelvic impingement, reduced vital capacity and eventually respiratory complications; spinal canal stenosis proximal to the kyphosis and paraplegia with healed disease, thus affecting the quality and span of life. These complications can be avoided by early diagnosis of tubercular spine lesion to heal with minimal or no kyphosis. When tubercular lesion reports with kyphosis of more than 50° or is likely to progress further, they should be undertaken for kyphus correction. The sequential steps of kyphosis correction include anterior decompression and corpectomy, posterior column shortening, posterior instrumentation, anterior bone grafting and posterior fusion. During the procedure, the spinal cord should be kept under vision so that it should not elongate. Internal kyphectomy (gibbectomy) is a preferred treatment for late onset paraplegia with severe healed kyphosis.
Kyphotic deformity; late onset paraplegia; TB spine; kyphus correction; extrapleural anterolateral approach
A retrospective study.
We evaluated the results of the use of anterior debridement and interbody fusion followed by posterior spinal instrumentation.
Overview of Literature
An early diagnosis of pyogenic spondylitis is difficult to obtain. The disease can be treated with various surgical methods (such as anterior debridement and bone graft, anterior instrumentation, and posterior instrumentation).
This study included 20 patients who received anterior debridement and interbody fusion with strut bone graft followed by posterior spinal fusion for pyogenic spondylitis between 1996 and 2005. We analyzed the culture studies, the correction of the kyphotic angle, blood chemistry, the bony union period, and the amount of symptom relief.
In terms of clinical symptoms relief, eight patients were grouped as "excellent", eleven patients as "good", and one patient as "fair". The vertebral body cultures were positive in 14 patients showing coagulase (-) streptococcus and S. aureus. The average times for normalization of the erythrocyte sedimentation rate and C-reactive protein level were 3.3 and 1.9 months, respectively. Four months was required for bony union. For complications, meralgia paresthetica was found in two
Due to early ambulation and the correction of the kyphotic angle, anterior interbody fusion with strut bone graft and posterior instrumentation could be another favorable method for the treatment of pyogenic spondyulitis.
Pyogenic spondylitis; Anterior interbody fusion; Posterior instrumentation
Approximately 5% of patients with spinal tuberculosis will develop a severe kyphotic deformity resulting in increased potential for pain, spinal cord compression, cardiopulmonary dysfunction, costopelvic impingement and cosmetic concerns. This manuscript reviews the evaluation and surgical management of tuberculous kyphosis.
This is a review article.
Risk factors for the development of severe kyphosis include those who develop spinal tuberculosis as children, multiple vertebral body involvement and thoracic spine involvement. These complications can be prevented by early diagnosis and treatment of spinal tubercular lesions at stages with little to no deformity. When tubercular lesions result in progression of kyphosis to more than 50 degrees, the deformity should be surgically corrected to avoid problems associated with sagittal imbalance. There are several operations described for the treatment of kyphosis secondary to tuberculous spondylitis. The type of the operation depends on the magnitude of correction required.
Anterior, posterior and combined techniques as well as osteotomies and vertebral column resection have been described to correct spinal alignment and restore sagittal balance.
This is a retrospective series.
We wanted to analyze the safety and effectiveness of using the newer generation metallic implants (pedicle screws and/or titanium mesh) for the treatment of tuberculous spondylitis.
Overview of the Literature
There have been various efforts to prevent the development of a kyphotic deformity after the treatment of tuberculous spondylitis, including instrumentation of the spine. Pedicle screws and titanium mesh cages have become more and more popular for treating various spinal problems.
Twenty two patients who had tuberculous spondylitis were treated with anterior radical debridement and their anterior column of spine was supported with a tricortical iliac bone graft (12 patients) or by mesh (10 patients). Supplementary posterior pedicle screw instrumentation was performed in 17 of 22 patients. The combination of surgeries were anterior strut bone grafting and posterior pedicle screws in 12 patients, anterior titanium mesh and posterior pedicle screws in 5 patients and anterior mesh only without pedicle screws in 5 patients. The patients were followed up with assessing the laboratory inflammatory parameters, the serial plain radiographs and the neurological recovery.
The erythrocyte sedimentation rate and C-reactive protein levels were eventually normalized and there was no case of persistent infection or failure to control infection in spite of a mettalic implant in situ. The overall correction of kyphotic deformity was initially 8.9 degrees, and the loss of correction was 6.2 degrees. In spite of some loss of correction, this technique effectively prevented clinically significant kyphotic deformity. The preoperative Frankel grades were B for 1 patient, C for 4, D for 4 and E for 13. At the final follow-up, 7 of 9 patients recovered completely to Frankel grade E and only two patients showed a Frankel grade of D.
Stabilizing the spine with pedicle screws and/or titanium mesh in patients with tubercuous spondylitis effectively prevents the development of kyphotic deformity and this did not prevent controlling infection when this technique was combined with radical debridement and anti-tuberculous chemotherapy.
Tuberculous spondylitis; Pedicle screw; Titanium mesh
Approach for surgical treatment of thoracolumbar tuberculosis has been controversial. The aim of present study is to compare the clinical, radiological and functional outcome of anterior versus posterior debridement and spinal fixation for the surgical treatment of thoracic and thoracolumbar tuberculosis.
Materials and Methods:
70 patients with spinal tuberculosis treated surgically between Jan 2001 and Dec 2006 were included in the study. Thirty four patients (group I) with mean age 34.9 years underwent anterior debridement, decompression and instrumentation by anterior transthoracic, transpleural and/or retroperitoneal diaphragm cutting approach. Thirty six patients (group II) with mean age of 33.6 years were operated by posterolateral (extracavitary) decompression and posterior instrumentation. Various parameters like blood loss, surgical time, levels of instrumentation, neurological recovery, and kyphosis improvement were compared. Fusion assessment was done as per Bridwell criteria. Functional outcome was assessed using Prolo scale. Mean followup was 26 months.
Mean surgical time in group I was 5 h 10 min versus 4 h 50 min in group II (P>0.05). Average blood loss in group I was 900 ml compared to 1100 ml in group II (P>0.05). In group I, the percentage immediate correction in kyphosis was 52.27% versus 72.80% in group II. Satisfactory bony fusion (grades I and II) was seen in 100% patients in group I versus 97.22% in group II. Three patients in group I needed prolonged immediate postoperative ICU support compared to one in group II. Injury to lung parenchyma was seen in one patient in group I while the anterior procedure had to be abandoned in one case due to pleural adhesions. Functional outcome (Prolo scale) in group II was good in 94.4% patients compared to 88.23% patients in group I.
Though the anterior approach is an equally good method for debridement and stabilization, kyphus correction is better with posterior instrumentation and the posterior approach is associated with less morbidity and complications.
Anterior approach; extracavitary approach; posterior approach; Pott's spine
Invasive spinal aspergillosis in an immunocompetent child is rare and often there is a considerable delay in diagnosis. A 13-year-old male child treated medically as tuberculosis of spine elsewhere for 1 year, came with complete paraplegia, dorsolumbar kyphosis and intermittently discharging sinus in the back. The child was taken up for surgical decompression and stabilization. Intraoperatively black granulomatous material was noted inside the canal extending anteriorly towards the vertebral body. There was complete cord transection with severe vertebral destruction and osteoporosis. The pathology and microbiology confirmed aspergillosis and the child was started on antifungal treatment. At further follow up, the infection was found to spread to the lung and caused further vertebral destruction. A change in the antifungal medication controlled further spread but failed to eradicate the infection at 2-year follow-up. In this patient, the delay led to extensive vertebral destruction with spine deformity and spontaneous cord transection. Retrospective review of the clinical and radiological findings suggests that this complication could have been prevented if these findings were carefully interpreted. In this era of transplantation and increase in use of immunosuppressive drugs the authors suggests having fungal infection as a differential diagnosis for infections of the spine.
Invasive aspergillus spondylitis; Immunocompetent; Vertebral destruction; Spontaneous cord transection
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.
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.
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.
Kyphosis; posterior fusion; tuberculosis; children
The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multiple staged with a high morbidity. Here, we describe the procedure and results of closing–opening osteotomy for correction of PTK which shortens the posterior column and opens the anterior column appropriately to correct the deformity without altering the length of the spinal cord. Seventeen patients with PTK (10 males; 7 females) with an average age of 18.3 ± 10.6 years (range 4–40 years) formed the study group. There were ten thoracolumbar, one lumbar and six thoracic deformities. The number of vertebrae involved ranged from 2 to 5 (average 2.8). Preoperative kyphosis averaged 69.2° ± 25.1° (range 42°–104°) which included ten patients with deformity greater than 60°. The average vertebral body loss was 2.01 ± 0.79 (range 1.1–4.1). The neurological status was normal in 13 patients, Frankel’s grade D in three patients and grade C in one. Posterior stabilization with pedicle screw instrumentation was followed by a preoperatively calculated wedge resection. Anterior column reconstruction was performed using rib grafts in four, tricortical iliac bone graft in five, cages in six, and bone chips alone and fibular graft in one patient each. Average operating time was 280 min (200–340 min) with an average blood loss of 820 ml (range 500–1,600 ml). The postoperative kyphosis averaged 32.4° ± 19.5° (range 8°–62°). The percentage correction of kyphosis achieved was 56.8 ± 14.6% (range 32–83%). No patient with normal preoperative neurological status showed deterioration in neurology after surgery. The last follow-up was at an average of 43 ± 4 months (range 32–64 months). The average loss of correction at the last follow-up was 5.4° (range 3°–9°). At the last follow-up, the mean preoperative pain visual analogue scale score decreased significantly from 9.2 (range 8–10 points) to 1.5 (range 1–2 points). There was also a significant decrease in mean preoperative Oswestry’s Disability Index from 56.4 (range 46–68) to 10.6 (range 6–15). Complications were superficial wound infections in two, neurological deterioration in one, temporary jaundice in one and implant failure requiring revision in one. Single-stage closing–opening wedge osteotomy is an effective method to correct severe PTK. The procedure has the advantage of being a posterior only, single-stage correction, which allows for significant correction with minimal complications.
Tuberculosis; Kyphosis; Closing–opening wedge; Osteotomy
An achondroplastic patient with a thoracolumbar kyphosis was first seen at the age of 16 at our institution. His only concern at that time was the aesthetic implication of his deformity. His physical examination was normal except for loss of the neurologic reflexes in the lower limbs. The radiographs showed a fixed 180° thoracolumbar kyphosis with correct frontal and sagittal balances. No spinal cord anomaly was found on MRI. Two years later, he developed a progressive neurogenic claudication of the lower limbs. He was still neurologically intact at rest. The MRI showed an abnormal central spinal cord signal in front of the apex of the kyphosis associated with the narrow congenital spinal canal. In regards to this progressive neurological worsening, a surgical treatment was decided. We decided to perform a front and back arthrodesis combined with a spinal cord decompression without reduction of the deformity. A five-level hemilaminotomy was performed with a posterior approach at the kyphosis deformity. The spinal cord was individualised onto 10 cm and the left nerve roots were isolated. A decancellation osteotomy of the three apex vertebrae and a disc excision were performed. The posterior aspect of the vertebral body was then translated forward 2 cm and in association with the spinal cord. Two nerve roots were severed laterally to approach the anterior part of the kyphosis and a peroneal strut graft was inlayed anterolaterally. A complementary anterior and a right posterolateral fusion was made with cancellous bone. The patient was immobilised in a cast for 3 months relayed by a thoracolumbosacral orthosis for 6 months. At 3 years follow-up, the neurogenic claudication had disappeared. No worsening of the kyphosis was observed. His only complaint is violent electric shock in the lower limbs with any external sudden pressure on the spinal cord in the area uncovered by bone.
Achondroplasia; Thoracolumbar kyphosis; Spinal stenosis
With the advancement of instrumentation and minimally access techniques in the field of spine surgery, good surgical decompression and instrumentation can be done for tuberculous spondylitis with known advantage of MIS (minimally invasive surgery). The aim of this study was to assess the outcome of the minimally invasive techniques in the surgical treatment of patients with tuberculous spondylodiscitis.
Materials and Methods:
23 patients (Group A) with a mean age 38.2 years with single-level spondylodiscitis between T4-T11 treated with video-assisted thoracoscopic surgery (VATS) involving anterior debridement and fusion and 15 patients (Group B) with a mean age of 32.5 years who underwent minimally invasive posterior pedicle screw instrumentation and mini open posterolateral debridement and fusion were included in study. The study was conducted from Mar 2003 to Dec 2009 duration. The indication of surgery was progressive neurological deficit and/or instability. The patients were evaluated for blood loss, duration of surgery, VAS scores, improvement in kyphosis, and fusion status. Improvement in neurology was documented and functional outcome was judged by oswestry disability index (ODI).
The mean blood loss in Group A (VATS category) was 780 ml (330-1180 ml) and the operative time averaged was 228 min (102-330 min). The average preoperative kyphosis in Group A was 38° which was corrected to 30°. Twenty-two patients who underwent VATS had good fusion (Grade I and Grade II) with failure of fusion in one. Complications occurred in seven patients who underwent VATS. The mean blood loss was 625 ml (350-800 ml) with an average duration of surgery of 255 min (180-345 min) in the percutaneous posterior instrumentation group (Group B). The average preoperative segmental (kyphosis) Cobb's angle of three patients with thoracic TB in Group B was 41.25° (28-48°), improved to 14.5°(11°- 21°) in the immediate postoperative period (71.8% correction). The average preoperative segmental kyphosis in another 12 patients in Group B with lumbar tuberculosis of 20.25° improved to –12.08° of lordosis with 32.33° average correction of deformity. Good fusion (Grade I and Grade II) was achieved in 14 patients and Grade III fusion in 1 patient in Group B. One patient suffered with pseudoarthrosis/doubtful fusion with screw loosening in the percutaneous group.
Good fusion rate with encouraging functional results can be obtained in caries spine with minimally invasive techniques with all the major advantages of a minimally invasive procedures including reduction in approach-related morbidity.
Minimally invasive spine surgery; tuberculous spondylodiscitis; video-assisted thoracoscopic surgery
We retrospectively studied the cases with tuberculous spondylitis of thoracolumbar region with two or more levels of involvement that underwent posterior instrumentation and fusion and anterior fusion with titanium mesh following anterior decompression using simultaneous successive posterior–anterior–posterior surgery. Among all patients with tuberculous spondylitis accompanied by medium or severe kyphosis, 20 patients who underwent simultaneous successive decompression, fusion and instrumentation with posterior–anterior–posterior surgery between 1999 and 2004 were included in the study. Patients were evaluated for fusion formation and neurological and functional status. Kyphosis angles were measured at early and long-term follow-up. Antituberculosis chemotherapy was initiated in all patients and continued for 9 months; initially as quadruple therapy for 3 months, and then as triple therapy. Average follow-up period was 52.7 months (range 37–94). Solid fusion was achieved in all patients. All patients returned to their previous occupation; 75% (15 subjects) with mild pain or no pain and 15% (3 subjects) with major limitations. There were 11 patients with neurological deficit, 9 of these achieved complete neurological recoveries. Regarding kyphosis angle, an average 35.1° correction (84.8%) was obtained in postoperative period (p < 0.001) and there was no significant correction loss during the follow-up period (p < 0.05). There were no grafts or instrumentation-related stabilization problems. In subjects with tuberculous spondylitis with involvements at two or more levels accompanied by medium and severe kyphosis, decompression, fusion and instrumentation by simultaneous successive posterior–anterior–posterior surgery is an effective and safe management method for effective kyphosis correction with high fusion rates.
Tuberculous spondylitis; Surgical treatment; Simultaneous successive posterior–anterior–posterior surgery; Kyphosis
A retrospective review was carried out on 23 patients with rigid fixed kyphosis who underwent surgical correction for their deformity.
To report the results of surgical correction of fixed kyphosis according to the surgical approaches or methods.
Overview of Literature
Surgical correction of fixed kyphosis is more dangerous than the correction of any other spinal deformity because of the high incidence of paraplegia.
There were 12 cases of acute angular kyphosis (6 congenital, 6 healed tuberculosis) and 11 cases of round kyphosis (10 ankylosing spondylitis, 1 Scheuermann's kyphosis). Patients were excluded if their kyphosis was due to active tuberculosis, fractures, or degenerative lumbar changes. Operative procedures consisted of anterior, posterior and combined approaches with or without total vertebrectomy. Anterior procedure only was performed in 2 cases, while posterior procedure only was performed in 8 cases. Combined procedures were used in 13 cases, including 4 total vertebrectomies.
The average kyphotic angle was 71.8° preoperatively, 31.0° postoperatively, and the average final angle was 39.2°. Thus, the correction rate was 57% and the correction loss rate was 12%. In acute angular kyphosis, correction rate of an anterior procedure only was 71%, correction rate of the combined procedures without total vertebrectomy was 49% and correction rate of the combined procedures with total vertebrectomy was 60%. In round kyphosis, correction rate of posterior procedure only was 65% and correction rate of combined procedures was 59%. The clinical results according to the Kirkaldy-Willis scale demonstrated 17 excellent outcomes, 5 good outcomes and one poor outcome.
Our data indicates that the combined approach and especially the total vertebrectomy showed the safety and the greatest correction rate if acute angular kyphosis was greater than 60 degrees.
Surgical correction; Fixed kyphosis; Total vertebrectomy
Study design: Two cases of intraoperative, iatrogenic cervical spine fractures in patients with ankylosing spondylitis are reported. Objective: To describe the uncommon complication of iatrogenic cervical spine fractures occurring during spine surgery in patients with ankylosing spondylitis. Summary of background data: To our knowledge, this is the first report on this rare complication. Methods: A 39-year-old patient (1) with ankylosing spondylitis was operated on for cervical stenosis due to C1/2 anterolisthesis. Fifteen hours postoperatively, he developed acute quadriplegia. MRI revealed a fracture/dislocation of C6 on C7 and compression of the spinal cord at this level. Revision was performed with decompression and instrumentation from the occiput to T3. A 55-year-old patient (2) with ankylosing spondylitis and thoracic hyperkyphosis underwent a correction procedure consisting of costotransversectomy, anterior cage implantation at T8/9, and posterior instrumentation from T4 to L1. Halo traction was temporarily applied for correction. At the end of the operation, with the patient still under anesthesia, increased mobility of the cervical spine was noticed. Emergent MRI revealed a fracture of the anterior structures of C6/7. Posterior instrumentation from C5 to T1 was then performed. Results: Quadriplegia persisted in patient 1 until his death secondary to further complications. Patient 2 was mobilized without any neurologic deficits. The fracture healed in good alignment. Conclusions: Iatrogenic fractures of the cervical spine during surgery in ankylosing spondylitis patients are a rare but potentially severe complication. Early diagnosis and therapy are necessary before dislocation, cord compression, and subsequent neurologic impairment occur.
Ankylosing spondylitis; Iatrogenic fracture; Cervical spine fracture
The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12–56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2° (range −20° to 64°) by 9.4° to −0.2° (range −32° to 40°) postoperatively and lost 0.9° during follow-up . All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0–22) in the Roland–Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.
Vertebral osteomyelitis; Spinal infection; Spondylodiscitis; Cages; Spinal fusion
Previous reports have emphasized the importance of neural decompression through either an anterior or posterior approach when reconstruction surgery is performed for neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine. However, the contribution of these decompression procedures to neurological recovery has not been fully established. In the present study, we investigated 14 consecutive patients who had incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine and underwent posterior instrumented fusion without neural decompression. They were radiographically and neurologically assessed during an average follow-up period of 25 months. The mean local kyphosis angle was 14.6° at flexion and 4.1° at extension preoperatively, indicating marked instability at the collapsed vertebrae. The mean spinal canal occupation by bone fragments was 21%. After surgery, solid bony fusion was obtained in all patients. The mean local kyphosis angle became 5.8° immediately after surgery and 9.9° at the final follow-up. There was no implant dislodgement, and no additional surgery was required. In all patients, back pain was relieved, and neurological improvement was obtained by at least one modified Frankel grade. The present series demonstrate that the posterior instrumented fusion without neural decompression for incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine can provide neurological improvement and relief of back pain without major complications. We suggest that neural decompression is not essential for the treatment of neurological impairment due to osteoporotic vertebral collapse with dynamic mobility.
Neurological deficit; Osteoporosis; Vertebral collapse; Thoracolumbar spine; Posterior fusion
An accepted comprehensive clinical approach to the deformed spine with tuberculous infection is still lacking. We aimed to determine the usage of a staged algorithm in the treatment of kyphotic spine with tuberculous infection and to present the clinical results of the patients treated with the help of this protocol.
Materials and Methods:
54 patients (28 females, 26 males) with a mean age of 39.2 (22-76) years. Preoperative, early postoperative, and followup clinical and radiologic results were evaluated retrospectively. The patients were classified into Kaplan A (kyphotic deformity <30°), Kaplan B (kyphotic deformity 30°-60°) and Kaplan C (kyphotic deformity >60°). They were operated by posterior instrument with anterior debridment (Kaplan A), debridment with anterior bone grafting (Kaplan B) and anterior column resection and bone grafting in Kaplan C.
Tuberculous involvement were seen at more than one level in 40 patients and paraspinal abscess were detected in 31. Preoperative focal kyphotic deformity was reconstructed with an average of 19 (9-38) degrees. Twenty-six patients had neurologic compromise with different severities and 12 of them improved after the surgical intervention. Improvement in work ability and pain status was detected in 52% and 61% of the patients, respectively. Wound complications responding to medical care were detected in nine patients. Initial kyphotic deformity was found as an important parameter in selecting the surgical procedure.
Regarding resected amount of infected osseous material, as planned preoperatively, have resulted with better concordance between anterior and posterior column heights and better sagittal alignment. We could correct kyphosis and improve sagittal balance with staged algorithm as used by us.
Debridement; kyphosis in tuberculous spondylitis; tuberculous spondylitis
A 26-year-old paraplegic schizophrenic Japanese woman suffered from severe kyphosis and back pain derived from lumbar burst fractures caused by jumping. She had already undergone resection of the L1 and L2 spinous processes for sharp angular kyphosis, but she still had severe kyphosis and back pain at the L1 and L2. Radiographical examination revealed fused anterior columns at L1 and L2 with severe local kyphosis and a significantly decreased percutaneous distance in the back. The patient underwent anterior instrumented bony resection including an L2 vertebral osteotomy: bilateral L2-L3 facetectomy and partial posterior osteotomy of the L2 vertebrae via a posterior approach followed by an anterior corpectomy of the L2 vertebrae and insertion of a cylindrical cage. No posterior instrumentation was used owing to the presence of atrophied paraspinal soft tissues. Lumbar interbody fusion was performed with vertebral body screws extending from T12 to L4 and corresponding anterior distension and posterior compression. The procedure corrected the kyphosis by 15° and enhanced local stability. Postsurgical visual analogue scale improved from 9.0 to 2.0 and Oswestry Disability Index from 40 to 17.8, respectively. In conclusion, we have demonstrated that anterolateral interbody fusion using extended fixation can compensate for posterior corrective surgery.
This is a retrospective study.
We wanted to evaluate the treatment outcomes of performing simultaneous anterior and posterior surgery for patients with tuberculous spondylitis and psoas abscess.
Overview of Literature
Although various treatment options have been used for spinal tuberculosis, there are only a few reports on the treatment of tuberculous spondylitis with psoas abscess.
Between March 1997 and February 2006, we performed operations on 14 cases of tuberculous spondylitis with psoas abscess. All the cases underwent anterior debridement with an interbody bone graft and posterior fusion with using pedicle screws.
Under the Frankel classification, 1 case improved by two grades, 10 cases improved by 1 grade and 3 cases demonstrated no change. The Kirkaldy-Willis functional outcomes were classified as excellent in 10 cases and good in 4. One year after surgery, bony union was confirmed in all 14 cases. The mean kyphotic angle of the spinal lesion was 12.4° and the mean lordotic angle at the final follow-up was 6.4°. Postoperative complications (superficial wound infections) were encountered in 2 cases.
Our results demonstrate that anterior debridement with interbody bone grafting and posterior instrumented fusion can provide satisfactory results for treating tuberculous spondylitis with psoas abscess in patients with neurological deficits.
Tuberculous spondylitis; Psoas abscess; Neurological deficit; Anterior and posterior surgery
The outcomes of surgical treatment and related complications of post-tubercular kyphotic (PTK) deformity of the cervical spine or the cervico-thoracic spine were evaluated.
From January 2005 to October 2010, 12 cases with PTK (7 males, 5 females) with an average age of 30 years (range 21–43 years) formed the study group. There were ten patients with cervical deformities and two with cervico-thoracic kyphosis. Neurological function of all the patients was evaluated by the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) score. Two patients with severe cervico-thoracic deformity received modified skeleton traction pre-operatively. Ten patients underwent anterior debridement and reconstruction, using iliac crest or cages with autografts, while two patients with cervico-thoracic kyphosis received posterior instrumentation and fusion.
The mean pre-operative focal kyphotic angle was 42.58° (range 30–67°), reducing to −8° (range −15–11°) postoperatively (at the last follow-up visit). The average operating time was 117.50 min (80–200 min) with an average blood loss of 110 ml (range 50–300 ml). Neurological assessment of all the patients, using the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) score, was improved significantly after surgery. All patients had solid fusion and no major complication was observed in the follow-up.
One-stage anterior debridement, instrumentation and fusion for cervical spinal TB and single posterior instrumentation for cervico-thoracic spinal TB followed by chemotherapy is practical to correct PTK. The procedure has the advantage of lower blood loss, effective kyphosis correction and minimal complications. To patients with severe deformity, skeletal traction seemed indispensible.
The purpose of this study was to validate the efficacy and safety of single-stage posterior instrumentation and anterior debridement for treatment of active spinal tuberculosis with kyphotic deformity.
From January 2005 to January 2009, 13 males and 24 females were enrolled in this retrospective study. All patients underwent single-stage posterior instrumentation and fusion, combined with anterior radical debridement and bone grafting. Clinical and radiographic results were analysed.
Patients were followed-up for 33.6 months on average. Bony fusion was achieved at six- to nine-month follow-up in all patients. The respective average kyphosis at the pre-operative and the last follow-up was 53.5° and 12.6°, with a mean correction of 40.9° (78.5%). Neurologic recovery averaged 1.5 grades on the Frankel scale. No recurrence of tuberculosis or instrumentation failure occurred.
Single-stage posterior instrumentation and anterior debridement with fusion was demonstrated to be a safe and effective method to achieve spinal decompression and kyphosis correction in patients with Pott’s disease.
Surgical treatment is mandatory for spinal pseudarthrosis in advanced ankylosing spondylitis (AS) patients with painful sagittal deformity and/or neurological deficits. However, the most effective and safe surgical procedure for AS-related symptomatic thoracolumbar pseudarthrosis is still controversial. The purpose of this study is to explore the outcomes of pedicle subtraction osteotomy (PSO) at the level of pseudarthrotic lesion combined with supplemental anterior fusion for patients suffering from kyphotic pseudarthrosis in AS.
Materials and methods
Seven AS patients with thoracolumbar pseudarthrosis and kyphotic deformity were reviewed. There were 6 males and 1 female with a mean age of 41.7 years. All patients had back pain. Imaging findings demonstrated 3-column extensive discovertebral destruction in all patients. The preoperative global kyphosis averaged 75° (range, 37°–114°) with the apex at the level of pseudarthrosis. Three patients had incomplete neurological deficits (Frankel D) preoperatively. All patients underwent PSO at the level of pseudarthrosis in the first stage followed by supplemental anterior fusion in the second stage. Radiographic and clinical outcomes were assessed with an average follow-up of 38 months (range, 24–59 months). The visual analogue scale (VAS) was compared before surgery and at the final follow-up.
All patients showed significant pain relief postoperatively and were satisfied with the kyphosis correction as well. Solid bony fusion was shown at the final follow-up. Three patients with neurological deficits had complete recovery of neurological function. The global kyphosis was corrected from 75º to 30º, with a mean correction of 45º. The VAS showed significant improvement. No surgical complication was observed.
PSO can be safely performed through the site of pseudarthrotic lesion in AS patients with pseudarthrosis and kyphotic deformity. After PSO, supplemental anterior fusion is sometimes necessary to support the anterior and middle column in a second stage if there is a bone defect in the osteotomy site.
Ankylosing spondylitis; Pseudarthrosis; Osteotomy
Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single “T” incision outcome in thoracolumbar spinal trauma and tuberculosis.
Patients and Methods:
Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single “T” incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height.
In traumatic spine group the mean duration of surgery was 269 minutes (range 215–315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550–1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750–2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care.
Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by “T” incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.
Extra pleural retroperitoneal approach; thoracolumbar spine; spinal trauma; tuberculosis of spine
The recommended surgical options for postoperative wound infections after instrumented spine surgery include a wide debridement and irrigation with antibiotics. In most cases, implant removal is not recommended for a solid fusion. However, there are few reports on the treatment choices for persistent postoperative wound infections following a posterior lumbar interbody fusion (PLIF) using cages. This paper reviewed ten patients referred to our department, who underwent revision surgery for a postoperative, deep infection after a PLIF with cages. The surgery included an anterior radical debridement and interbody fusion with removal of all implants. The clinical and laboratory results, including a bacteriologic study for the causative organism and the radiological changes, were analyzed. All patients complained of persistent severe back pain after the primary surgery. MRSA was the main organism found in these patients (five cases). Complete bony fusion was obtained in nine patients (90%). In one patient, back pain and radiating pain prevented him from returning to his original work. Despite the anterior interbody fusion with an autogenous iliac bone graft, all cases had a complete collapse of the intervertebral disc space, without a dislodgement or collapse of the graft bone. The mean loss of the height and lordosis in the involved segment was 12.7 mm (range 4–46 mm) and 5.6° (range 0–15°), respectively. Anterior radical debridement with the removal of all implants would be an effective way to manage patients with postoperative spondylitis after a PLIF using cages.
Spondylitis; Posterior lumbar interbody fusion; Cage