SPINAL TUBERCULOSIS :ROLE OF

SURGERY

KHALED ABDEEN,AHMED AZAB* ,HISHAM ABORAHMA*

ALEXANDRIA UNIVERSITY

* ALMONEFIA UNIVERSITY-EGYPT

Epidemiology

• 8.8 million new cases of TB/year . • Developing counteries account for nearly 75% of

all case of TB . • TB spine accounts for 2% of all cases .• 50% of skeletal TB .• Thorcic and thoracolumbar regions mostly

affected .• Cervical TB accounts 3-9 % .• Skip lesions 7-10 % .

TWO Groups

• Radical surgery patients :

• Progressive neurological deficits .

• Abscess .

• Kyphosis .

• Interactable pain .

• ATT alone patients .

• 52 TB spine patients treated surgically . • 2001-2012. • Age: 12-70 years . • 32 male:20 females • Follow up between 1-10 years . • All patients received anti tuberculous treatment . • Plain x ray , MRI , ESR .

Group A. The lesion was limited to the anterior column, with no abnormal signals on MRI at, or posterior to, the pedicles. No deformity was present. The lesion was either paradiscal or central body in type

Group B. The lesions involved the anterior and posterior columns atthe same levels and were unstable with an associatedkyphosis .

Isolated posterior lesion

J. S. Mehta, MS Orth, D Orth, MCh Orth, Orthopaedic SpecialistRegistrar JBJS VOL. 83-B, NO. 6, AUGUST 2001

• Objective : to evaluate different surgical modalities in the treatment of spinal tuberculosis and its outcome as regard neurological improvement ,bony fusion ,and spinal stability .

• This study included 25 patients with spinal tuberculosis [10 of them with cervical affection ,and 15 with dorsolumbar tuberculosis] ,their mean age 38.5 ys [average 28 –56 ys ] with an average follow up period of 15 months [12- 36 months ].This study included two groups ,the cervical group[C3-7] included 10 patients and the dorsolumbar group included 15 patients .All of our patients presented with neurologic deficits for short period with average 2-6 months.All patients received antituberculous medications for 9-12 months.

Diagnosis

• Culture , antigen demonstration, serology tests ,and polymerasechain reaction are of high priority .

• The polymerase chain reaction has facilitated the diagnosis and treatment .

Treatment

• Effective chemotherapy for spinal tuberculosis is the gold standard and mainstay of treatment and all other methods of treatment are regarded as supplementary .

• Triple chemotherapy should be given for 12 months [ rifampicin, isoniazide , and pyazinamide ]

RESULTS

• Microbiological and histopathological studies of the operative specimen revealed specific, granulomatous infection consistent with tuberculosis. All patients had an increased erythrocyte sedimentation rate before anti-tuberculous medication returnedto normal within 6 months after medication .

• Neurological outcome: Neurological deficits were improved at final up examination

as defined by the scoring system of Frankel . two patients of grade B before surgery , had improvement to grade C and grade D , of the 12 with grade C , 8 had complete recovery to grade E , and 4 had improvement to grade D , 5patients with grade D had complete recovery to grade E .

RESULTS

• Radiological evaluation: x-ray showed the destruction of contiguous vertebral bodies with involvement of the disc space between them in 23 patients(paradiscal type , collapsed C4 vertebral body (central type) in two patients and the presence of widened prevertebral space was evident in all patients . CT delineated bone involvement and paravertebral abscess extension . MRI was performed in all cases to show the epidural abscess and degree of spinal cord compression . (fi.

• Bony Fusion:Clinical and radiological evidence of stable fusion observed in all patients,

with one segment fusion was obtained at average of 4 months and 2 segments fusion was obtained at average of 5 months (3.5 to 6 months) .

• Angle of kyphosis:In the dorsolumbar groupThe average of pre-operative Kyphosis angle was 36 degrees (range 32-48 degrees)and the average angle of kyphosis in last follow-up was 17 degrees (range 13-19 degrees) while in the cervical group, there was bone destruction but no significant kyphotic deformity

• The cervical group: 9 of them treated by anterior cervical approach for decompression followed by fixation by iliac bone graft and cervical plating ,one patient with C3 tuberculosis managed by single stage- combined anterior decompression and fusion by iliac bone graft followed by posterior occipitocervical fixation by Ransford Loop . There was an improvement in the Nurick grade from a preoperative mean of 2.5 to mean 0.3 at the last follow up .

• The dorsolumbar group: 6 cases managed by posterior instrumentation [4 cases segmental fixation by transpedicular screws and 2 cases with Hartshill rectangle with sublaminar wires] , anterior approach in 7 cases, and another 2 cases circumferential fusion were done at one operative setting.

C3 TUBERCULOSIS

APPROACH

COMBINED SINGLE STAGE {ANTERIOR&POSTERIOR}

C3 Tuberculosis

RESULTS

• All patients showed improved neurological outcome.All of them had solid fusion within average 6 months .

• In the dorsolumbar group ,angle of kyphosis was improved in all patients , average angle of kyphosis preoperative was 36 degree and at the late follow up ,it was 17 degree and no implant complications .

CONCULSIONS

• Early surgical intervention ,either posterior rigid fixation ,anterior interbody fusion or circumferential fusion plus chemotherapy were found to help in arresting the disease providing satisfactory stabilization ,as well as preventing progression of kyphosis and correcting kyphosis .there is no additional risk related to the use of an implant even if large quantities of pus were present

SPINAL TUBERCULOSIS :ROLE OF

SURGERY

KHALED ABDEEN,AHMED AZAB* ,HISHAM ABORAHMA*

ALEXANDRIA UNIVERSITY

* ALMONEFIA UNIVERSITY-EGYPT

Epidemiology

• TB spine accounts for 2% of all cases .

• 50% of skeletal TB .

• Thorcic and thoracolumbar regions mostly affected .

• Cervical TB accounts 3-9 % .

• Skip lesions 7-10 % .

• Objective : to evaluate different surgical modalities in the treatment of spinal tuberculosis and its outcome as regard neurological improvement ,bony fusion ,and spinal stability .

• This study included 25 patients with spinal tuberculosis [10 of them with cervical affection ,and 15 with dorsolumbar tuberculosis] ,their mean age 38.5 ys [average 28 –56 ys ] with an average follow up period of 15 months [12- 36 months ].This study included two groups ,the cervical group[C3-7] included 10 patients and the dorsolumbar group included 15 patients .All of our patients presented with neurologic deficits for short period with average 2-6 months.All patients received antituberculous medications for 9-12 months.

Diagnosis

• Culture , antigen demonstration, serology tests ,and polymerasechain reaction are of high priority .

• The polymerase chain reaction has facilitated the diagnosis and treatment .

Treatment

• Effective chemotherapy for spinal tuberculosis is the gold standard and mainstay of treatment and all other methods of treatment are regarded as supplementary .

• Triple chemotherapy should be given for 12 months [ rifampicin, isoniazide , and pyazinamide ]

Antituberculous treatment

• All received antituberculous chemotherapy starting two• weeks before surgery. Pyrazinamide was given for the first• Three months only. • Treatment with ethambutol, rifampicin, isonicotinic acid

hydrazide and folic acid supplement continued for a total 9 months .

• Patients with resistant atypical mycobacterial strains were treated on the basis of microbiological advice, the reserve drugs being kanamycin and ciprofloxacillin

RESULTS

• Microbiological and histopathological studies of the operative specimen revealed specific, granulomatous infection consistent with tuberculosis. All patients had an increased erythrocyte sedimentation rate before anti-tuberculous medication returnedto normal within 6 months after medication .

• Neurological outcome: Neurological deficits were improved at final up examination

as defined by the scoring system of Frankel . two patients of grade B before surgery , had improvement to grade C and grade D , of the 12 with grade C , 8 had complete recovery to grade E , and 4 had improvement to grade D , 5patients with grade D had complete recovery to grade E .

RESULTS

• Radiological evaluation: x-ray showed the destruction of contiguous vertebral bodies with involvement of the disc space between them in 23 patients(paradiscal type , collapsed C4 vertebral body (central type) in two patients and the presence of widened prevertebral space was evident in all patients . CT delineated bone involvement and paravertebral abscess extension . MRI was performed in all cases to show the epidural abscess and degree of spinal cord compression . (fi.

• Bony Fusion:Clinical and radiological evidence of stable fusion observed in all patients,

with one segment fusion was obtained at average of 4 months and 2 segments fusion was obtained at average of 5 months (3.5 to 6 months) .

• Angle of kyphosis:In the dorsolumbar groupThe average of pre-operative Kyphosis angle was 36 degrees (range 32-48 degrees)and the average angle of kyphosis in last follow-up was 17 degrees (range 13-19 degrees) while in the cervical group, there was bone destruction but no significant kyphotic deformity

• The cervical group: 9 of them treated by anterior cervical approach for decompression followed by fixation by iliac bone graft and cervical plating ,one patient with C3 tuberculosis managed by single stage- combined anterior decompression and fusion by iliac bone graft followed by posterior occipitocervical fixation by Ransford Loop . There was an improvement in the Nurick grade from a preoperative mean of 2.5 to mean 0.3 at the last follow up .

• The dorsolumbar group: 6 cases managed by posterior instrumentation [4 cases segmental fixation by transpedicular screws and 2 cases with Hartshill rectangle with sublaminar wires] , anterior approach in 7 cases, and another 2 cases circumferential fusion were done at one operative setting.

C3 TUBERCULOSIS

APPROACH

COMBINED SINGLE STAGE {ANTERIOR&POSTERIOR}

C3 Tuberculosis

RESULTS

• All patients showed improved neurological outcome.All of them had solid fusion within average 6 months .

• In the dorsolumbar group ,angle of kyphosis was improved in all patients , average angle of kyphosis preoperative was 36 degree and at the late follow up ,it was 17 degree and no implant complications .

CONCULSIONS

• Early surgical intervention ,either posterior rigid fixation ,anterior interbody fusion or circumferential fusion plus chemotherapy were found to help in arresting the disease providing satisfactory stabilization ,as well as preventing progression of kyphosis and correcting kyphosis .there is no additional risk related to the use of an implant even if large quantities of pus were present

• When tuberculosis is suspected, a purified protein derivative skin test will be positive in 95% of cases.

• Immunosuppressed patients may be anergic, leading to falsenegative results.

• Recently, polymerase chain reaction testing has been used to amplify the microbial genome for identification within a few hours when standard culture methods fail.

• Isolation of an organism is necessary for appropriate antibiotic treatment, especially for nonsurgical management; however, definitive identification of the pathogen can only be accomplished using tissue cultures obtained directly from the site of infection.

• In the case of Pott disease, treatment lasts for a mean of 12 months, with variations in duration and type of chemotherapy

depending on regional resistance patterns.

Initially, isoniazid, ethambutol, rifampin, and pyrazinamide are prescribed for the first 2 months. If no information o

sensitivities is available, isoniazid, ethambutol, and rifampin are continued for 12 months. If sensitivities are known, two drugs can be used. If isoniazid and rifampin are active, they are continued for 12 months. If other combinations are used, therapy is extended to 18 to 24 months. In immunocompromised patients, indinavir and rifabutin are added.