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

Surgery for deformities in pediatric spinal tuberculosis: single centre review of 51 cases

PURPOSE

To retrospectively report on the clinical presentation, radiological features, indication, and outcome of surgical management of children with posttubercular spinal deformities with long term outcome.

METHODS

This retrospective study was conducted in a single center operated by a single surgeon from 2002 to 2022, and data from an electronic medical record was reviewed. The indications for surgery included failure of medical treatment, to prevent deformity (depending on location, extent of bone loss, stabilization patterns (A, B, or C), and the presence of "Spine at Risk" signs) or correct deformity and in the presence of major neurodeficit.

RESULTS

51 children (< 15 years) of mean age 12.5, and mean follow-up of 7 years (2-15) were included. Pain, deformity/instability, and limb weakness were seen in 34 (66.6%) patients (mean mJOA score was 13.44, which improved to 14.7 and 16.8 at immediate postoperative and latest follow-up), with 17 (33.3%) patients presenting with deformity alone. Dorsal affection was commonest (60.8%), followed by lumbosacral (19.6%) and cervical (19.6%), with multilevel/skip lesions seen in four patients. The mean coronal/sagittal Cobb at presentation was 24.2°/40.96°, which improved to 8.2°/25.6° in the immediate and 8.8°/24.8° at the latest follow-up. Gene Xpert positivity was found in 95%, AFB culture positivity in 84%, and histopathology was positive in 91%. All patients had posterior surgery with an additional anterior reconstruction in 6. The complication rate was 5.8% (N = 3); 2 had implant loosening requiring revision surgery, 1 with prolonged discharging sinus with MDR TB, healed with chemotherapy.

CONCLUSION

Pediatric post-tuberculous spinal deformities require identification of those who are likely to worsen, and close follow-up is mandatory. Failure of medical management, major destruction of vertebral bodies, type C stabilization pattern, and worsening deformity/neurodeficit require surgery with a good outcome.

Posterior-Only Approach for the Correction of Severe Post-tubercular Kyphosis

Tuberculosis of the vertebral column (Pott's disease) accounts for up to one-half of musculoskeletal tuberculous infections. The eradication of the infective organism (Mycobacterium tuberculosis) is achievable with chemotherapy. However, such patients with spinal tuberculosis are at risk of developing spinal deformity, and 3%-5% of the patients develop severe deformity greater than 60°. A 30-year-old female presented with back pain of 11 years, discharging sinus, and progressively worsening kyphotic deformity of eight-year duration. She had completed a full course of anti-tubercular chemotherapy. Her neurological examination was within normal limits. Antero-posterior and lateral view radiographs showed osteolytic destruction and collapsed T12 and L1 vertebrae with a thoracic kyphosis of 90°. We did a single-stage posterior-approach closing-opening osteotomy surgery utilizing costotransversectomy (T12 and L1 corpectomy, the insertion of expandable titanium cage, T10 to L3 pedicle screw, and rod fusion). Postoperative kyphosis was 25°. Her motor and sensory functions remained preserved following surgery. The duration of follow-up was 18 months post operation. The mainstay of treatment of severe post-tubercular kyphosis (PTK) is surgery. The correction is complex and could be staged or with multiple approaches and consequent high risk of complications. A single-stage posterior-approach surgery is less invasive.

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

PURPOSE

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy.

METHODS

The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded.

RESULTS

The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient.

CONCLUSION

Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Comparison of the Clinical Efficacy of 3 Surgical Methods for Treating Spinal Tuberculosis in Children

Background

This study aimed to investigate the safety and clinical efficacy of 3 different surgical methods for treating spinal tuberculosis (ST) in children.

Material/Methods

We reviewed the cases of 62 children with ST who were treated in our hospital from January 2010 to December 2014. In this study, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Frankel classification of neurological function, pain visual analog scale (VAS) score, and kyphosis Cobb (k-Cobb) angle were dynamically monitored to evaluate the efficacy of different surgical methods. Complications in the patients were evaluated at 3 time points: before surgery (T1), after surgery (T2), and during final follow-up (T3). The average follow-up was 27.4 months. Twenty-two patients underwent simple anterior debridement alone or combined with internal fixation (Method A), 13 patients underwent posterior debridement alone (Method B), and 27 patients received anteroposterior debridement and bone graft fusion together with internal fixation (Method C).

Results

In all 3 groups after surgery, ESR, CRP levels, VAS scores, and k-Cobb angles significantly decreased. However, compared with patients who received Methods B and C, patients who received Method A had a significant rebound in k-Cobb angle and a higher incidence of complications at the T3 time point. The overall reoperation rate during follow-up was 37.10%. Fourteen patients (22.58%) had kyphosis, 2 patients (3.23%) had tuberculosis recurrence combined with kyphosis, and other complications were reported in 5 patients (8.06%).

Conclusions

Considering the incidence of complications and level of postoperative biochemical indicators, we concluded that caution should be exercised in using an anterior approach to treat pediatric ST.

Surgical strategy for correction of severe, rigid, post-tubercular cervical kyphosis: an experience of two cases

STUDY DESIGN

Case series.

OBJECTIVES

To describe a novel surgical strategy for severe, rigid post-tubercular cervical kyphosis with treatment outcomes in two patients.

BACKGROUND DATA

Spinal tuberculosis is a common cause of kyphotic deformity in the developing world with 3-5% of non-operatively managed patients ending up with kyphosis exceeding 60°. Ventral, dorsal and combined approaches have been described for cervical kyphosis, but there is no established surgical strategy for severe, rigid post-tubercular cervical kyphosis.

METHODS

We operated on two girls with severe, rigid cervical kyphosis with preoperative kyphosis measuring 98° and 62°. Our surgical strategy included a three-step approach in the same sitting-(1) An anterior approach to osteotomize the fused vertebral body mass, decompress the spinal cord ventrally and place a temporary cage to stabilize the spine, (2) A posterior approach to osteotomize the fused facets and decompress the cord dorsally. With the completion of the osteotomy, a combination of pedicle screws and lateral mass screws was used to correct the deformity via an anterior opening, posterior closing type of osteotomy. This was followed by, (3) An anterior approach to replace the corpectomy cage with a larger one supplemented with an anterior cervical plate.

RESULTS

Our 540° approach achieved a substantial improvement in each of the clinical and radiological parameters we measured, viz. C2-C7 lordosis angle, C2-C7 sagittal vertical axis, neck tilt and Neck Disability Index.

CONCLUSION

For severe, rigid post-tubercular cervical spine kyphosis, a three-step, anterior-posterior-anterior procedure can be used for achieving acceptable correction, improving symptoms and avoiding further progression.

LEVEL OF EVIDENCE

IV.

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

Study Design

Retrospective case series.

Purpose

Describe the technique and evaluate the outcome of apical vertebral column resection (VCR) with sagittal rotation and anterior opening and posterior closing (AOPC) maneuver for correction of severe post-tubercular kyphosis (PTK).

Overview of Literature

The surgical procedures described for the correction of PTK are VCR, pedicle subtraction osteotomy, transpedicular decancellation osteotomy, and closing-opening osteotomy.

Methods

We retrospectively evaluated 21 patients who had been operated on with single stage apical VCR with AOPC maneuver. Radiographs were obtained before surgery and at regular follow-up intervals. These were used to calculate the angle of kyphosis. Back pain was rated using the Visual Analog Scale (VAS) and neurological status was graded using Frankel grading. Radiological outcome was assessed by the improvement in the angle of kyphosis and fusion following surgery. Neurological status was assessed using Frankel grading.

Results

The study included eight males and 13 females with a mean age of 21.9 and average follow-up time of 30.4 months. The average number of vertebral bodies destroyed was 2.57. Kyphosis was improved from a mean of 68.42°±13.23° preoperative to 8.71°±4.58° postoperative. The average correction achieved was 87.10%. Preoperative VAS score improved from a mean of 6.38±0.92 preoperative to 1.38±0.49 postoperative. No patients had any sign of neurological deterioration. Seven out of eight patients with a preoperative neurological deficit improved following surgery. Two patients developed superficial wound maceration, one had persistent postoperative hypotension, and the other developed hemothorax. All patients recovered fully without a need for additional surgery.

Conclusions

Single stage simultaneous anterior column lengthening and posterior column shortening is an effective method for surgical correction of severe PTK.

The outcome of intervertebral surgery in the treatment of lumbar tuberculosis in children: A case series and long-term follow-up

During the operation of treating lumbar tuberculosis in children, a long-segment or short-segment fixation, and fusion method were usually applied, which would adversely affect the function of normal motion unit. And so, we have been focusing on how we can shorten the range of fixation and fusion using intervertebral surgery. The objective of this retrospective study is to investigate the clinical outcome of intervertebral surgery, in the treatment of lumbar tuberculosis in children.From June 2003 to June 2013, 18 children with lumbar tuberculosis underwent intervertebral surgery, using a combined posterior and anterior approach, in our hospital. The surgical treatments included posterior pedicle screw fixation of affected vertebrae and posterolateral bone grafting, anterior debridement, compression, and strut bone grafting. Indicators such as preoperative and postoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, neurological function, visual analog scale (VAS) score, kyphotic Cobb angle, complications, healing of lesions, bone graft healing, and recurrence were statistically analyzed.The mean follow-up time was 86.5 months (range, 62-120 months). Three months after the operation, all patients' ESR and CRP levels decreased to normal, and both the American Spinal Injury Association neurological function scores and VAS scores improved. Successful bone graft healing was achieved, with lesions completely healed at 6 months after surgery, and no recurrence occurred. The preoperative kyphotic was 24.00° ± 13.15° (range -10°-39°), which decreased to -4.61° ± 7.31° (range -19°-10°) postoperative (Z = -4.34, P < .01); the mean deformity correction angle was 28.61° ± 8.43° (range 9°-43°). There was no significant difference between the kyphotic angle measured immediately after surgery at (-4.61° ± 7.31°) and the kyphotic angle measured at 5-year follow-up at (-3.11° ± 7.56°). The mean loss of correction was 1.50° ± 0.90°.Intervertebral surgery using a combined posterior and anterior approach is an effective and safe method for the treatment of lumbar tuberculosis in children. It can also preserve the function of normal motor segments to the maximum extent.

The epidemiology of spinal tuberculosis in the United States: an analysis of 2002–2011 data

OBJECTIVE

The aim of this study was to investigate the incidence of spinal tuberculosis (TB) in the US between 2002 and 2011.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients with a discharge diagnosis of TB and spinal TB. Demographic and hospital data were obtained for all admissions, and included age, sex, race, comorbid conditions, insurance status, hospital location, hospital teaching status, and hospital region. The incidence rate of spinal TB adjusted for population growth was calculated after application of discharge weights.

RESULTS

A total of 75,858 patients with a diagnosis of TB were identified, of whom 2789 had a diagnosis of spinal TB (3.7%); this represents an average of 278.9 cases per year between 2002 and 2011. The incidence of spinal TB decreased significantly—from 0.07 cases per 100,000 persons in 2002 to 0.05 cases per 100,000 in 2011 (p < 0.001), corresponding to 1 case per 2 million persons in the latter year. The median age for patients with spinal TB was 51 years, and 61% were male; 11.6% were patients with diabetes, 11.4% reported recent weight loss, and 8.1% presented with paralysis. There were 619 patients who underwent spinal surgery for TB, with the most common location being the thoracolumbar spine (61.9% of cases); 50% of patients had instrumentation of 3 or more spinal segments.

CONCLUSIONS

During the examined 10-year period, the incidence of spinal TB was found to significantly decrease over time in the US, reaching a rate of 1 case per 2 million persons in 2011. However, the absolute reduction was relatively small, suggesting that although it is uncommon, spinal TB remains a public health concern and most commonly affects male patients approximately 50 years of age. Approximately 20% of patients with spinal TB underwent surgery, most commonly in the thoracolumbar spine.

Surgical Treatment of Angular Pott's Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening

Background:

It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk.

Methods:

Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23.

Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed.

The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal.

Results:

Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root.

Conclusion:

A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards.

Comparison between the antero-posterior and posterior only approaches for treating thoracolumbar tuberculosis (T10-L2) with kyphosis in children: a minimum 3-year follow-up

PURPOSE

There are few papers in the literature comparing outcomes between antero-posterior and posterior-only approaches for treating thoracolumbar tuberculosis (T10–L2) in children.

METHODS

We performed a retrospective review of 47 children who were diagnosed and treated as thoracolumbar tuberculosis (T10–L2) in our department from January 2005 to June 2009. Forty-seven cases of thoracolumbar tuberculosis were treated by two different surgical approaches. All the cases were divided into two groups: 25 cases in group A underwent one-stage posterior debridement, transforaminal fusion, and instrumentation, and 22 cases in group B underwent anterior debridement, bone graft, and posterior instrumentation in a single- or two-stage procedure. Two approaches were compared in terms of average operative time, blood loss, hospitalizations, bony fusion, intraoperative and postoperative complications, the Oswestry disability index score, neurological status, and the angle of kyphosis.

RESULTS

All 47 patients (24 M/23F), averaged 9.1 ± 2.6 years old (range 5 to 14 years), who were followed up for mean of 49.3 ± 8.6 months (range 36 to 65 months). Spinal tuberculosis (TB) was completely cured, and the grafted bones were fused in 9 months in all cases. It was obviously that the average operative time, blood loss, hospitalization, and complication rate of group A was less than those of group B. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the antero-posterior and posterior approaches can effectively heal T10–L2 vertebral tuberculosis, but the average surgical time, blood loss, complications, and hospital stay following the posterior approach are prominently less than those following the antero-posterior approach. It might be a better surgical treatment for thoracic spinal tuberculosis in children with poor health status, especially for cases in early phase of bone destruction and/or mild and moderate kyphosis.

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

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