Single-stage closing-opening wedge osteotomy of spine to correct severe post-tubercular kyphotic deformities of the spine: a 3-year follow-up of 17 patients

Post-tubercular Lumbosacral Kyphotic Deformity in a 11-Year-Old Child: A Case Report

CASE

An 11-year-old girl with intact neurology presented with a lumbosacral kyphotic deformity due to healed tuberculosis. Radiological imaging showed sagittal balanced spine with compensatory thoracic lordosis and cervical kyphosis. She underwent L4 and L5 posterior vertebral column resection (PVCR) with posterior instrumentation from L2 to pelvis. The patient demonstrated immediate correction of compensatory curves postoperatively. At 3-year follow-up, she returned to her activities of daily living with Oswestry Disability Index and Scoliosis Research Society scores of 12 and 4.8% respectively.

CONCLUSION

Pediatric post-tubercular deformities in the lumbosacral region are rare. They can cause secondary changes in other regions, such as the loss of thoracic kyphosis or cervical lordosis. These deformities should be addressed at an early age to prevent structural changes in compensatory curves.

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.

The pre-surgical role of halo-traction in patients with cervical infection associated with refractory kyphosis: a retrospective study

To minimize surgical complications and staged procedures halo-traction is often used during deformity corrections. But the use of halo-traction in the treatment of refractory cervical kyphosis secondary to infections has never been reported. This study investigated the role of halo-traction in the treatment of cervical infection patients associated with refractory kyphosis. We retrospectively reviewed 48 patients with cervical infection associated with refractory kyphosis who were treated in our spine department. Patients were divided into two groups, the traction group (A) and the non-traction group (B). Group A underwent preoperative halo-traction followed by surgery, while group B underwent surgery alone. Between the two groups, we analyzed the kyphosis deformity correction, level of fusions, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), functional improvement by Neck disability index (NDI) score, and complications. Group A had a better correction of kyphosis deformity compared to group B (27.01 ± 11.54)⁰ versus (18.08 ± 10.04)⁰ (P = 0.01, Z =  - 2.44). No statistically significant differences between the two groups in terms of functional improvement, level of fusions, ESR and CRP. Group B had 3 revision surgery cases. Preoperative halo-traction followed by surgery is superior in kyphosis correction in the treatment of patients with cervical infections with refractory kyphosis.

Global realignment after posterior vertebral column resection in severe thoracolumbar post-tubercular kyphosis: correlation with patient-reported outcomes

PURPOSE

To investigate spinal realignment in patients with severe post-tubercular kyphosis (PTK) who underwent posterior vertebral column resection (PVCR) and its correlation with patient-reported outcomes (PROs).

METHODS

Eighty-two patients were included in this study. Spinopelvic parameters (focal scoliosis (FS), coronal balance (CB), sagittal vertical axis (SVA), focal kyphosis (FK), C2-7 lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and pelvic incidence minus lumbar lordosis (PI-LL)) and PROs (Visual Analog Scale (VAS) and Oswestry Disability Index (ODI)) were analyzed. The correlation between spinopelvic parameters and PROs was evaluated.

RESULTS

FK, FS, CL, TK, LL, and PI-LL significantly changed after surgery. FK decreased from pre-operative 108.5 ± 16.4° to 31.8 ± 4.5° at three months after surgery and increased to 38.7 ± 6.6° at final follow-up (P < 0.001). FS decreased from pre-operative 20.9 ± 2.2° to 5.1 ± 2.2° at final follow-up (P < 0.001). CL decreased from pre-operative 7.2 ± 7.3° to 3.3 ± 8.3° at final follow-up (P = 0.002). TK improved from pre-operative - 5.6 ± 7.1° to 12.9 ± 8.2° at final follow-up (P < 0.001). LL decreased from pre-operative 75.5 ± 12.6° to 45.5 ± 7.9° at final follow-up (P < 0.001). PI-LL improved from pre-operative - 24.8 ± 13.4° to 4.8 ± 9.9° at final follow-up (P < 0.001). The improvement of PROs was found to be significantly correlated with the variations of FK, CL, TK, LL, and PI-LL. The multiple regression analysis revealed that FK was an independent predictor for the improvement of VAS and ODI.

CONCLUSIONS

PVCR is effective in treating severe PTK, which can significantly improve patients' clinical and radiographic outcomes. Spine surgeons should pay more attention to reducing the residual kyphosis.

Two-stage treatment for severe spinal kyphotic deformity secondary to tuberculosis: halo-pelvic traction followed by a posterior-only approach correction

Background and purpose

Several surgical procedures are used to treat tuberculous kyphosis. However, the treatment of extreme spinal kyphosis is challenging, and associated with various complications. Halo traction has been used as an adjunctive method in the treatment of severe spinal deformities. However, there are few reports about the effectiveness of halo-pelvic traction (HPT) for the treatment of extreme spinal kyphosis secondary to tuberculosis. This study evaluated the effectiveness of halo-pelvic traction followed by a posterior-only approach correction in the treatment of severe spinal kyphosis secondary to tuberculosis.

Methods

The records of 19 patients with severe spinal kyphosis secondary to tuberculosis were retrospectively reviewed. All 19 patients were treated with a two-stage approach: HPT combined with posterior fusion surgery by a posterior-only approach. Radiographic parameters were measured and evaluated. America Spinal Injury Association grade (ASIA), Scoliosis Research Society outcome (SRS-22) score, and complications were also evaluated.

Results

There were 9 males and 10 females, with an average age of 29.7 years at the time of surgery. The average HPT duration was 10.4 weeks. The mean kyphosis angle decreased from 131.40 ± 10.7° pre-traction to 77.1 ± 7.4° post-traction (P < 0.01). The traction correction rate was 41.3%. The mean postoperative kyphosis angle was 65.7 ± 8.5°, and the surgical correction rate was 8.7%. Of the total correction, 82.6% was the result of HPT. At a mean follow-up of 26.5 months, the average kyphosis correction loss was 2.9°. The mean sagittal balance was 11.1 ± 45.2 mm before traction, − 25.0 ± 37.4 mm after traction, 7.0 ± 13 mm after surgery, and 2.8 ± 9.6 mm at the final follow-up. The mean preoperative SRS-22 score was 3.0 and postoperative was 4.2 (P < 0.01). The neurological status of most patients was improved. The total complication rate was 15.7%, including 1 neurological and 2 non-neurological complications.

Conclusions

HPT is effective in the management of severe spinal kyphotic deformity secondary to tuberculosis. Preoperative HPT can greatly reduce global kyphosis, and the need for corpectomy.

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

Background

Posterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.

Methods

Patients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.

Results

A total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.

Conclusion

Posterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.

One-Stage Posterior Vertebral Column Resection in the Treatment of Adolescent Thoracic and Lumbar Tuberculosis Complicated With Severe Kyphotic Deformity

BACKGROUND

Our study aims to investigate the clinical outcome of 1-stage posterior vertebral column resection (PVCR) for adolescent thoracic and lumbar tuberculosis with severe kyphotic deformity (Cobb angle≥60°).

METHODS

Between January 2008 and January 2016, we recorded 16 (9 male, 7 female) adolescent cases of thoracic and lumbar tuberculosis complicated with severe kyphotic deformity treated by 1-stage PVCR (average age: 15.38 ± 1.54 years; range: 13-18 years). The Cobb angle of kyphosis was 64.56° ± 3.41°. According to the American Spinal Injury Association (ASIA) classification, all patients were classified preoperatively. The lesions involved T4-T11 in 10 cases and T12-L2 in 6 cases.

RESULTS

The mean follow-up time was 19.06 ± 11.42 months (range: 12-48 months). Based on ASIA classification, postoperative grades were significantly increased compared with preoperative grades (P < 0.05), The mean Cobb angle was significantly corrected to 20.25° ± 13.83° at 1 week after surgery, when compared with preoperative Cobb angle (P < 0.05). There was no significant difference in Cobb angle between 1-week after operation and the last follow-up (20.69° ± 13.83°) (P > 0.05). All the patients achieved bony fusion at a mean time of 14 months (range: 10-20 months) postoperatively. No fixation loosening, displacement, or fracture was observed during follow-up.

CONCLUSIONS

One-stage PVCR is an effective surgical method for the treatment of adolescent thoracic and lumbar spinal tuberculosis with severe kyphotic deformity, which can completely remove the lesion, effectively correct the kyphosis deformity, and prevent related complications.

Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes

PURPOSE

To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK).

METHODS

The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months.

RESULTS

Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group.

CONCLUSION

Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

Safety and efficacy of posterior vertebral column resection in complex pediatric deformities

Background

Vertebral column resection (VCR) is a well-known technique used for correction of complex spinal deformities. VCR could be done through a posterior only approach (Pvcr), or a combined anteroposterior approach, with almost comparable results. Early studies of Pvcr have reported high rates of complications, while subsequent studies have reported a reasonable complication rate. In this study, the authors represent and evaluate the initial results of using the Pvcr technique to correct complex pediatric deformities.

Objective

To evaluate the safety and efficacy of performing Pvcr to correct complex pediatric deformities.

Methods

Retrospective cohort study of data was collected from the database of pediatric deformity patients who were operated for correction of their deformities using posterior instrumentation and Pvcr at a single institution from 2015 to 2019.

Results

Twenty-one pediatric patients with a mean age 15.2 ± 3.5 years were enrolled in this study. The mean follow-up period was 26.3 ± 3.1 months. The mean Cobb angle has been decreased significantly from 82.9 ± 23.9 degrees to 28.8 ± 14.2 immediately after correction (correction rate 66.9 ± 10.8%, p < 0.001) with slight increase to 30.2 ± 14.9 after 24 months of follow-up (correction loss 4.3 ± 3.1%). The mean kyphotic angle has decreased significantly from 74.1 ± 15.9 to 25.4 ± 4.5 immediately after correction (correction rate 65.4 ± 2.9%, p < 0.001) with slight increase to 26.7 ± 5.2 after 24 months of follow-up (correction loss 4.8 ± 3.5%). The mean estimated blood loss was 2816.7 ± 1441.5 ml. The mean operative time was 339 ± 84.3 min. Self-image domain (part of SRS-22 questionnaire) has significantly improved from a mean preoperative of 2.3 ± 0.5 to a mean postoperative of 3.9 ± 0.4 after 24 months of correction (p < 0.001). As regards complications, chest tubes were inserted in 17 cases (81%), one case (4.8%) had suffered from deep wound infection and temporary respiratory failure, while 3 cases (14.3%) had neurological deficits.

Conclusion

Posterior vertebral column resection is considered a highly effective release procedure that aids in the correction of almost any type of complex pediatric deformities with a correction rate reaching 66.9 ± 10.8%. However, Pvcr is a challenging procedure with high estimated blood loss and risk of neurological deficits, so it must be done only by experienced spine surgeons in the presence of good anesthesia and neuromonitoring teams.

Posterior Three-column Osteotomy for Treatment of Congenital Kyphosis with Multiple Thoracolumbar/lumbar (TL/L) Anterior Unsegmented Vertebrae (AUVs): A Comparison between Patients with Increasing Number of AUVs

BACKGROUND

Three-column osteotomy (3-CO) is sometimes challenging when confronting many anterior unsegmented vertebrae in congenital kyphosis (CK-AUVs).

OBJECTIVE

To compare the surgical outcomes of single level 3-CO and the associated complications between CK with increasing number of AUVs.

METHODS

25 consecutive operated patients with CK-AUVs at a mean age of 16.2±10.3 years were retrospectively reviewed. They were stratified into two groups according to the number of AUVs: 3-AUVs group and ≥4 AUVs group. The osteotomy types, surgical outcomes and the related complications were analyzed and compared between the two groups.

RESULTS

13 and 12 patients were recruited in the 3-AUVs group and the ≥4 AUVs group, respectively. The ratio of Pedicle Subtraction Osteotomy, Grade IV osteotomy, Vertebra Column Resection and Vertebral Column Decancellation were 15.4%, 38.5%, 46.1% and 0% for 3-AUVs group and 8.3%, 0%, 83.3% and 8.3% for ≥4 AUVs group, respectively. Preoperative focal kyphosis was significantly higher in the ≥4 AUVs group (82.9±28° vs.59.7±9.4°, p=0.010), which was remarkably corrected in both groups postoperatively. While ≥4 AUVs group had a significantly higher remaining kyphosis (33.6±13.4° vs. 15.1±9.1°, p<0.001) with a significantly lower correction rate (61.2±13.6% vs. 75.0±15.6%, p=0.001). The complication rate was significantly higher in ≥4 AUVs group than 3-AUVs group (8/12 vs. 1/13, p=0.004), mainly involving vertebral subluxation and proximal junctional kyphosis.

CONCLUSIONS

Posterior single-level grade Ⅲ-Ⅴ 3-CO can achieve satisfactory kyphosis correction in CK with 3 AUVs. Decreasing kyphosis correction and increasing surgery-related complications are prone to develop when treating CK with ≥4 AUVs.

Corpectomy and spinal stabilization using a 3D-printed spine model and custom jigs to address severe spinal deformities from T9-11 and L2-4 in a 6-month-old German shepherd puppy

This report describes surgical decompression and stabilization of 2 hemivertebrae in a German shepherd dog. Long-term clinical and imaging outcomes are documented. Spinal cord decompression via corpectomy improved neurological function and intrinsic spinal cord changes on MRI. The dog improved to have minimal paraparesis and an active lifestyle.

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.

Clinical, radiological, and functional outcomes of posterior-only three-column osteotomy in congenital kyphosis : a minimum of two years' follow-up

AIMS

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

METHODS

Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by 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), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded.

RESULTS

The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient.

CONCLUSION

Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J 2021;103-B(7):1309-1316.

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

To assess the clinical and radiographic outcomes after surgical management of post-tuberculous kyphosis. Post-tuberculous (TB) kyphosis can lead to progressive pulmonary and neurological deterioration. Surgery is indicated to decompress neural elements and correct the spine deformity. Although posterior vertebral column resection (PVCR) has been established as the treatment of choice for severe TB kyphosis, there is paucity of studies on the clinical outcomes among patients treated in West Africa.

METHODS

Clinical and radiographic data of 57 patients (pts) who underwent surgical correction of post-TB kyphosis at a single site in West Africa between 2013 and 2018 (≥ 2-year follow-up in 36 pts, ≥ 1-year FU in 21 pts). Pre- and post-op SRS scores and radiographic outcomes were compared using Paired t test.

RESULTS

57 patients, 36M:21F. Mean age 19 (11-57 years). 22/57 pts (39.3%) underwent pre-op halo gravity traction (HGT) for an average duration of 86 days (8-144 days). HGT pts had a higher baseline regional kyphosis (125.1 ± 20.9) compared to non-HGT pts (64.6 ± 31.8, p < 0.001). Post-HGT regional kyphosis corrected to 101.2 ± 23 (24° correction). 53 pts (92.9%) underwent posterior-only surgery and 4 (7.0%) combined anterior-posterior surgery. 39 (68.4%) had PVCR, 11 (19.3%) PSO, and 16 (28.1%) thoracoplasty. Intraoperative neuromonitoring (IOM) signal changes occurred in 23/57 pts (≈ 40%), dural tear in 5 pts (8.8%), pleural tear in 3 pts (5.3%), ureteric injury in 1 pt (1.7%), and vascular injury in 1 pt (1.7%). Post-op complications included four (7.0%) infection, three (5.3%) implant related, two (3.5%) radiographic (one PJK and one DJK), one (1.7%) neurologic, one (1.7%) wound problem, and two (3.5%) sacral ulcers. IOM changes were similar in the VCR (48.7%) and non-VCR (23.5%) pts, p > 0.05. Complication rates were similar among HGT and non-HGT groups. Significant improvements from baseline were seen in the average SRS Total and domains scores and radiographic measurements for patients who attained 2-year follow-up.

CONCLUSION

PVCR ± HGT can provide safe and optimal correction in cases of severe post-TB kyphosis with good clinical and radiographic outcomes in underserved regions.

One-Stage Debridement and Bone Grafting With Internal Fixation via Posterior Approach for Treatment of Thoracic Spine Tuberculosis

The study aimed to investigate the clinical efficacy and feasibility of one-stage surgical treatment for thoracic spinal tuberculosis by internal fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach. A total of 12 patients (8 male, 4 female) with thoracic tuberculosis whose lesions were confined to 2 adjacent segments were admitted to our hospital. The American Spinal Injury Association (ASIA) impairment scale was used to assess neurologic function. All patients were treated with one-stage surgical treatment by internal fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach. Patients were evaluated preoperatively and postoperatively by measurement of thoracic kyphotic angles using Cobb angle evaluation, determination of erythrocyte sedimentation rate, evaluation of ASIA impairment scale, and radiologic examination. Operation time ranged from 60 to 150 minutes (average, 120 minutes). Intraoperative blood loss ranged from 300 to 850 mL (average, 500 mL). All patients were followed up for 24 to 48 months postoperatively (average, 32 months). No sinus tract formation, cerebrospinal meningitis, or recurrence of tuberculosis occurred. All patients had significant postoperative improvement in ASIA classification scores. The thoracic kyphotic angles were significantly decreased to 12° to 30° postoperatively, and at final follow-up were 14° to 28°. The erythrocyte sedimentation rate recovered to normal within 6 months postoperatively in all patients. Bone fusion was achieved within 3 to 6 months (average, 5 months). One-stage surgical treatment for thoracic spinal tuberculosis by internal fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach can be an effective and feasible treatment method.

POSTERIOR VERTEBRAL COLUMN RESECTION (PVCR): A SAFE AND EFFECTIVE OPTION TO TREAT KYPHOSIS FROM SPINAL TUBERCULOSIS

ABSTRACT Objective: To evaluate the clinical and radiological results of posterior vertebral column resection (PVCR) for the treatment of kyphosis from spinal tuberculosis. Methods: Retrospective study of a series of 14 cases, 9 female and 5 male, with a mean age of 28 years (1 to 64) at the time of surgery, with spinal tuberculosis with mean kyphosis of 56.42° (2° to 95°). Results: All patients underwent surgical treatment with PVCR, with a mean number of 2.57 (1 to 6) resected vertebrae and a mean number of instrumented vertebrae of 6.14 (4 to 8). The mean kyphosis correction was 64% after up to one year of follow-up. Prior to surgery, eight patients had signs of spinal cord impairment (ASIA score ranging from A to D), and six did not present any deficit of strength or sensory function (ASIA E). There was no neurological worsening and everyone with deficits improved by at least one degree on the scale. In the postoperative follow-up, bone consolidation was observed in all patients, except one. Among the intra- and postoperative complications, pleurotomy was the most prevalent. Conclusion: Posterior vertebral column resection has proven to be a safe and effective option for the treatment of kyphotic deformity from spinal tuberculosis. Level of evidence IV; Therapeutic studies - Investigation of treatment results.

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.

Using Satellite Rod Technique in Patients with Severe Kyphoscoliosis Undergoing Three-Column Osteotomy: A Minimum of 2 Years' Follow-up

OBJECTIVE

To introduce the satellite rod technique utilized in severe spinal deformity after three-column osteotomy (3CO) and to evaluate the radiographic and clinical outcomes at 2-year follow-up, further discussing its utilization in this particular cohort.

METHODS

A total of 32 (19 females and 13 males) with an average age of 32.9 ± 18.3 years from December 2012 to March 2016 were retrospectively reviewed. Radiographic measurements were performed on standing full-spine anteroposterior and lateral radiographs preoperatively, postoperatively, and at last follow-up. The coronal parameters including Cobb angle and distance between C₇ plumb line and center sacral vertical line (C7PL-CSVL), as well as the sagittal parameters including global kyphosis (GK) and sagittal vertical axis (SVA) were measured at three time points. The Scoliosis Research Society-22 questionnaire (SRS-22) was fulfilled preoperatively and at each follow-up. Paired t test would be used to determine whether there was a significant difference between time points.

RESULTS

A total of 32 patients were enrolled in this study with mean age of 32.9 ± 18.3 (range, 12 to 66) years old. Twenty patients underwent pedicle subluxation osteotomy (PSO) and 12 patients underwent vertebral column resection (VCR). The pathogenesis of this cohort included neuromuscular scoliosis (11 cases), congenital kyphoscoliosis (seven with hemivertebrae and five with segmentation failure), degenerative spinal deformity (five cases), and thoracolumbar tuberculosis with angular kyphosis (four cases). The post-operative Cobb angle decreased significantly from 49.1° ± 28.0° to 19.0° ± 16.7° with a correction rate of 65.2% ± 21.8%. At final follow-up, the average Cobb angle was 19.4° ± 16.9° and no obvious loss of correction was found. The preoperative, postoperative, and last follow-up C7PL-CSVL were 23.9 ± 14.5 mm, 15.7 ± 11.1 mm, and 12.1 ± 7.4 mm, respectively. Significant postoperative improvement was attained while there was no change observed at last follow-up. Postoperative GK significantly improved from 73.8° ± 28.1° to 23.2° ± 11.7° with the correction rate of 66.0% ± 17.9%. SVA decreased significantly from 42.9 ± 33.9 mm to 24.1 ± 21.1 mm. The average GK and SVA at final follow-up were 22.7° ± 10.1° and 23.5 ± 21.1 mm, respectively and no obvious loss of correction was observed of them during follow-up. In addition, no change or loss of motor or somatosensory evoked potential occurred during surgery. During the follow-up, two malposition screws and one rod breakage were found.

CONCLUSION

The satellite rod used in patients with severe kyphoscoliosis undergoing 3CO could yield favorable radiological and clinical outcomes. With the utilization of this technique, the coronal and sagittal balance could be well-maintained during follow-up.

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.

The efficacy of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis

Background

The bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis has not been explained in detail. We aimed to analyze the efficacy of bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis.

Methods

We treated 32 thoracic or thoracolumbar tuberculosis patients by one-stage posterior debridement, allograft bone graft using titanium mesh, posterior instrumentation, and fusion from May 2011 to September 2015. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were analyzed preoperatively, postoperatively, and at final follow-up. The Cobb angles were recorded to evaluate the kyphosis correction and the loss of correction. The bony fusion was evaluated by X-ray and computed tomography images, and the bony fusion classifications were recorded.

Results

All patients had pain relief. The erythrocyte sedimentation rate, C-response protein, and hepatorenal function were normal at final follow-up. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were improved in all the patients. All patients achieved bone fusion. Twenty-eight patients achieved complete fusion (Grade I), whereas only four patients achieved partial fusion (Grade II). The preoperative Cobb angle was 33.6 ± 9.3°. The Cobb angle was reduced to 10.6 ± 2.6° postoperatively and was found to be 11.4 ± 3.1° at the final follow-up. The mean angle correction was 23.0 ± 8.9°, and the correction rate was 66.2 ± 12.2%. The mean angle lost was 0.8 ± 0.9°, and the lost rate was 5.8 ± 5.4% at the final follow-up.

Conclusions

Allograft bone using titanium mesh in the posterior-only surgical treatment is effective for patients with thoracic and thoracolumbar spinal tuberculosis. It can correct kyphosis, and most patients can achieve complete bony fusion.

Validation Study of Rajasekaran's Kyphosis Classification System: Do We Clearly Understand Single- and Two-Column Deficiencies?

Study Design

Multicenter validation study.

Purpose

To evaluate the inter-rater reliability of Rajasekaran’s kyphosis classification through a multicenter validation study.

Overview of Literature

The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation.

Methods

A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations.

Results

The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte’s (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6).

Conclusions

Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.

Ventral sculpting decompression: a novel bone scalpel-based technique in thoracic ventral stenosis/kyphosis with myelopathy

Background

Thoracic kyphosis is not so uncommon, which presents with devastating myelopathy. In the past, the surgical treatment for it had been somewhat controversial. Traditionally, it had been addressed by open decompression and stabilization with significant dissection and disruption of normal tissues and complications.

Main body

Recently, correction techniques have evolved as the standard of care. A substantial body of evidence now supports the benefits of correction but can be questioned in view of the fact that upper dorsal kyphosis is never a cosmetic concern in our part of the world. New technique has reduced complications, but it is not solely due to the technique but due to accessory gadgets like O-arm, navigation, and IONM making it safer. We describe a method of 360° decompression alone with the use of an Ultrasonic Bone Scalpel (UBS) that preserves maximum bony stability and achieves an optimum bone sculpting that negates the need for correction.

Conclusion

This technique of ventral sculpting decompression in the thoracic spine may be more utilized in the future to be applied for more wider indications.

Vertebral column resection for post tuberculosis severe kyphotic deformity: Results of 5 year follow-up

Background

Spinal TB is endemic in our study region and many patients present with severe kyphotic deformities and neurological deficit. We corrected such deformities with all posterior single stage surgeries. This study was undertaken to evaluate the results, efficacy and safety of this technique.

Methods

Deformity correction of 16 patients was done during January 2012 to December 2014. All patients underwent posterior only approach for vertebral column resection at peri-apical region, posterior instrumentation with pedicular screws and anterior reconstruction using mesh cage. Postoperative X-ray films were evaluated. All patients were followed up at six weeks, 12 weeks, 18 weeks, six months and yearly thereafter. At follow-up patients were evaluated neurologically and radio-graphically.

Results

Mean age of the patients was 19.43 years. (Range 3-37) An average 1.62 vertebrae were excised and 5.93 vertebral levels were instrumented. Mean blood loss was 1013 ml and the mean duration of surgery was 6.78 h. The decrease in mean kyphotic deformity from preoperative 90.08⁰ to postoperative 38.06⁰ was statistically significant. (P < 0.000) Mean percentage correction was 57.59%. No pseudoarthrosis was found on X-rays. The decrease in Oswestry's Disability Index was from 55.43 to 10.06 was statistically significant. (P < 0.000) Two patients had neurological complications and one patient had wound complication.

Conclusion

The safety and efficacy of Posterior VCR technique for post tuberculosis severe kyphotic deformity is favorable with no severe late stage complications. Excision of ribs, careful handling of cord and gradual correction of deformity with good hemostasis is important.

Spinal tuberculosis: a comprehensive review for the modern spine surgeon

Nearly one-third of the human population is infected with tuberculosis. Of those with active disease, approximately 10% are impacted by skeletal tuberculosis. Though, traditionally a disease of the developing world and susceptible populations, with the rise of immigration, patients may present in developed countries. The microbe responsible is the mycobacterium tuberculosis complex bacillus. The infection begins in the anterior vertebral bodies. The natural history and presentation are notable for cold abscesses causing mass effect, early or late neurological deficit, and kyphotic deformity of the spine caused by anterior vertebral body destruction. The disease can be diagnosed with laboratory studies and characteristic imaging findings, but tissue diagnosis with cultures, histology, and polymerase chain reaction is the gold standard. The cornerstone of medical management is multidrug chemotherapy to minimize relapse and drug resistance, and can be curative for spinal tuberculosis with minimal residual kyphosis. Surgical management is reserved for patients presenting with neurological deficits or severe kyphosis. The mainstays of surgical management are debridement, correction of spinal deformity and stable fusion. With appropriate and timely management, clinical outcomes of the treatment of spinal tuberculosis are overall excellent.

POSTERIOR VERTEBRAL COLUMN RESECTION IN MULTIPLE LEVELS IN CHILDREN WITH VERTEBRAL TUBERCULOSIS

ABSTRACT Objective To evaluate the clinical and radiological results of posterior vertebral column resection in the treatment of kyphosis due to vertebral tuberculosis in children under 9 years of age with neurological deficit. Methods Retrospective study of a series of 5 cases, 4 females and 1 male, mean age of 4.7 years at the time of surgery, with spinal tuberculosis and mean kyphosis of 89 degrees. Results All patients underwent surgical treatment with PVCR in multiple levels, with a mean number of 3.6 resected vertebrae, mean surgical time of 359 minutes, mean postoperative stay of 21.2 days. The mean follow-up was 29 months. The mean kyphosis correction was 62.6%. Before surgery, all patients had signs of spinal cord injury, one of which did not present a deficit of strength or sensibility (ASIA E), but there were pyramidal signs and a history of falls. The other 4 had some degree of sensory-motor dysfunction, with ASIA score varying from A to D. Postoperative complications included two dehiscences of suture, one pneumothorax and one pneumonia, all with favorable evolution. Four patients progressed with neurological improvement and one of them had persistence of the neurological deficit until the last follow-up. Conclusions Multiple-level PVCR has proven to be a safe and effective option for the treatment of kyphotic deformity in spinal tuberculosis in children with neurological deficit. Level of evidence IV; Case Series.

Late-onset neurological deficits induced by proximal adjacent segment degeneration related to severe post-tuberculous kyphotic deformities of the spine: a series of 7 cases and surgical correction concept

OBJECTIVE

Late-onset neurological deficits are a rare complication of spinal tuberculosis that may be caused by proximal adjacent segment degeneration (ASD) above the kyphus. The objective of this study was to report several cases of neurological deficits due to proximal ASD in patients with post-tuberculous kyphotic deformity and discuss the characteristics of the authors' corrective surgical technique.

METHODS

The inclusion criteria in this study were severe angular kyphosis due to a post-tuberculous kyphotic deformity and a late-onset neurological deficit. The cause of these deficits was related to a lesion in the proximal cephalad portion of the kyphotic deformity. Surgical intervention, including decompression and compromised restoration of the sagittal imbalance, was performed in all patients. Preoperative surgical planning with a radiological evaluation included CT, plain radiograph, and MRI studies. Clinical outcomes were evaluated using the American Spinal Injury Association Impairment Scale and the Oswestry Disability Index (ODI).

RESULTS

The main goal of our surgical technique was the correction of sagittal malalignment by positioning the patient's head above the kyphotic deformity on the sagittal plane, excluding aggressive osteotomy. The neurological symptoms showed immediate improvements postoperatively, except in 1 patient. Compared to the preoperative value of 66.9, the mean ODI score improved to 42.6 at the final follow-up for all patients. Preoperatively, the mean values of the angles of deformity and the sagittal vertical axis were 99.7° and 157.7 mm, respectively, and decreased to 75.3° and 46.0 mm, respectively, at the final follow-up. No major complications were observed, and the patients' self-satisfaction was high with respect to both cosmetic and functional outcomes.

CONCLUSIONS

Clinicians should be aware of the degeneration of the vertebrae above the kyphotic segment in patients with post-tuberculosis deformity. Successful neurological recovery and compromised sagittal balance could be obtained by using our "head on kyphus" surgical concept.

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.

Transpedicular Decompression/Debridement and Posterior Spinal Fusion With Instrumentation for Single-Level Thoracic Spinal Tuberculosis With Myelopathy-Is Anterior Column Reconstruction Necessary?

OBJECTIVES

The purpose of this study is to study the safety and efficacy of single-stage transpedicular decompression/debridement and instrumented posterior spinal fusion for single-level thoracic spinal tuberculosis with myelopathy without anterior column reconstruction.

SUMMARY OF BACKGROUND DATA

Existing literature has many reports of transpedicular decompression/debridement and instrumented posterior spinal fusion with anterior column reconstruction. The quoted loss of correction is around 2°, but there is no strong evidence analyzing the loss of kyphosis correction, assessment of fusion in the same, without anterior column reconstruction.

STUDY DESIGN

Retrospective study.

METHODS

Study consisted of 57 patients of single-level thoracic tuberculosis with myelopathy from a single center who fulfilled the selection criteria. All underwent pedicle screw-rod instrumentation (2 up and 2 down), bilateral transpedicular decompression/debridement of granulation tissue/abscess, followed by instrumented posterior spinal fusion with local bone/B-tri-calcium phosphate. Patients were analyzed clinically (ASIA scoring) and radiologically by radiographs for kyphosis correction and CT scans at 2 years (for assessment of fusion). The grade of destruction was correlated with loss of kyphosis correction and neurologic improvement.

RESULTS

There are 43 female and 14 male patients with a mean age of 46.7 years (18.4-74.2), mean follow-up of 3.4 years (2.1-8.4). The mean pre-op Cobb angle is 26.4° and mean correction obtained is 12.6° (47.8%). The mean loss of kyphosis after 2 years' follow-up is 3.6° (13.6%). The mean American Spinal Injury Association (ASIA) grade improvement after surgery is 1.05 (p = .001). There is no correlation observed between neurologic recovery and grade of destruction (R = -0.11). There is no correlation between the improvement in kyphosis and neurologic recovery (R = -0.05). Two-year postoperative CT scan showed solid interbody (55 patients) and posterior fusion (57 patients).

CONCLUSION

Significant neurologic recovery, kyphosis correction, and posterior/interbody bony fusion can be obtained by transpedicular decompression/debridement and instrumented posterior spinal fusion (without anterior reconstruction) with maintained correction at 2 years.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB).

METHODS

A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "spinal tuberculosis," "diagnosis," "epidemiology," "etiology," "management," "surgery," and "therapy."

RESULTS

Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability.

CONCLUSIONS

The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

Incidence and risk factors of neurological complications during posterior vertebral column resection to correct severe post-tubercular kyphosis with late-onset neurological deficits: case series and review of the literature

Background

Severe post-tubercular kyphosis with late-onset neurological deficits is difficult to treat, with high risk of neurological complications. This study retrospectively evaluates the efficacy and safety of posterior vertebral column resection (PVCR) for treating severe post-tubercular kyphosis with late-onset neurological deficits.

Methods

From January 2012 to December 2015, 13 patients with severe post-tubercular kyphosis underwent PVCR. All these patients were of late-onset neurological deficits. The operative time, blood loss, preoperative and postoperative kyphotic angles, sagittal vertical axis (SVA), neurological status, and complications were recorded. The preoperative and postoperative Oswestry Disability Index (ODI) scores and visual analog scale (VAS) scores for back pain were compared. The American Spinal Injury Association (ASIA) grading system was used to evaluate neurological function.

Results

The mean postoperative follow-up period was 28.6 months. The mean operative time was 388 ± 46 min. The mean blood loss was 2554 ± 1459 ml. The mean preoperative and postoperative kyphotic angles were 93.7 ± 14.4° and 31.7 ± 7.3°, respectively, with a mean correction of 62.0 ± 13.8°. The mean preoperative and postoperative SVA were 43.2 ± 44.4 mm and 17.8 ± 16.2 mm, respectively. The mean ODI score improved from 56.3 ± 5.1 preoperatively to 18.3 ± 18.5 at last follow-up. The mean VAS score improved from 6.4 ± 1.8 preoperatively to 1.8 ± 0.8 at last follow-up. Two cases had spinal cord injuries, including one complete paraplegia and one incomplete paraplegia, and a total neurological complication rate of 15.4%. The risk factors for neurological complications were summarized.

Conclusions

Severe post-tubercular kyphosis with late-onset neurological deficits can be corrected by PVCR carefully and properly to prevent neurological complications. In many cases with stenosis adjacent to the angular kyphosis, sufficient decompression of the spinal cord at the segments with stenosis is necessary before correcting the kyphosis.

Outcomes Following Single-Stage Posterior Vertebral Column Resection for Severe Thoracic Kyphosis

INTRODUCTION

Thoracic kyphosis can result in neurologic deficits, pain, and cardiopulmonary dysfunction. Vertebral column resection (VCR) is a powerful technique that can be employed for large curves and fixed deformities. This study reports the outcomes of posterior VCR for adult spinal deformity with severe thoracic kyphosis.

METHODS

A retrospective review of all patients with adult spinal deformity who underwent posterior VCR for severe thoracic kyphosis (defined as segmental kyphosis greater than 80°) was performed. Patients with kyphosis secondary to trauma, tumor, or infection were excluded. Perioperative, radiographic, and minimum 2-year outcomes were assessed.

RESULTS

Nineteen patients were included. Mean age was 57.1 years and 31.6% were male. Mean preoperative sagittal vertical axis was 57.7 mm and thoracic kyphosis was 92.2°. Among 19 patients, 24 VCR were performed. Mean blood loss was 2188 mL. Perioperative complication rate was 36.8% and mortality rate was 5.3%. Mean postoperative sagittal vertical axis was 42.3 mm and thoracic kyphosis was 58.1°. Incidence of junctional failure at 2-year follow-up was 14.8%: 1 proximal and 2 distal. All patients with junctional disease required reoperation. At mean 35.7-month follow-up, 61.1% of patients reported a significant reduction of back pain and 50.0% were able to reduce their dose of opioid medications.

CONCLUSIONS

Single-stage posterior VCR is a powerful technique for the correction of severe thoracic kyphosis. Perioperative morbidity can be high, but a majority of patients fare well at follow-up. Junctional disease occurs both proximal and distal; surgeons should continue to implement strategies to minimize distal junctional disease.

A Classification for Kyphosis Based on Column Deficiency, Curve Magnitude, and Osteotomy Requirement

BACKGROUND

There is a lack of a classification system providing uniformity in description and guiding management decisions for kyphotic spinal deformities. We developed such a classification based on column deficiency, flexibility of disc spaces, curve magnitude, and correlation with the corrective osteotomy required.

METHODS

A classification was developed based on analysis of 180 patients with thoracolumbar kyphosis requiring osteotomy. The deformity was classified as Type I if the anterior and posterior columns were intact (IA indicated mobile disc spaces and IB, ankylosed segments). Type II indicated deficiency of only 1 column (IIA = anterior column and IIB = posterior column). Type III indicated deficiency of both columns (IIIA = kyphosis of ≤60°, IIIB = kyphosis of >60°, and IIIC = buckling collapse). A prospective analysis of 76 patients was performed to determine interobserver variability and the ability of the classification to guide selection of osteotomies of increasing complexity, including the Ponte osteotomy, pedicle subtraction osteotomy, disc bone osteotomy, single vertebrectomy, multiple vertebrectomies, and anterior in situ strut fusion procedure.

RESULTS

The mean age of the 76 patients was 21.2 years, the mean kyphosis was 69.9° (range, 26° to 120°), and the mean follow-up duration was 30 months. Six deformities were classified as IA, 5 as IB, 5 as IIA, 2 as IIB, 13 as IIIA, 35 as IIIB, and 10 as IIIC. Four surgeons classifying the deformities had a high agreement rate (kappa = 0.83), with the highest agreement for Types IA, IB, and IIIB. A correlation between the type of deformity and the osteotomy performed demonstrated that the classification could indicate the type of osteotomy required. All 18 patients with Type-I or II kyphosis were treated with Ponte, pedicle subtraction, or disc bone osteotomy. Forty-three (90%) of the 48 patients with Type IIIA or IIIB underwent vertebrectomy (single in 27 [56%] and multiple in 16 [33%]), and only 5 (10%) underwent disc bone osteotomy. Seven of the 10 patients with Type-IIIC kyphosis were treated with multiple vertebrectomies, with 5 of them needing preoperative halo gravity traction; the other 3 patients underwent an anterior in situ strut fusion procedure.

CONCLUSIONS

The proposed classification based on the morphology of column deficiency, flexibility, and curve magnitude demonstrated a high interobserver agreement and ability to guide selection of the appropriate osteotomy.

CLINICAL RELEVANCE

A novel classification system for kyphosis based on spinal column deficiency, flexibility of disc spaces, and curve magnitude would bring uniformity in management and help guide surgeons in the choice of the appropriate corrective osteotomy.

Surgical approaches to upper thoracic Pott's disease with spinal instability during childhood: two cases

PURPOSE

Tuberculosis is a common disease worldwide that is caused by Mycobacterium tuberculosis. Tuberculosis is primarily a pulmonary disease, but extrapulmonary manifestations are not uncommon, especially in children and adolescents.

METHODS

We present two pediatric patients who underwent surgery in our clinic for Pott's disease in the upper thoracic region. The patients were investigated to describe their age, complaints, neurological examination results, disease location, surgical procedure, and complications.

RESULTS

The patients were 2 and 14 years old and exhibited disease located in the upper thoracic region (T2-T3 and T1-T2). Both patients displayed severe neurological deficits (Frankel B and C). The kyphotic angles were 82.2° and 43.2°. The patients were stabilized by applying fusion using transpedicular screws via a posterior approach. They also underwent anti-tuberculosis treatment for approximately 1 year. One year later, neither patient exhibited any neurological deficit, and their kyphotic angles were measured as 11° and 1°, respectively.

CONCLUSIONS

The recommended treatment approach for unstable cases of Pott's disease located in the upper thoracic region who exhibit neurological deficit and severe kyphotic angling or the development of kyphosis on the thoracic vertebrae is surgical. Decompression, stabilization, and fusion and kyphotic correction can be safely performed via a posterior approach. One of the present cases is the youngest patient described in the literature to undergo transpedicular surgery as a result of Pott's disease. Our other case is the first described in the literature who developed ptosis as a result of tuberculosis and underwent a procedure via posterior transpedicular screw.

Tuberculosis of the spine with severe angular kyphosis

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Patients and Methods

This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed.

Results

All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years).

Conclusion

Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. Cite this article: Bone Joint J 2017;99-B:1381–8.

Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation

BACKGROUND The aim of this study was to evaluate the efficiency and clinical outcomes of mini-open anterior approach focal cleaning combined with posterior internal fixation compared to conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in the treatment of lumbar tuberculosis (TB). MATERIAL AND METHODS Medical records from 124 patients were collected from February 2010 to April 2015; patients were divided into two groups: group A (mini-open anterior approach focal cleaning combined with posterior internal fixation) and group B (conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in period I). The data on postoperative mechanical ventilation time, preoperative, postoperative, and last follow-up Cobb angle, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and Frankel classification were collected and analyzed. Operative complications, internal stability, and bone graft fusion were also observed. RESULTS All patients were followed-up for 12 to 36 months (average 22.5 months). Seven cases (five in group A and two in group B) had side psoas abscess and were cured after secondary drainage surgery. The rest of the cases were all cured after primary surgery, with no formation of sinus, incisional hernia, cerebrospinal fluid leakage, or recurrence of spinal TB, with no TB symptoms. Bone graft fusion ranged from 3 to 8 months (average 4.7 months). Compared to group B, group A, which had less time on postoperative mechanical ventilation, had a higher VAS score. Both groups had distinct improvements in Cobb angle, ESR, and Frankel classification after surgery. CONCLUSIONS Treating lumbar TB by mini-open anterior approach focal cleaning combined with posterior internal fixation was safe and effective.

Posterior three-column osteotomies for the treatment of rigid thoracic kyphosis - a case series

OBJECTIVE

To evaluate the results and complications of a series of patients who underwent three-column osteotomy using the posterior approach for correction of complex cases of rigid dorsal kyphotic deformity.

METHODS

Review of clinical records and images of 15 consecutive cases of pedicle subtraction osteotomies, bone-disk-bone osteotomies, or vertebral column resection, recording the etiology, type and level of osteotomy, extension of fixation, complications, and pre- and post-surgical measurements of the sagittal curves and pelvic parameters.

RESULTS

Six pedicle subtraction osteotomies were performed, one of which in two adjacent vertebrae, as well as two bone-disk-bone osteotomies and seven vertebral column resection, two of which were performed in two adjacent vertebrae. The mean correction was 39.3° for the angular kyphosis and 33.9° for dorsal kyphosis. The corrections were similar regardless of the kind of osteotomy, the operated spinal segment, or the approach in one or two levels, but this may be a sample effect. Eight complications were observed in six patients (40% of cases): two medical complications, five early and one late surgical complication (over 90 days after surgery). There were three reoperations within less than one year from the initial surgery and one case of persistent paraparesis. Clinical complications were resolved without sequelae. There was no significant loss of correction during the segment, except in two cases of major mechanical failure due to a junctional segment fracture.

CONCLUSION

Despite being complex and aggressive procedures, prone to various complications, osteotomies with resection of the three columns are highly effective in the correction of rigid kyphotic deformities and safe enough to justify its use in selected cases.

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.

Surgical Treatment of Lower Cervical TuberculosisWith Kyphosis Deformity

The objective of this paper was to investigate the outcome of the patients with lower cervical tuberculosis with kyphosis deformity who underwent 1-stage anterior debridement, autograft fusion combined anterior or posterior fixation. From January 2007 to December 2012, 10 cases were enrolled in this retrospective study. There were 7 patients with cervical deformity and 3 with cervicothoracic kyphosis. Seven patients underwent anterior debridement and reconstruction, using iliac crest or cage with autograft, while 3 patients with cervicothoracic kyphosis received single-stage kyphosis correction and posterior fixation combined anterior debridement and autograft fusion. Neurologic function of all the patients was evaluated by JOA score and visual analogue scale (VAS) score. Patients were followed up for 26 months on average. The mean preoperative focal kyphotic angle was 49.1° (range, 25–90°), reducing to −4.9° (range, −15 to 13°) postoperatively at the last follow-up visit. Neurologic assessment of all the patients using the JOA and VAS score was improved significantly after surgery. All patients had solid fusion and no major complications were observed in the follow-up. One-stage anterior debridement, autograft fusion combined anterior or posterior fixation was demonstrated to be a safe and effective method to achieve spinal decompression and kyphosis correction in patients with lower cervical tuberculosis.

Trends of spinal tuberculosis research (1994-2015): A bibliometric study

BACKGROUND

Spinal tuberculosis is the most common form of skeletal tuberculosis. However, there were limited data to evaluate the trend of spinal tuberculosis research. This study aims to investigate the trend of spinal tuberculosis research and compare the contribution of research from different countries and authors.

METHODS

Spinal tuberculosis-related publications from 1994 to 2015 were retrieved from the Web of Science database. Excel 2013, GraphPad Prism 5, and VOSviewer software were used to analyze the search results for number of publications, cited frequency, H-index, and country contributions.

RESULTS

A total of 1558 papers were identified and were cited 16,152 times as of January 25, 2016. The United States accounted for 15.1% of the articles, 22.3% of the citations, and the highest H-index (33). China ranked third in total number of articles, fifth in citation frequency (815), and ranked seventh in H-index (13). The journal Spine (IF 2.297) had the highest number of publications. The author Jain A.K. has published the most papers in this field (20). The article titled "Tuberculosis of the spine: Controversies and a new challenge" was the most popular article and cited a total of 1138 times. The keyword "disease" was mentioned the most for 118 times and the word "bone fusion" was the latest hotspot by 2015.

CONCLUSION

Literature growth in spinal tuberculosis is slowly expanding. Although publications from China are increasing, the quality of the articles still requires improvements. Meanwhile, the United States continues to be the largest contributor in the field of spinal tuberculosis. According to our bibliometric study, bone fusion may be an emerging topic within spinal tuberculosis research and is something that should be closely observed.

V, Jayaswal A. Management of Tuberculous Infection of the Spine

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.

One-stage surgical treatment for thoracic and lumbar Spinal tuberculosis by transpedicular fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach

This study examined the clinical outcomes of one-stage surgical treatment for patients with spinal tuberculosis via a posterior-only approach. Twenty-four patients with thoracic or lumbar spinal tuberculosis whose lesions were confined to adjacent segments were admitted to our hospital and treated. The American Spinal Injury Association (ASIA) impairment scale was used to assess the neurological function. All patients were treated with one-stage surgical treatment via a posterior-only approach. The clinical efficacy was evaluated by the Japanese Orthopaedic Association (JOA) scores and oswestry disability index (ODI) of nerve function. Patients were evaluated preoperatively and postoperatively by measurement of spinal deformity using Cobb angle and radiological examination. All the patients were followed up for 13 to 27 months. They had significantly postoperative improvement in JOA score, ODI and ASIA classification scores. The kyphotic angles were significantly corrected and maintained at the final follow-up. Bone fusion was achieved within 4-12 months. It was concluded that one-stage surgical treatment via a posterior-only approach is effective and feasible for the treatment of spinal tuberculosis.

Use of Intramedullary K-Wire to Enhance Fibular Graft Placement in 4-Level Thoracolumbar Corpectomy for Pott Disease: Case Report and Review of Literature

BACKGROUND

Reports of tuberculosis involving ≥4 contiguous spinal levels are rare. Surgery is often required in this population for neurological decompression and stabilization. These patients appear to be particularly predisposed to complications that include incomplete recovery of neurological function after decompression as well as post-treatment kyphosis. In settings with limited available instrumentation, reconstruction of the anterior column can be challenging.

CASE DESCRIPTION

A 35-year-old woman presented with back pain, progressive weakness in her bilateral lower extremities, and inability to walk for 2 months. Imaging demonstrated anterior destruction of T10, T11, T12, and L1 with severe retropulsion and cord impingement at T11-T12. The patient was taken for anterolateral corpectomies of T10-L1 with decompression of the thoracic spinal cord and fibular strut autograft placement followed by a T8 to L3 posterior spinal fusion. An intramedullary Kirschner-wire (K-wire) was placed during the anterolateral procedure to enhance fibular graft placement and prevent dislodgement before definitive posterior fusion.

CONCLUSIONS

At follow-up five-and-a-half months after the operation, the patient had recovered full strength and was ambulating without difficulty. Imaging at this time demonstrated stable restoration of alignment without graft dislodgement. Intramedullary fibular K-wire placement in this procedure helped to optimize anterior column reconstruction. The principles used in this report may prove beneficial to surgeons in developing countries who encounter pathology of this extent.

Stage I posterior osteotomy and instrumentation and stage II anterior debridement and bone grafting for lumbar spinal tuberculosis with severe kyphosis

The purpose of this study was to determine the efficacy of stage I posterior osteotomy and instrumentation followed by stage II anterior debridement and bone grafting in patients with lumbar spinal tuberculosis (TB) with severe kyphosis. The records of patients with lumbar spinal TB and severe kyphosis treated with 2-stage surgery at our hospital from 2005 to 2010 were retrospectively reviewed. Outcome measures were kyphosis correction rate, visual analogue scale (VAS) pain scores, and American Spinal Injury Association (ASIA) spinal cord injury and sensation function scores. A total of 53 patients (34 male, 19 female; mean age 32 years) were included. The number of involved kyphosis segments ranged from 7 to 14, and the average preoperative kyphosis angle was 107.3 ± 18.1°. All procedures were performed without serious complications. The average follow-up time was 42 months. Bone fusion occurred at a range of 6 to 9 months after surgery, and none of the patients had internal fixation failure, position change, or pseudoarthrosis. The mean postoperative kyphosis angle was 29.4 ± 12.4°, with a mean improvement of 77.9°, and the correction rate was 72.6% (P < 0.001). At final follow-up, average correction loss was 1.35°. The mean postoperative VAS pain score was 2.4 ± 0.8, and the change from the preoperative value was significant (P < 0.001). ASIA spinal injury scores were increased postoperatively. Stage I posterior osteotomy and instrumentation followed by stage II anterior debridement and bone grafting can achieve good results in patients with lumbar TB and severe kyphosis.

Comparison of Clinical and Radiological Improvement Between the Modified Trephine and High-speed Drill as Main Osteotomy Instrument in Pedicle Subtraction Osteotomy

High-speed drill is the main osteotomy instrument in pedicle subtraction osteotomy (PSO) currently. Considering the long duration of surgery, the large amount of blood loss, and the high incidence of neurovascular injury, the osteotomy procedure is challenging. Use of trephine for the osteotomy displays high efficiency by shortening surgery time and reducing blood loss in anterior cervical corpectomy and fusion. However, the potential risk of neurological injury is high. We modified the trephine by adding locking instrument, when the serrated top of the trephine reaches the tip of the probe; the locking instrument on the probe restricts the trephine and improves security during the osteotomy procedure.The aim of this study was to compare the clinical and radiological improvement between the modified trephine and high-speed drill as main osteotomy instrument in PSO.From February 2009 to 2013, 50 patients with severe thoracolumbar kyphotic deformity caused by old compressive vertebrae were prospectively reviewed. All patients were randomly assigned to the experimental group (27 patients received PSO with modified trephine) and the control group (23 patients received PSO with high-speed drill). The clinical records were reviewed and compared for surgical time, operative blood loss, functional improvement (Oswestry Disability Index), and pain relief (visual analog scale). The radiological records were reviewed and compared for correction of kyphotic deformity postoperatively and correction loss at 2-year follow-up.All patients successfully finished the PSO procedure, and got satisfactory kyphotic deformity correction and overall function improvement. The surgery time was shorter in the experimental group than that in the control group (132.7 ± 12.6 vs 141.7 ± 16.7 min; P = 0.03). No significant difference was found in blood loss (882.9 ± 98.9 mL vs 902.2 ± 84.9 mL; P = 0.47) or correction of the kyphotic angle (33.4 ± 3.4° vs 32.1 ± 2.5°, P = 0.13) postoperatively between the 2 groups. At 24-month follow-up, no difference was discovered in loss of the correction (4.9 ± 1.6° vs 4.5 ± 1.6°; P = 0.42), change of Oswestry Disability Index (49.4 ± 6.2% vs 48.2 ± 4.2%; P = 0.44), or in back pain relief (6.2 ± 1.4 vs 6.4 ± 1.2 min; P = 0.51) between the 2 groups. No internal fixation related complication occurred and bony fusion was detected in lateral X-ray in all patients. In the control group, 2 patients had transient nerve root deficit, 14 patients at 3-month follow-up and 3 patients at 2-year follow-up experienced graft donor site morbidity, and pain killer medicine was always required.In conclusion, the modified trephine obviously shortens surgery time, and prevents graft donor site morbidity when compared to a high-speed drill. The learning curve for using the modified trephine in PSO procedure is short.

Surgical treatment of selected patients with multilevel contiguous thoracolumbar spinal tuberculosis by only posterior instrumentation without any bone fusion

The retrospective clinical study is to determine the feasibility and efficacy of surgical management of multilevel contiguous thoracolumbar spinal tuberculosis (MCTLST) by only posterior instrumentation without posterior or anterior bone fusion and without anterior fixation in the study of eleven selected cases. Eleven selected cases with MCTLST were treated with combined posterior instrumentation and debridement and/or decompression without any bone fusion. The mean follow-up was 33.1 months (range 20-48 months). The kyphosis angle ranged from 9.2 to 40.4° before operation, 27.8° in average. The American Spinal Injury Association (ASIA) score system was used to evaluate the neurological deficits and erythrocytesedimentationrate (ESR) used to judge the activity of tuberculosis, which were collected at certain time. Spinal tuberculosis (STB) was completely cured in all eleven patients. There was no recurrent tuberculosis infection. The postoperative kyphosis angle was 7.1° to 12.5°, 9.6° in average and there was no significant loss of the correction at the final follow-up. Solid fusion was achieved in all cases. Neurological condition in all patients was improved after surgery. In conclusions, combined posterior instrumentation and debridement and/or decompression without any bone fusion can be a feasible and effective method in treatment of patients with MCTLST. However, the strict selection of patients was the critical of the surgery success.

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

Background

The 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.

Methods

The 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).

Results

All 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.

Conclusions

Debridement, 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.