Expert's comment concerning Grand Rounds case entitled "Closing-opening wedge osteotomy for severe, rigid thoraco-lumbar post-tubercular kyphosis" (by S. Rajasekaran, P. Rishimugesh Kanna and Ajoy Prasad Shetty)

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.

Vertebral column decancellation: a new spinal osteotomy technique for correcting rigid thoracolumbar kyphosis in patients with ankylosing spondylitis

AIMS

The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS).

PATIENTS AND METHODS

We took 39 patients from between January 2009 and January 2013 (26 male, 13 female, mean age 37.4 years, 28 to 54) with AS and a TLKD who underwent VCD (VCD group) and compared their outcome with 45 patients (31 male, 14 female, mean age 34.8 years, 23 to 47) with AS and TLKD, who underwent pedicle subtraction osteotomy (PSO group), according to the same selection criteria. The technique of VCD was performed at single vertebral level in the thoracolumbar region of AS patients according to classification of AS kyphotic deformity. Pre- and post-operative chin-brow vertical angle (CBVA), sagittal vertical axis (SVA) and sagittal Cobb angle in the thoracolumbar region were reviewed in the VCD and PSO groups. Intra- , post-operative and general complications were analysed in both group.

RESULTS

lf patients could lie on their backs and walk with horizontal vision and sagittal profile, radiographic parameters improved significantly post-operatively in both groups. No major acute complications such as death or complete paralysis occurred in either group. In the VCD group, five patients (12.8%) experienced complications such as severe CSF leak (n = 4), deep wound infection (n = 1) and in one patient a transient neurological deficit occurred. In the PSO group, eight patients (17.8%) suffered conditions such as severe CSF leak (n = 5), infections (n = 2) and sagittal translation at osteotomy site (n = 1). Scoliosis Research Society outcomes instrument (SRS-22) improved significantly in both groups. All patients achieved solid fusion at latest follow-up and no implant failures were noted in either group.

TAKE HOME MESSAGE

The VCD technique is a new, safe and effective strategy for correction of rigid TLKD in AS patients. The main advantage of the new correction mechanism is that it achieved a satisfactory correction by controlled anterior column opening and posterior column closing, avoiding the occurrence of sagittal translation. Cite this article: Bone Joint J 2016;98-B:672-8.

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS-GOP site

INTRODUCTION

Spinal tuberculosis (TB) accounts for approximately half of all cases of musculoskeletal tuberculosis. Kyphosis is the rule in spinal tuberculosis and has potential detrimental effects on both the spinal cord and pulmonary function. Late-onset paraplegia is best avoided with the surgical correction of severe kyphosis, where at the same time anterior decompression of the cord is performed and the remnants of the tuberculosis-destroyed vertebral bodies are excised.

MATERIAL AND METHODS

Review of the literature on late surgical treatment of TB-associated kyphosis; description and comparative analysis of the different surgical techniques.

RESULTS

Kyphosis can be corrected either at the acute stage or at the healed late stage of tuberculous infection. In the late stage, the stiffness of the spine and chronic lung disease are additional considerations for the surgical approach and technique. Contrary to the traditional anterior transpleural approach used in the acute spinal tuberculosis infection, extrapleural approaches, either antero-lateral or direct posterior, are favored in late treatment.

CONCLUSION

The correction of deformity is only feasible with three-column osteotomies, and posterior vertebral column resection (PVCR) is the treatment of choice in extreme kyphosis. The prognosis of the neurologic deficit (late paraplegia) is dependent on the extent of gliosis of the spinal cord.