Short-course chemotherapy for tuberculosis of the spine. A comparison between ambulant treatment and radical surgery--ten-year report

Postoperative clinicoradiological outcome of pott's spine

Introduction:

Tuberculosis (TB) is one of the main diseases impacting humanity. Fifty percent of all the cases of skeletal TB belong to spinal TB (STB), and it is also the most common form of TB. In India, patients usually present late after the onset of neurological symptoms, for which surgical management is essential for recovery. In our study, we have evaluated the outcome of forty patients of STB who underwent posterior decompression and instrumentation.

Methods:

Forty patients with STB who underwent posterior decompression and instrumentation were reviewed. All cases were followed up for 18 months. The groups were compared by parameters such as improvement in pain, improvement in kyphosis, and neurological recovery. Visual Analog Scale (VAS) score and american spinal cord injury assosciation (ASIA) score are used for the assessment.

Results:

VAS score was significantly decreased postoperatively (mean: 1.28) as compared to preoperative values (mean: 7.25). Erythrocyte sedimentation rate (ESR) was significantly decreased postoperatively (mean: 30.95) as compared to preoperative values (76.15). Cobb's angle was significantly decreased immediate postoperatively (mean: 7.8) as compared to preoperative values (mean: 24.8). There was no deterioration of neurological symptoms in any of the patients.

Conclusion:

Surgical intervention in Pott's spine with posterior decompression and stabilization, whenever indicated, gives good improvement in pain, decreases kyphotic deformity, and in most cases, also improves neurology.

Efficacy and safety of short-term chemotherapy for patients with spinal tuberculosis undergoing surgery in Chinese population: a meta-analysis

Objective

The aim of this meta-analysis was to systematically evaluate the clinical efficacy and safety of short-course chemotherapy (≤ 6 months) compared with the standard therapy (9–18 months) for patients with spinal tuberculosis (TB) undergoing surgery in Chinese population.

Methods

In this meta-analysis, we searched electronic databases in the Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), and Wanfang data to determine the equivalence of short-course therapy (group A) and standard therapy (group B) for the drug therapy of TB in Chinese population up to December 24, 2019. Weighted mean difference (WMD), odds risk (OR), and their 95% confidence interval (CI) were calculated. All analyses of relevant outcome indicators were managed by using the Review Manager (RevMan) 5.2 software.

Results

This meta-analysis included six trials published involving 851 patients (group A, 397; group B, 454) with spinal TB. Results showed there were no significant differences between group A and group B in clinical cure rate (OR = 0.61; 95% CI 0.19–2.00, p > 0.05), change of erythrocyte sedimentation rate (ESR) (WMD = − 0.75; 95% CI − 3.33 to 1.83; p > 0.05) and bone graft fusion rate (OR = 2.32; 95% CI 0.36–14.81, p > 0.05). Meanwhile, there were fewer side effects (OR = 0.37; 95% CI 0.24–0.58, p < 0.05) in group A compared with group B.

Conclusions

The results of this meta-analysis showed that for patients with spinal TB undergoing surgery in Chinese population, short-course chemotherapy could be equivalent to the standard chemotherapy in terms of efficacy and have less side effects than the latter.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02375-9.

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.

Role of Additional Coronal Magnetic Resonance Imaging in Decompression and Reconstruction with or without Segment Salvage in Thoracic Spine Tuberculosis

Study Design

Retrospective and observational study.

Purpose

The present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).

Overview of Literature

Indications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.

Methods

Sixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.

Results

This method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.

Conclusions

For segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.

Challenges in the Diagnosis and Management of Spinal Tuberculosis: Case Series

Though uncommon in developed countries, spinal tuberculosis must still be considered in patients with a suspicious clinical history, to avoid delays in treatment. This case series highlights the special considerations that need to be taken into account while tackling the diagnostic and therapeutic challenges associated with this disease.

We present two interesting cases of spinal tuberculosis. The first case was a 26-year-old female who presented with chronic back pain and an initial misdiagnosis of ankylosing spondylitis. The second case was a 26-year-old male with new lower extremity weakness, numbness, and urinary retention.

Both cases had clear indications for surgery, however, the first case was treated with medical management upon patient request. The patient was managed non-surgically and improved clinically though she may need surgery in the future. The second case was treated with emergency surgery and the patient regained full neurologic function at follow-up.

These cases demonstrate the importance of considering spinal tuberculosis in the differential diagnosis of high-risk patients as well as individualizing treatment strategies for each patient.

The spectrum of tuberculosis of the spine in pediatric age group: a review

INTRODUCTION

Pediatric spinal tuberculosis is characterized by rapid bone destruction and carries the risk of rapid onset neurological deficits and severe deformity of the spine. Behavior of spinal deformity over time is affected by growth of spine. Owing to this dynamic behavior of pediatric spinal tuberculosis both in active phase and in healed phase, it presents with challenges which are quite different from adults with caries spine. A clinician must have high index of suspicion for accurate and early diagnosis of spinal tuberculosis in the pediatric population and should also have a thorough knowledge of differences in natural history between adult and pediatric spinal tuberculosis.

DISCUSSION

This is based on the senior author's experience of dealing with tuberculosis of the spine in children over the last two decades. Recent advances in field of rapid diagnosis of tuberculosis based on nuclear material-related diagnostic tests have further improved the management of tuberculosis. At the same time, the basic treatment principles remain the same. However, the threshold for surgical vs conservative treatment have subtle differences when compared to adult population. The importance of long-term follow-up after treatment must be appreciated.

CONCLUSION

Tuberculosis in the spine in children needs early attention. Prompting to diagnostic and medical therapy measures can avoid neurological sequellae and delayed deformity.

Single-Stage Posterior Instrumentation and Unilateral Transpedicular Debridement for the Treatment of Thoracolumbar Tuberculosis: Three Years of Follow-Up

OBJECTIVE

The present study compared the efficacy and safety of single-stage posterior instrumentation and unilateral transpedicular debridement with the traditional posterior operation for the treatment of thoracolumbar tuberculosis.

METHODS

Of the 97 included patients, 53 had undergone posterior unilateral transpedicular debridement and pedicle screw fixation (group A) and 44 had undergone the traditional posterior operation (group B). We compared the outcomes, including correction of kyphosis (Cobb angle), bone fusion rate, visual analog scale score, Frankel classification, and short-form 12-item health survey between the 2 groups.

RESULTS

All patients obtained intervertebral bone fusion. The mean interval to bone graft fusion was 4.1 months (range, 3-8 months). The patients in the 2 groups showed significant improvement in kyphosis correction, short-form 12-item health survey score, and nerve function. In addition, single-stage posterior instrumentation and unilateral transpedicular debridement resulted in comparable clinical outcomes for the treatment of thoracolumbar tuberculosis. However, the patients experienced less trauma, greater spinal stability, and better functional recovery compared with the traditional posterior operation group.

CONCLUSIONS

Our results suggest that single-stage posterior instrumentation and unilateral transpedicular debridement can be considered an effective and safe therapy for spinal tuberculosis with single-level and/or bi-level segments.

Comparison of single posterior debridement, bone grafting and instrumentation with single-stage anterior debridement, bone grafting and posterior instrumentation in the treatment of thoracic and thoracolumbar spinal tuberculosis

Background

To compare the clinical efficacy of single posterior debridement, bone grafting and instrumentation with that of single-stage anterior debridement, bone grafting and posterior instrumentation for treatment of adult patients with thoracic and thoracolumbar spinal tuberculosis (TB).

Methods

We performed a retrospective analysis of 64 adult patients with thoracic and thoracolumbar spinal TB who underwent surgery between January 2011 and December 2014. Of the 64 patients, 34 patients were treated using a single posterior-only approach (posterior debridement, bone grafting and instrumentation; Group A). Thirty patients were treated with a combined anterior and posterior approach (single-stage anterior debridement, bone grafting and posterior instrumentation; Group B). Clinical manifestations, laboratory and imaging results were subjected to statistical analysis.

Results

The mean (±standard deviation) duration of follow-up was 16.8 ± 1.4 months (range, 10–34). Bony fusion was achieved in all the bone grafts with no loosening or breakage of internal fixation. In both of the groups, the visual analog scale (VAS) pain score, ESR and CRP at 6 weeks after operation and at the most recent follow-up were significantly lower than the preoperative level (p < 0.05). The operation time, intraoperative blood loss and length of hospital stay in group A were significantly less than those in group B (P < 0.05). As of most recent follow-up, no significant between-group difference was observed with respect to the American Spinal Injury Association classification status (p > 0.05). Furthermore, no significant between-group difference was observed with respect to preoperative kyphosis angle, and postoperative angle correction and angle correction rate (P > 0.05). One patient in group A relapsed 20 months after operation, and was successfully treated with debridement using the combined anterior and posterior approach.

Conclusion

Single posterior debridement, bone grafting and instrumentation for treatment of thoracic and thoracolumbar spinal TB can achieve similar curative effect as that with single-stage anterior debridement, bone grafting and posterior instrumentation, and is associated with additional advantages of shorter operation time, less bleeding and shorter length of hospital stay.

Efficacy of alternate day Directly Observed Treatment Short-course (DOTS) in skeletal tuberculosis - A retrospective study

OBJECTIVE

To assess the efficacy of alternate day (thrice a week) Directly Observed Treatment Short-course (DOTS) regimen spanning six to nine months in providing sustained cure for skeletal tuberculosis (TB) under programmatic conditions.

DESIGN

Retrospective cohort study.

SETTING

An urban district tuberculosis centre in India under the Revised National Tuberculosis Programme.

PARTICIPANTS

A cohort of 218 patients treated with alternate day DOTS regimen for skeletal TB between 2007 and 2012.

METHODS

All patients with the diagnosis of skeletal TB registered between 2007 and 2012 who successfully completed treatment were followed up for evidence of disease recurrence or relapse using structured interviews conducted between August 2013 and October 2015 after ensuring a minimum follow up of two years.

RESULTS

Of the 200 patients eligible for follow up in this study, 117 (58.5%) had a minimum follow up of two years. The remaining 83 cases could not be traced. 105 (89.7%) of these 117 patients were symptom free for two years or more after the completion of treatment. There were four cases who had a relapse of the disease within two years of completion of treatment. Eight cases were administered further ATT soon after the completion of treatment under DOTS.

CONCLUSIONS

This study confirms the efficacy of the alternate day DOTS regimen in successfully treating all forms of skeletal TB, including spinal TB, with a success rate of 89.7%.

Trends in Spinal Surgery for Pott's Disease (2000-2016): An Overview and Bibliometric Study

STUDY DESIGN

Systematic review.

OBJECTIVES

(1) What are the surgical indications? Have they changed over time since the year 2000? (2) What is the current surgical approaches of choice? Have they changed over time since the year 2000? Do they vary by geographical region? (3) What are the most common outcome measures following surgery?

METHODS

Electronic databases and reference lists of key articles were searched from database inception from January 1, 2000 to December 31, 2016 to identify studies specifically evaluating surgical indications, current surgical approaches, and outcome measures for spinal tuberculosis.

RESULTS

Six randomized controlled trials were identified from our search (1 excluded: no surgical arm identified after review) Neurological deficit, instability and deformity were common indications identified. Surgical approach included predominantly anterior for cervical spine and posterior for thoracic and lumbar spine. Combined approach was preferred in pediatric cases. Degree of deformity correction, neurological outcomes, and fusion formed the main bases of assessing surgical outcomes.

CONCLUSIONS

Majority of the current literature is from South Asia. The presence of neurological compromise, deformity, and instability were the primary criteria for surgical intervention. The preferred approach varied with the anatomical region of the spine in adults. Outcome measures predominantly involved deformity correction, neurological deficit, and fusion.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome and management of spinal tuberculosis according to severity at a tertiary referral center

Objective:

Anti-tuberculosis (TB) treatment remains the mainstay of treatment of spinal TB. There is a lack of consensus regarding the timing of interventional procedures and surgery in the patients with spinal TB. This study aims to prospectively study the clinical outcome and management in patients presenting with spinal TB at our tertiary referral center and teaching hospital.

Methods:

Data were collected prospectively from 48 patients treated for spinal TB presenting to us from August 2011 to December 2012. All the patients were followed-up for the duration of anti-TB treatment.

Results:

The categorization of patients into different management groups was based on the clinical and radiological findings at the time of diagnosis. The patients with mild disease (n = 23) were successfully managed with anti-TB treatment alone. The other 25 patients needed an intervention either in the form of pigtail catheter drainage of the paravertebral collection (n = 18) or an extensive surgical debridement followed by the fusion techniques (n = 7). All the patients responded well to the treatment, and there were no significant complications in any of the patients. It had been observed that various stages of spinal TB demand different approaches for the treatment in the form of either chemotherapy alone, chemotherapy with pigtail drainage of the paravertebral collection, or surgery in conjunction with chemotherapy.

Conclusions:

Judicious use of pigtail drainage and surgical intervention in addition to anti TB treatment can be rewarding in the patients with spinal TB.

India contribution to Spine Surgery: 15 most influential articles

OBJECTIVE

To determine the number of articles published by Indian authors related to spine surgery and to enumerate the 15 most influential articles from India published in the field of spine surgery in national & international journals based on the citations they have received both in pubmed and google scholar.

MATERIAL AND METHODS

A retrospective study using Pubmed database was performed for the years between 1960 and 2015, for the articles published from India in the field of spine surgery in various national and international journals. A total of 3181 citations were received for top 15 most influential articles in the field of spine surgery from India.

RESULTS

A total of 885 papers from India were identified which were published by Indian authors related to spine surgery between year 1960 to 2015. The largest numbers of papers were published in International journals such as Spine (82) and in European Spine Journal (47).

CONCLUSION

There are an increasing number of papers from India in the field of spine surgery literature. Most of the highly cited papers were related to tuberculosis. We expect further contributions from our country to the medical literature in the future.

Minimally invasive surgery through the interlaminar approach in the treatment of spinal tuberculosis: A retrospective study of 31 patients

The aim of this study was to evaluate the efficacy of minimally invasive spinal decompression combined with local chemotherapy in treating patients with thoracic/lumbar tuberculosis (TB) and abscess compression of the spinal canal. Clinical data of 31 patients with thoracic/lumbar TB and spinal epidural abscess, admitted to our hospital between December 2005 and June 2014 were retrospectively analyzed. All patients received initial conservative treatment but achieved unsatisfactory results and then underwent minimally invasive spinal canal decompression, focus debridement and catheter drainage through a posterior interlaminar approach. Postoperatively, a short-course (1-2months) of local chemotherapy was given. The patients were followed up on a regular basis. The neurologic status was graded according to the American Spinal Injury Association (ASIA) score system. Kyphotic deformity was evaluated using Cobb angle measurement. Patients were followed up for an average of 37months (range: 12-96months). At the last follow-up, ASIA scores were improved in all patients, and there was a mild increase in the Cobb angle, but satisfactory spinal stabilization was achieved. Hepatorenal function, erythrocyte sedimentation rate and C-reactive protein levels all returned to normal. One complication was observed, where the patient had worsened deficit postoperatively but achieved a satisfactory recovery (from Grade C to Grade E) one year after a second surgery. Minimally invasive spinal canal decompression combined with local chemotherapy appears to be an effective treatment for patients with thoracic/lumbar TB and abscess compression in the spinal canal.

Evaluation of the Behavior of Spinal Deformities in Tuberculosis of the Spine in Adults

Study Design

A prospective clinical study.

Purpose

The objective of the present study was to evaluate the behavior of spinal deformities in tuberculosis (TB) of the spine during the initial 2 years and to suggest remedial measures.

Overview of Literature

Spinal TB is the most common cause of a kyphotic deformity in many parts of the world. Treatment of the established deformity is difficult, hazardous and has a high complication rate.

Methods

We followed 50 adult patients treated for spinal TB for a minimum of 2 years. Average values of vertebral body height loss (VBL), deformity angle, kyphosis angle, and lumbosacral joint angle at the final follow-up were compared with the values at initial presentation. The relationship between the amount of initial VBL and final kyphotic angle was analyzed.

Results

Average values of VBL, deformity angle, kyphosis angle, and lumbosacral joint angle at initial presentation were 0.26, 12.51°, 2.26°, and 12.3°, respectively; and the corresponding values at the final follow-up were 0.7, 17.8°, 5.64°, and 10.8°, respectively. The increase was extremely significant for the deformity angle (initial vs. 6th month, p=0.000; 6th month vs. 24th month, p=0.000) and kyphotic angle (initial vs. 6th month, p=0.003; 6th month vs. 24th month, p=0.000) in the thoracic and thoracolumbar regions during the first 2 years of the disease process. The increase in the deformity angle in the lumbar region was significant only in the initial 6 months (p=0.01). We could not find any correlation between the initial VBL and the final kyphotic angle (r=0.302, p>0.05).

Conclusions

Different regions of the vertebral column respond differently to bony destruction caused by spinal TB. Deformity progression is more significant during the initial 6 months of the disease process, and this may be the best time to take remedial measures to prevent development/progression of the deformity. Kyphotic deformity keeps increasing even after 6 months of antituberculous treatment, and it does not correlate with the initial VBL in adults.

Characteristics and Clinical Outcome of Bone and Joint Tuberculosis From 1994 to 2011: A Retrospective Register-based Study in Denmark

BACKGROUND

Most information on bone-joint (BJ)-tuberculosis is based on data from high-incidence areas. We conducted a nationwide register-based analysis of BJ-tuberculosis in Denmark from 1994 to 2011.

METHODS

We linked data from the national tuberculosis surveillance system on BJ-tuberculosis, hospital records, the Danish Hospital and Civil Registration System.

RESULTS

We identified 282 patients with BJ-tuberculosis, 3.6% of all tuberculosis cases (n = 7936). Spinal tuberculosis was found in 153 of 282 patients (54.3%); 83.3% of all cases were immigrants. Danes were older and had higher Charlson comorbidity index scores than immigrants (P < .01). C-reactive protein and erythrocyte sedimentation rates were elevated in most cases. Median time to diagnosis after first hospital contact was 19.5 days for spinal tuberculosis and 28 days for other forms of BJ-tuberculosis (P = .01). Of patients with spinal tuberculosis, 54/133 (40.6%) had neurologic deficits at admission and 17.3% presented with cauda equina. Diagnosis was culture verified in 87%. (Resistance to any drug was found in 10.2%). Median time on antituberculous treatment for patients with spinal and other forms of BJ-tuberculosis was 9 months and 7 months, respectively (P < .01). Surgery was required in 44.4% patients with spinal tuberculosis and in 32.6% patients with other forms of BJ-tuberculosis (P = .04). Sequelae were reported in 57.5% of patients with spinal tuberculosis and 29.1% of patient with other forms of BJ-tuberculosis (P < .01). One-year mortality was 25.5% among Danes compared with 1.3% among immigrants (P < .01).

CONCLUSIONS

BJ-tuberculosis was rare and seen mainly in younger immigrants in Denmark. More than half of cases were spinal tuberculosis, presenting with more severe symptoms and worse outcome, compared with other forms of BJ-tuberculosis.

A retrospective controlled study of three different operative approaches for the treatment of thoracic and lumbar spinal tuberculosis: three years of follow-up

OBJECTIVE

The purpose of this study was to determine the optimal operative approach for the treatment of spinal tuberculosis. We analyzed two types of pathological vertebrae (thoracic and lumbar) and three cardinal operative approaches for surgery.

METHODS

Sixty patients with spinal tuberculosis were divided into thoracic (n=30) and lumbar groups (n=30) based on locations of the foci. These patients underwent anti-tuberculosis drug and surgical therapy. The operative approaches for the surgical treatments were the anterior approach (AA, n=20), posterior approach (PA, n=20), and combined anterior and posterior approach (CAPA, n=20). All clinical data from the patients was collected and included surgical time, blood loss, correction of kyphosis, and vertebral body height reconstruction. Differences in the means between the groups were evaluated statistically with one-way analyses of variance (ANOVAs).

RESULTS

The surgery time in the CAPA group was longer than that of AA group (P<0.05), and there were no significant differences between the CAPA and PA groups or the AA and PA groups. The average vertebral body height reconstruction in the AA group was larger than that of the PA or CAPA groups, and there was no significant difference between the PA and CAPA groups (P>0.05). There were no interactions between the location of the pathological vertebra and the type of surgical approach, with the exception of blood loss. The blood loss of the CAPA was greater than those of the AA and PA patients in the thoracic group (P<0.05), and no significant difference was found in the lumbar group (P>0.05).

CONCLUSIONS

AA was well-suited for serious vertebral collapse that required reconstruction of the height of the vertebrae. CAPA was unfit for patients with poor basic conditions due to the long surgical time, but the long surgery time of CAPA did not necessarily lead to greater blood loss compared to the other approaches.

Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation

BACKGROUND CONTEXT

Traditional focal debridement involves clearing of cold abscesses, caseous necrosis, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Reports have demonstrated that approximately 13% to 26% of patients were not better or relapsed after traditional focal debridement; these patients required a second surgery or prolonged antituberculous therapy. The presence of retained and diseased focal tissues requiring removal remains poorly understood. The contents of these retained tuberculous foci, improvement of surgical strategies, and improvement in spinal tuberculosis success rate are key subjects for discussion.

PURPOSE

To explain the contents of foci and explore the surgical methods and curative effect of complete debridement.

STUDY DESIGN

Retrospective study of the curative effect of treatment of thoracolumbar spinal tuberculosis by using complete debridement.

PATIENT SAMPLE

A total of 289 patients were included.

OUTCOME MEASUREMENT

The outcomes were evaluated clinically by Frankel grading. The status of the anterior fusion was assessed according to the Moon standard. Eradication of infection was determined by the level of C-reactive protein and erythrocyte sedimentation rate. X-ray, computed tomography, and magnetic resonance imaging were used to evaluate disease localization and morphology.

METHODS

A total of 289 patients with spinal tuberculosis (150 male and 139 female patients, aged 18-82; average age, 41.0±1.4 years) were included in this study. Damage to the vertebrae was as follows: 86 patients had thoracic damage, 49 had thoracolumbar damage, 125 had lumbar damage, and 47 had lumbosacral segment damage. After 2 to 4 weeks of antituberculous therapy, all patients underwent anterior debridement, deformity correction, graft fusion, and internal fixation. In this study, complete debridement was defined as the clearing of any damage or disease, including psoas abscesses, granulomas, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Tuberculosis cavities, sclerotic walls, and bony bridges that had no support and that were eroded by the foci were also removed. A total of 108 patients underwent anterior fixation with the Zephir system (Medtronic Sofamor-Danek, Minneapolis, MN, USA), Z plates (Medtronic Sofamor-Danek), or Ventrifix (China Great Wall Corporation, Beijing, China). A total of 181 patients underwent fixation, posterior correction, and one or two second anterior debridements and graft fusions. Posterior fixation, including TSRH (Medtronic Sofamor-Danek), Cotrell-Dubousset (Medtronic Sofamor-Danek), General Spinal System (WeiGao Orthopaedic Devices Company, Weihai City, China), or UPASS (WeiGao Orthopaedic Devices Company), was performed. All patients underwent structural bone grafting, including autologous iliac bone (251 patients), titanium mesh (32 patients), and rib (6 patients).

RESULTS

The 289 patients were followed for 72.0±2.8 months, with 265 patients (91.69%) completely treated and 24 incompletely treated, including 3 who suspended chemotherapy because of liver or renal failure. Twenty-one patients (7.27%) failed to have a complete debridement, including 16 with incomplete bone debridement, 6 of whom underwent a second surgery, and 10 who received conservative therapy; 5 of this group had incomplete abscess debridement, 3 underwent a second surgery, and 2 received puncture aspiration of abscess under computed tomographic guidance; the second surgery rate was 3.81%. Twenty-two patients had surgery complications, including three with graft displacement, five with wound infection and fat liquefaction, four with pleural effusion, six with pain at the graft harvesting site, and four with incisional hernia. Bone graft healing was observed 4.3±1.2 months after surgery. The Cobb angle before and after surgery and at the final follow-up was 22.16±11.51°, 8.11±4.83°, and 9.96±3.49°, respectively, with a mean correction of 63.40% after surgery; however, a 1.85±1.34° loss was observed at the final follow-up with loss rate of 8.35%.

CONCLUSIONS

Sclerotic bone, multiple cavities, and bony bridges are foci in spinal tuberculosis. Clearing tuberculous foci, sclerotic bone, multiple cavities, and bony bridges to increase the curative effect is an effective treatment method.

Outcome assessment in conservatively managed patients with cervical spine tuberculosis

STUDY DESIGN

Cervical spine tuberculosis is a relatively less frequent form of spinal tuberculosis. Cervical spine tuberculosis has a greater propensity to involve the spinal cord and results in major sensory motor deficit. In this prospective study, we aimed to evaluate the clinical and imaging predictors of outcome in conservatively managed patients.

METHODS

In this study, 42 patients of cervical spine tuberculosis were included. Patients were subjected to a detailed clinical evaluation and magnetic resonance imaging. Patients were treated with antituberculosis treatment and were followed up for 18 months. The Modified Barthel index (MBI) was used to assess the disability. Good outcome was defined as MBI >12 and poor outcome as MBI ⩽12. Clinical and imaging characteristics were used to analyze the predictors of outcome, using univariate and multivariate analysis.

RESULTS

Four (9.5%) patients required surgery. Data from 38 patients, who were conservatively managed, were analyzed for predictors of outcome. Among conservatively managed patients, at presentation, 29 patients had an MBI score of ⩽12. At 18 months, the majority of patients (81.6%) had a good outcome. On univariate analysis, a duration of illness >3 months, a major motor deficit, bladder involvement, flexor spasms, significant cord compression and spinal extension of the abscess were significantly associated with a poor outcome. However, on multivariate analysis significant cord compression (P=0.003) and spinal extension (P=0.02) showed a significant correlation with a poor outcome.

CONCLUSION

Medical management was effective in cervical spine tuberculosis. Patients with significant cord compression and spinal extension of the abscess showed poorer outcome.

Management of spinal tuberculosis: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) studying the clinical benefit of chemotherapy with surgical intervention over chemotherapy alone for the treatment of spinal tuberculosis.

METHODS

Relevant RCTs were identified by computerized database searches. Trial eligibility and methodological quality were assessed and data were extracted and analysed using odds ratios with 95% confidence intervals. The primary outcome measure was kyphosis angle.

RESULTS

The literature search identified two RCTs conducted in the 1970s and 1980s and a Cochrane Database Systematic Review published in 2006. There were no significant between-group differences in kyphosis angle, bony fusion, bone loss or development of neurological deficit.

CONCLUSIONS

There is no obvious statistically significant clinical precedence to suggest that routine surgery will improve the prognosis of patients with spinal tuberculosis.

Ultra-short-course chemotherapy for spinal tuberculosis: five years of observation

PURPOSE

This study aimed to explore the feasibility of ultra-short-course chemotherapy in the treatment of spinal tuberculosis.

METHODS

One hundred and eighty-five patients with confirmed spinal tuberculosis and surgical indication were included. The chemotherapy regimen was 2SHRZ/XHRZ. According to the duration of the chemotherapy, the patients were divided into two groups, the ultra-short-course chemotherapy group with an average duration of 4.5 months, and the standard chemotherapy group with an average duration of 9 months. The same surgery was performed for patients in the two groups.

RESULTS

The duration of the follow-up ranged from 61 to 87 months, with an average of 69.1 months. Erythrocyte sedimentation rate and C-reactive protein, kyphosis and nerve function, recovery of work, and activities of daily living were not significantly different between the two groups before or after treatment; however, the aforementioned indices were significantly different before and after treatment within groups. There was no significant difference in postoperative bone graft healing between the two groups. The drug side effects were significantly different between the two groups.

CONCLUSIONS

With thorough focus debridement, bone grafting, and internal fixation, the efficacy of ultra-short chemotherapy was similar to that of standard chemotherapy for the treatment of spinal tuberculosis. The ultra-short-course chemotherapy can shorten the course of treatment and reduce drug side effects.

Spinal tuberculosis: diagnosis and management

The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Therefore, early diagnosis and management of spinal TB has special importance in preventing these serious complications. In order to extract current trends in diagnosis and medical or surgical treatment of spinal TB we performed a narrative review with analysis of all the articles available for us which were published between 1990 and 2011. Althoug h the development of more accurate imaging modalities such as magnetic resonance imaging and advanced surgical techniques have made the early diagnosis and management of spinal TB much easier, these are still very challenging topics. In this review we aim to discuss the diagnosis and management of spinal TB based on studies with acceptable design, clearly explained results and justifiable conclusions.

Two-stage surgical management using posterior instrumentation, anterior debridement and allografting for tuberculosis of the lower lumbar spine in children of elementary school age: minimum 3-year follow-up of 14 patients

PURPOSE

Various surgical methods have been described for the management of lumbar tuberculous spondylitis in the literature. However, there were few reports on the two-stage surgical treatment of lumbar tuberculosis in children of elementary school age. We present a retrospective clinical study of 14 patients with lumbar and lumbosacral tuberculous spondylitis treated by two-stage surgery (first stage: posterior instrumentation; second stage: anterior debridement and allografting). The purpose is to determine the clinical efficacy of such surgical treatment for lumbar tuberculosis in children.

METHOD

Our series was comprised 9 males and 5 females with an average age of 7.5 years treated with the above-mentioned surgical procedure. All patients had lumbar and lumbosacral involvement with one patient having spondylitis at L2-3, three at L3-4, seven at L4-5, and three at L5-S1. All patients had single motion segment involvement. The Frankel scoring system was used to assess the neurological deficits. Frankel's grade B in two patients, grade C in four and grade D in eight. The following data were followed-up for an average period of 50.1 months (42-64 months) in these patients: healing of disease, deformity correction and its maintenance, neurologic function, and spinal bony fusion.

RESULTS

The average preoperative local deformity angle was -13.8°, correcting to 3.4° postoperatively and 1.5° at the final follow-up. With the exception of one patient who received a D at the final follow-up, all cases obtained complete neurological recovery. No breakage and looseness of internal fixation was found. Bony fusion was achieved in all cases within 6 months postoperatively. There was no recurrent tuberculous infection.

CONCLUSION

Two-stage (posterior and anterior) surgery is a safe and effective procedure for the patient of elementary school age suffering from lumbar and lumbosacral tuberculous spondylitis, especially for the patients in poor general condition. The procedure has the advantage of minor surgical invasion, effective kyphosis correction and less complications.

Natural history of Pott's kyphosis

The natural history of Pott's kyphosis is different from that of other spinal deformities. After healing of the spinal infection, the post-tubercular kyphosis in adults is static but in children variable progression of the kyphosis is seen. The changes occurring in the spine of children, after the healing of the tubercular lesion, are more significant than the changes that occur during the active stage of infection. During growth, there is a decrease in deformity in 44 % of the children, an increase in deformity in 39 % of the children and no change in deformity in 17 % of the children. The critical factor leading to the progress of the deformity is dislocation of the facets. This can be identified on radiographs by the "Spine-at-risk" signs. Dislocation of facets at more than two levels can lead to the "Buckling collapse" of the spine, which is characteristically seen only in severe tubercular kyphosis in children. Age below 10 years, vertebral body loss of more than 1-1.5 pre-treatment deformity angle of greater than 30° and involvement of cervicothoracic or thoracolumbar junction are the other risk factors for deformity progression. In children, the kyphosis can progress even after healing of the spinal infection and hence children with spinal tuberculosis must be followed-up till skeletal maturity.

Tuberculosis of the spine. A systematic review of case series

PURPOSE

The objective of this systematic review was to characterise the methodological issues, as well as clinical, diagnosis, microbiological and treatment characteristics of patients with spinal tuberculosis.

METHODS

We conducted a systematic review including prospective or retrospective case series written in English, Spanish, French, German and Italian published in the period from January 1980 to March 2011.

RESULTS

Thirty-seven articles were included with a total of 1,997 patients; the median of the percentage of men was 53% (interquartile range [IQR] 48-64) and the median of the patients mean age was 43.4 (IQR 37-55). The most common symptom reported was back pain, and thoracic spine was the most frequent segment involved. Spinal plain radiography was done in 35 studies (94.6%), magnetic resonance imaging (MRI) in 26 (70.2%), computed tomography scan (CT-scan) in 13 (35%) and microbiological diagnosis in 29 (78.3%). Surgical treatment was reported in 28 articles 75.7%; finally, 24 articles reported follow-up, and in 15 of them at least 80% of patients improved.

CONCLUSIONS

Spinal TB is still an important public health issue, it must be suspected in the presence of back pain or characteristic images and should be confirmed with microbiological procedures. Chemotherapy treatment is often used; in contrast, there is heterogeneity in the percentage of patients treated by surgery.

Kyphotic deformity in spinal tuberculosis and its management

Spinal tuberculosis is the most common cause of severe kyphosis in many parts of the world. Three percent of patients treated conservatively end up with a deformity greater than 60 degrees which can cause serious cosmetic, psychological, cardio-respiratory and neurological problems. Severe kyphotic deformities are usually the result of childhood spinal deformities and 'Spine at risk' radiological signs are helpful to identify children at risk of deformity. In children, a severe type of collapse, termed as 'Buckling Collapse' is also noted where the kyphosis is more than 120 degrees. Risk factors for buckling collapse include an age of less than seven years at the time of infection, thoracolumbar involvement, loss of more than two vertebral bodies and the presence of radiographic 'Spine-at-risk' signs. In correction of established deformity, posterior only surgery with a variety of osteotomies is now preferred. In patients with deformity of more than 90 degrees, an opening-closing wedge osteotomy must be done to prevent neurological deficit.

Efficacy of directly observed treatment short-course intermittent regimen in spinal tuberculosis

BACKGROUND

Most important cause of treatment failure and emergence of drug resistance in the treatment of tuberculosis is noncompliance. Compliance can be improved by direct observation of drug intake, intermittent therapy, and short-course treatment. The efficacy of Directly Observed Treatment Short Course (DOTS) strategy advocated by World Health Organization (WHO) in spinal tuberculosis is not yet proven. We conducted a prospective clinical study on a consecutive series of patients with spinal tuberculosis treated by Category I Revised National Tuberculosis Control Programme (RNTCP) regimen based on DOTS strategy of WHO from 2004 to 2007 to evaluate the efficacy.

MATERIALS AND METHODS

Forty-nine consecutive patients of spinal tuberculosis were treated with short-course intermittent chemotherapy under Category I RNTCP/DOTS strategy. Patients were followed up for a minimum period of 2 years. Surgery was done if the patient presented with significant neurologic deficit or when the drug treatment failed. Outcome was assessed by clinical, radiologic, and laboratory criteria, and graded into excellent, good, fair, and poor based on various parameters.

RESULTS

63.4% (n=26) of the patients had excellent results. 14.6% (n=6) of the patients had good and fair results. Three patients (7.3%) had poor results 48.7% (n=20) of the patients had but only one of them was severe enough to warrant change of drug.

CONCLUSIONS

Efficacy of DOTS was comparable with other standard regimens. There was a significant reduction in adverse side effects when compared with daily regimens. Study showed that the outcome was better in those treated early.

Efficacy of extended DOTS category I chemotherapy in spinal tuberculosis based on MRI-based healed status

BACKGROUND

Duration of treatment in tuberculosis of spine has always been debatable in the absence of marker of healing. The objective of the study was to evaluate the efficacy of extended DOTS regimen (2 months of intensive phase and 6 months of continuation phase) as recommended by WHO, by using MRI observations as the healing marker.

MATERIALS AND METHODS

51 (Group A -28 prospective and Group B- 23 retrospective) patients of spine TB with mean age of 26.8 years (range 15-54 years) diagnosed clinico radiologically/imaging (n=36), histopathology or by PCR (n=15) were enrolled for the study. They were treated by extended DOTS regimen (2 months of HRZE and 6 months of HR) administered alternate day. The serial blood investigations and X-rays were done every 2 months. Contrast MRI was done at the end of 8 months and healing changes were recorded. Criteria of healing on the basis of MRI being: complete resolution of pre and paravertebral collections, resolution of marrow edema of vertebral body (VB), replacement of marrow edema by fat or by calcification suggested by iso- intense T1 and T2 weighted images in contrast enhanced MRI. Patients with non healed status, but, responding lesion on MRI after 8 months of treatment were continued on INH and rifampicin alternate day and contrast MRI was done subsequently at 12 months and 18 months till the healed status was achieved .

RESULTS

9 patients had paraplegia and required surgical intervention out of which 1 did not recover neurologically. All patients have completed 8 months of extended DOTS regimen, n=18 achieved healed status and duration of treatment was extended in rest (n=33) 5 were declared healed after 12 months, 8 after 18 months and one after 36 months of treatment, thus 32 were declared healed at varying periods.

CONCLUSION

35.2% patients demonstrate MRI based healed vertebral lesion at the end of 8 months of extended category 1 DOTS regimen. It is unscientific to stop the ATT by fixed time frame and MRI evaluation of the patients is required after 8 months of ATT and subsequently to decide for the continuation stoppage of treatment.

Lumbar vertebral growth is governed by "chondral growth force response curve" rather than "Hueter-Volkmann law": a clinico-biomechanical study of growth modulation changes in childhood spinal tuberculosis

STUDY DESIGN

Vertebral defects were created in a validated 3D finite element model (FEM) to simulate destructive tubercular lesions of increasing severity. Forces in various parts of the spine were then calculated and correlated to deformity progression and growth modulation (GM) changes.

OBJECTIVE

To understand the biomechanical basis of GM, which governs spinal growth and the progression of kyphosis in posttubercular kyphotic (PTK) deformities.

SUMMARY OF BACKGROUND DATA

Hueter-Volkmann Law (HVL), chondral growth force response curve (CGFRC), and regional growth acceleratory phenomenon have all been proposed to explain the modulation of growth in limbs but have not been tested in vertebral end plates (VEP). We have previously documented various GM changes in posttubercular kyphotic. By simulating the kyphotic collapse in a validated FEM, the mechanical basis of GM can be established.

METHODS

Sixty-three children with tuberculosis treated conservatively formed the clinical material. The progress of deformity and GM changes in the fusion mass and the kyphotic curve was documented. Defects simulating lesions of four levels of severity (types A, B, C, and D) were created in a validated 3D FEM and subjected to load till restabilization occurred. The stresses at the end plates, discs, facet joints, and the points of contact were calculated.

RESULTS

Regional growth acceleratory phenomenon and favorable growth changes were found in type A collapse where the facets were intact. With increasing destruction, the forces in the facet capsules increased beyond 30 MPa predicting facet dislocations in types B, C, and D collapse. As the contact stress on the VEP increased to 16.6 MPa (type B) and 40 MPa (type C), this was associated with growth suppression. Type D collapse involved facet dislocation at multiple levels leading to "buckling collapse". Acceleratory growth was found both in tension and compression phases proving that VEP growth followed principles of CGFRC rather than HVL.

CONCLUSION

This is the first study in the current literature to demonstrate that spinal growth follows CGFRC rather than HVL. This observation opens a potential window of opportunity to treat spinal deformities by mechanical GM.

Closing-opening wedge osteotomy for severe, rigid, thoracolumbar post-tubercular kyphosis

Childhood spinal tuberculosis, especially when associated with severe vertebral destruction of more than two vertebral bodies can end up in severe deformity. These children show progressive deformity throughout the period of growth and can develop severe kyphosis of >100°. Such kyphosis is severely disabling with significant risk of neurological deficit and respiratory compromise. Surgical correction of these deformities by both anterior and posterior approaches has been described but each have serious limitations of approach, correctability and safety. We describe here a technique of posterior closing-anterior opening osteotomy, which allowed us to correct a rigid post-tubercular deformity of 118° in a 13-year-old boy with neglected spinal tuberculosis. The patient was a 13-year-old boy, who had contracted spinal tuberculosis at the age of 6 years. Although the disease was cured by anti-tubercular chemotherapy, he continued to deteriorate in deformity and presented to us with severe thoracolumbar kyphosis (118°). He was neurologically intact but was beginning to show shortness of breath on exertion. Patient also had fore shortening of the trunk with impingement of the rib cage on the iliac crest. Radiographs revealed complete destruction of T12, L1 and L2 vertebral bodies with the T11 vertebra fusing with L3 anteriorly. CT scans and MRI revealed severe collapse of the vertebral column and the spinal cord being stretched over the 'internal gibbus', which was formed by the remnants of the destroyed vertebrae. A single stage closing-opening osteotomy was done by a midline posterior approach with continuous intraoperative spinal cord monitoring. The procedure involved extensive laminectomy of T11-L2, pedicle screw fixation of three levels above and three levels below the apex, a wedge osteotomy at the apex of the deformity from both sides, anterior column reconstruction by appropriate-sized titanium cage and gradual correction of deformity by closing the posterior column using the cage as a fulcrum. This allowed us to achieve a correction to 38° (68% correction). There was no intraoperative or perioperative adverse event and patient had good functional and radiological outcome at 1-year follow-up. In this Grand Rounds case presentation, we have also discussed the aetiology and evolution of severe post-tubercular kyphosis, which is the most common cause of spinal deformity in the developing world. Early identification of children at risk for severe deformity, the time and ideal methods of prevention of such deformities are discussed. The pros and cons of the available options of surgical correction of established deformity and the merits of our surgical technique are discussed.

Tuberculose vertebral: análise descritiva de uma série de casos submetidos a tratamento cirúrgico

OBJETIVO: apresentar a casuística cirúrgica no tratamento da tuberculose vertebral e comparar os resultados com a literatura atual. MÉTODOS: foi realizada a análise retrospectiva dos prontuários dos pacientes submetidos à cirurgia para tratamento da espondilite tuberculosa. Foram estudados o tipo de cirurgia realizada, o estado neurológico e o grau de cifose antes da cirurgia e ao final de 12 meses. O Estado neurológico foi definido pela escala de Frankel modificada. A deformidade cifótica foi medida pelo método de Cobb. Foram identificados 23 pacientes com diagnóstico confirmado de tuberculose vertebral. Foram submetidos a tratamento cirúrgico 13 dos 23 pacientes. Três pacientes foram excluídos e dez pacientes participaram do estudo. RESULTADOS: a maioria dos pacientes foi submetida à descompressão, artrodese anterior e posterior por via combinada ou posterior com instrumentação. Seis dos dez pacientes apresentavam déficit neurológico ao diagnóstico, sendo duas crianças que apresentavam a lesão denominada de Mal de Pott à admissão. Três pacientes apresentaram recuperação completa da função motora dos membros inferiores. Um paciente apresentou piora do déficit neurológico após a cirurgia devido à resistência bacteriana ao uso de quatro drogas diferentes e à meningite tuberculosa. Em relação às medidas da cifose angular e regional no início e ao final do seguimento, constatou-se que a média da cifose angular no início foi de 26,7º (0º a 90º) e de 21,2º (0º a 50º) ao final do seguimento. A média da cifose regional no início foi de 24,10º (-27º a +60º) e de 21º (-33º a +65º) ao final do seguimento. Houve uma redução da média de cifose angular e regional de 5,7º e 3,1º, respectivamente. Não se observou progressão significativa da cifose em nenhum dos pacientes operados. CONCLUSÃO: o tratamento cirúrgico da espondilite tuberculosa nesta série de casos foi eficaz na prevenção da progressão da cifose avaliada em um período mínimo de 12 meses. O déficit neurológico relacionado à tuberculose vertebral foi mais grave nas crianças.

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

The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multiple staged with a high morbidity. Here, we describe the procedure and results of closing-opening osteotomy for correction of PTK which shortens the posterior column and opens the anterior column appropriately to correct the deformity without altering the length of the spinal cord. Seventeen patients with PTK (10 males; 7 females) with an average age of 18.3 +/- 10.6 years (range 4-40 years) formed the study group. There were ten thoracolumbar, one lumbar and six thoracic deformities. The number of vertebrae involved ranged from 2 to 5 (average 2.8). Preoperative kyphosis averaged 69.2 degrees +/- 25.1 degrees (range 42 degrees -104 degrees ) which included ten patients with deformity greater than 60 degrees . The average vertebral body loss was 2.01 +/- 0.79 (range 1.1-4.1). The neurological status was normal in 13 patients, Frankel's grade D in three patients and grade C in one. Posterior stabilization with pedicle screw instrumentation was followed by a preoperatively calculated wedge resection. Anterior column reconstruction was performed using rib grafts in four, tricortical iliac bone graft in five, cages in six, and bone chips alone and fibular graft in one patient each. Average operating time was 280 min (200-340 min) with an average blood loss of 820 ml (range 500-1,600 ml). The postoperative kyphosis averaged 32.4 degrees +/- 19.5 degrees (range 8 degrees -62 degrees ). The percentage correction of kyphosis achieved was 56.8 +/- 14.6% (range 32-83%). No patient with normal preoperative neurological status showed deterioration in neurology after surgery. The last follow-up was at an average of 43 +/- 4 months (range 32-64 months). The average loss of correction at the last follow-up was 5.4 degrees (range 3 degrees -9 degrees ). At the last follow-up, the mean preoperative pain visual analogue scale score decreased significantly from 9.2 (range 8-10 points) to 1.5 (range 1-2 points). There was also a significant decrease in mean preoperative Oswestry's Disability Index from 56.4 (range 46-68) to 10.6 (range 6-15). Complications were superficial wound infections in two, neurological deterioration in one, temporary jaundice in one and implant failure requiring revision in one. Single-stage closing-opening wedge osteotomy is an effective method to correct severe PTK. The procedure has the advantage of being a posterior only, single-stage correction, which allows for significant correction with minimal complications.

Prospective randomized trial of six-month versus nine-month therapy for intestinal tuberculosis

Intestinal tuberculosis (TB) continues to be a common disease worldwide. However, the optimal duration of anti-TB medication has not been well established. We therefore compared the efficacy of 6-month and 9-month therapy in the treatment of intestinal TB. Ninety patients definitely diagnosed with intestinal TB were randomized into 6-month (n = 45) or 9-month (n = 45) treatment groups, prospectively. The primary end point was complete response, defined as endoscopic healing of active lesions. Patients were followed up monthly for 3 months after therapy initiation, then every 3 months until the end of therapy, and finally 1 year later. Relapse was assessed 1 year after the end of therapy by patient interview and colonoscopy. Baseline characteristics were similar in the 6-month and 9-month groups. Intention-to-treat analysis revealed no significant differences between the two groups in complete response (6-month group, 93.3%; 9-month group, 91.1%; P = 1.00) or recurrence rate (6-month group, 2.4%; 9-month group, 0.0%; P = 1.00). Median follow-up duration was 39 months in the 6-month group and 32 months in the 9-month group. No surgery was performed on any patient in either group. In conclusion, the 6-month therapy was as effective as 9-month therapy in patients with intestinal TB and may have the additional benefits of reduced treatment cost and increased compliance.

One-stage surgical management for children with spinal tuberculosis by anterior decompression and posterior instrumentation

The goal of this study was to assess the efficacy of one-stage surgical management for children with spinal tuberculosis by anterior decompression, bone grafting, posterior instrumentation, and fusion. Between January 2002 and December 2006, 15 cases with spinal tuberculosis were treated with one-stage posterior internal fixation and anterior debridement. All cases were followed-up for an average of 30.3 months (range 12-48 months). The average neurological recovery in the patients was 0.93 grades on the scale of Frankel et al. (Paraplegia 7:179-192, 1969). The average preoperative kyphosis was 36 degrees (range 19-59 degrees ), and the average postoperative kyphosis was 23 degrees (range 15-38 degrees ) at final follow-up. At final follow-up, minimal progression of kyphosis was seen, with an average kyphosis of 27 degrees (range 16-40 degrees ). An average loss of correction of 4 degrees was seen at final follow-up. One-stage surgical management for children with spinal tuberculosis by anterior decompression, bone grafting, posterior instrumentation, and fusion was feasible and effective.

Outcome and management of spinal tuberculosis according to the severity of disease: a retrospective study of 137 adult patients at Korean teaching hospitals

STUDY DESIGN

A retrospective study examining the clinical features, management, and treatment outcome of patients with spinal tuberculosis (TB).

OBJECTIVE

To determine the influence of disease severity and treatment modality on outcome of patients with spinal TB.

SUMMARY OF BACKGROUND DATA

Although anti-TB chemotherapy is now the mainstay treatment for spinal TB, it may not be applicable to all situations, especially in patients with risk of deformity, instability, and progression of neurologic deficit.

METHODS

In this retrospective study (1994-2003), medical records and radiographic findings of patients with spinal TB were reviewed at 7 teaching hospitals in South Korea. The duration of triple chemotherapy with isoniazid, rifampin, and ethambutol, disease severity, operative procedures, and outcome were analyzed. The outcome was assessed as both favorable and unfavorable according to predefined criteria.

RESULTS

A total of 137 patients were diagnosed with spinal TB during the study period. Twenty-one patients were lost to follow-up and excluded from analysis. The mean age was 44.07 +/- 16.57 years. The most common vertebral area involved was the lumbar (44.8%). The mean number of vertebra involved was 2.25. The mean angle of kyphosis was 21.58 degrees. Forty-seven patients (35.1%) had severe symptoms. Radical surgery was carried out in 84 (62.2%) patients. Twenty patients were treated with short-term chemotherapy, while 96 under long-term. At the end of chemotherapy, 94 patients had achieved a favorable status and 22 an unfavorable one. Statistically, there was no significant difference between the 2 groups in terms of gender, chemotherapy duration, or the severity of spinal TB; however, age (P = 0.025; odds ratio = 0.963; 95% confidence interval 0.932-0.995) and radical surgery (P = 0.043; odds ratio = 3.047; 95% confidence interval 1.038-8.942) were significantly related to a favorable outcome by logistic analysis.

CONCLUSIONS

Our results showed that a younger age and radical surgery in conjunction with anti-TB chemotherapy were significant favorable prognostic factors.

Prediction of deformity in spinal tuberculosis

Tuberculosis of the spine may cause kyphosis, which may in turn cause late paraplegia, respiratory compromise, and unsightly deformity. Surgical correction therefore may be considered for large or progressive deformities. We retrospectively analyzed clinical and radiographic parameters to predict the final kyphotic angle in spinal tuberculosis and to identify patients at risk of unfavorable outcomes at an early stage of the disease when surgery may be indicated. Unfavorable outcome was defined as progression of 10 degrees or greater and/or a final angle of 40 degrees or greater. We analyzed 53 patients with active spinal tuberculosis located in the thoracic (T1 to T10) and thoracolumbar spine (T11 to L2) and with initial kyphotic angles less than 40 degrees. We calculated the indexed total bone height loss, a value of 1 being the equivalent of the loss of a total vertebral body. There were no independent predictors. A bone height loss greater than 0.3 on the initial radiograph in combination with a thoracolumbar location indicated a 38% chance of unfavorable outcome versus only a 3% chance of unfavorable outcome when bone height loss was 0.3 or less in combination with a thoracic location. We present a simple and clinically useful algorithm for predicting kyphosis in spinal tuberculosis.

Tratamento da tuberculose da coluna vertebral: conservador ou cirúrgico?

Desde a primeira descrição por Percivall Pott da tuberculose de coluna vertebral, tem-se evoluído muito na abordagem dessa doença. Porém ainda existem muitas controvérsias em relação à prevenção das deformidades. Os objetivos de nosso estudo são avaliar as características clínicas e radiológicas de pacientes com tuberculose de coluna e comparar o tratamento conservador isolado com o cirúrgico associado a antibioticoterapia, principalmente quanto à deformidade residual e déficit neurológico. Nosso trabalho é retrospectivo com avaliação de prontuários e radiografias iniciais e ao final do seguimento. O quadro neurológico foi avaliado através da escala da ASIA e as deformidades foram medidas pelo método de Cobb. Foram avaliados 38 pacientes, 11 pacientes foram operados e 27 receberam somente antibioticoterapia. 15 pacientes tinham déficit neurológico, todos melhoraram independente do tipo de tratamento. A média de cifose torácica focal e regional no início do seguimento foi respectivamente 48,8º e 47,86º. Houve aumento da deformidade na região torácica, segmento mais acometido, de 6,3º focal e 9,8 regional ao final de 5 anos. O tipo de tratamento não influenciou na progressão da cifose. Paciente com menos de 15 anos e cifose maior que 30º tiveram pior prognóstico quanto à progressão da deformidade.

One-stage lateral rhachotomy and posterior spinal fusion with compression hooks for Pott's paralysis in the elderly

PURPOSE

To evaluate the safety and effectiveness of one-stage lateral rhachotomy and posterior fusion with compression hooks, for the treatment of Pott's paralysis in the elderly.

METHODS

11 elderly patients underwent lateral rhachotomy (costotransversectomy and pediculectomy) to debride the tuberculosis focus extending into the epidural space and to decompress the spinal cord. After debridement, the interbody cavity was packed with autologous iliac bone chips. For stabilisation, posterior fusion was performed using a compression lamina hook system. Patients were followed up for at least 2 years for complications. Neurological status was assessed using the Frankel score. The kyphotic deformity was measured on lateral radiographs taken before surgery and at follow-up.

RESULTS

During separation of the adhesion around the abscess, a dural tear occurred in one patient and a pleural tear in another. Both tears were successfully repaired. One patient had mild pneumonia after surgery. The Frankel scores of the 11 patients improved from C or D before surgery to D or E after surgery. No relapse of spinal tuberculosis was encountered. The mean deformity angle was 25.5 degrees before surgery and 23.2 degrees at the final follow-up. Spinal fusion was achieved in all patients.

CONCLUSION

Without the need of thoracotomy, one-stage lateral rhachotomy with posterior spinal fusion using compression hooks was an effective option for treating Pott's paralysis in the elderly.

Comprehensive findings on clinical, bacteriological, histopathological and therapeutic aspects of cutaneous tuberculosis

OBJECTIVE

To define the bacteriological and histological correlates of the three predominant clinical forms of cutaneous tuberculosis and to evaluate the efficacy of a 9-month daily regimen containing rifampicin and isoniazid.

METHODS

In the dermatological clinics of two major teaching hospitals in Chennai, 213 patients with suspected clinical manifestations of cutaneous tuberculosis underwent examination and a skin biopsy for bacteriological and histological tests. They were treated with a daily regimen of rifampicin and isoniazid for 9 months and follow-up for 3 years.

RESULTS

Bacteriological and/or histological confirmation of tuberculosis was obtained in 88% of the cases. Lupus vulgaris lesions were seen mainly in the extremities and verrucosa cutis occurred predominantly on the sole and foot, while the cervical and axillary regions were the commonest sites for scrofuloderma. Ninety-two per cent of the patients showed resolution of the lesions within the first 6 months of chemotherapy; 1% failed to respond to this regimen. There was no relapse in any of the cases during the follow-up period of 3 years.

CONCLUSIONS

Clinical findings were adequate to identify major forms of cutaneous tuberculosis as evidenced by bacteriological and histopathological examination. A daily regimen of rifampicin and isoniazid for 9 months was effective in treating cutaneous tuberculosis.

[Extra-pulmonary tuberculosis in childhood]

Extra-pulmonary tuberculosis (EPT) accounts for around 25% of cases of the disease, and around 20% in children. In Pott's disease and other forms of bone and joint involvement (globally 10-15% of EPT cases), modern imaging techniques like MRI scan have improved diagnosis and follow-up of treatment outcomes. Tuberculous meningitis has not disappeared even in BCG vaccinated children and remains a severe form of the disease. Techniques like the polymerase chain reaction and MRI contribute to an early diagnosis and controversy persists regarding the role of corticosteroid therapy in the treatment strategy. Other localisations are rare in children, including tuberculosis of the urogenital tract, infection of the digestive tract or pericarditis.

Tuberculous tenosynovitis of the tibialis anterior tendon: a case report

Tuberculous tenosynovitis is an uncommon form of extrapulmonary tuberculosis occurring primarily in the hands and wrists with limited reports involving the lower extremities. We report a rare case of tuberculous tenosynovitis of the tibialis anterior tendon occurring in a 37-year-old Filipino male. The tendon was surgically debrided and the patient was given a six month course of antituberculin chemotherapy. At one year postoperatively, the patient has good function with no evidence of recurrence.

Tuberculous spondylitis: analysis of 69 cases from Saudi Arabia

DESIGN

Retrospective chart and radiographic review of all cases admitted to the authors' hospital and diagnosed to have tuberculous spondylitis.

OBJECTIVE

To identify the frequency, presenting features, utility of diagnostic tests, and treatment outcome of spinal tuberculosis in a tertiary care center.

METHODS

All cases of spinal tuberculosis treated in the authors' hospital over 14 years were reviewed. Only those with histologic or microbiologic confirmation or those who responded to antituberculous spondylitis therapy were included. Outcome was assessed according to predefined criteria.

RESULTS

Between 1985 and 1998, 69 cases of tuberculous spondylitis were found, i.e., 5% of all tuberculous spondylitis cases diagnosed. The mean age was 52.8 years (range, 15-80 years), and 37 (53.6%) were male. Only five patients had a history of tuberculosis. The most frequent symptoms were backache (84%) and fever (32%), and the most frequent sign was spinal tenderness (45%). Nineteen (28%) patients had paraparesis and 12 (17%) had kyphosis. Except for elevated sedimentation rate (94.5%), the laboratory workup was not helpful. Both computed tomography and magnetic resonance imaging were found to be helpful in diagnosis, often with complementary information. Thirty-eight patients (55%) had thoracic spine involvement and 55 patients (80%) had paraspinal abscesses. Tissue aspirates had a yield of 70%, 35%, and 57% for granulomas, acid-fast bacilli smear, and culture, respectively. Medical therapy alone was given in 37 cases (54%), whereas 32 patients (46%) required additional surgical intervention, mainly those with spinal cord compression, spinal deformity, or risk of spinal instability. There was definite improvement in 63 cases (91%). The best outcome was in those patients presenting early before the occurrence of spinal deformity or neurologic symptoms.

CONCLUSION

Tuberculous spondylitis is prevalent in the authors' hospital. Both computed tomography and magnetic resonance imaging are extremely helpful for diagnosis, and tissue aspirate is a good confirmatory method. A good outcome is expected if the diagnosis is made in early stages before the appearance of spinal deformity and neurologic symptoms. Surgical intervention can be avoided in these cases regardless of the presence or absence of paraspinal abscesses.