Surgery for spinal tuberculosis: a multi-center experience of 582 cases

Navigating Perioperative Challenges in Pott's Spine: A Comprehensive Review

Pott's spine, or tuberculous spondylitis, remains a significant public health concern in regions where tuberculosis is endemic. The management of Pott's spine poses unique perioperative challenges due to the complexity of the disease process, including vertebral destruction, spinal instability, and neurological compromise. This comprehensive review explores the intricacies of navigating perioperative challenges in Pott's spine surgery. Beginning with an overview of Pott's spine, including its etiology, clinical presentation, and classification, the review delves into the significance of perioperative challenges in this condition. Emphasis is placed on the need for multidisciplinary collaboration, meticulous preoperative assessment, and tailored surgical planning to optimize outcomes while minimizing the risk of complications. Critical considerations in the preoperative, intraoperative, and postoperative phases of care are discussed in detail, including patient assessment, imaging modalities, surgical techniques, anesthesia considerations, and postoperative rehabilitation. Special considerations such as pediatric Pott's spine and multidrug-resistant tuberculosis are also addressed. The review concludes by summarizing key points, highlighting implications for clinical practice, and providing recommendations for future research. By synthesizing current evidence and clinical expertise, this review offers valuable insights into the optimal management of perioperative challenges in Pott's spine, ultimately aiming to improve patient outcomes and reduce the burden of this debilitating condition.

Tuberculosis of the Cervical Spine: A Case Report

Tuberculosis of the cervical spine is a rare but deadly form of tuberculosis (TB), where the infection affects the cervical vertebrae or bones of the neck. It is also known as Pott's disease. The causative organism is Mycobacterium tuberculosis. It usually occurs when TB bacteria spread from other body parts, such as the lungs, to the cervical vertebrae through the bloodstream or lymphatic system. It also shows extrapulmonary involvement, including the central nervous, genitourinary, and lymphatic systems, bones, and joints. Tuberculosis of the spine is often seen. Cervical spine tuberculosis is a rare form of the disease though. If the infection is not treated, it might harm the spinal cord and nerves, resulting in paralysis and other neurological complications. This article presents a 40-year-old female with tuberculosis of the cervical spine complaining of neck pain and stiffness with neurological manifestations and its management with anterior spinal instrumentation. The patient showed improvement in the next follow-up.

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.

Comparison of Affected-Vertebra Fixation of Cortical Bone Trajectory Screw and Pedicle Screw for Lumbar Tuberculosis: A Minimum 3-Year Follow-Up

Purpose

This study is aimed at comparing the clinical efficacy of cortical bone trajectory (CBT) screw fixation and pedicle screw (PS) fixation of the affected vertebrae in lumbar tuberculosis.

Methods

We retrospectively analyzed the outcomes in 52 patients (27 cases in the CBT group, 25 cases in the PS group) with lumbar TB who underwent posterior affected-vertebra fixation combined with anterior debridement and bone grafting. The intraoperative blood loss, operative time, visual analog scale (VAS) scores for incision pain and leg pain, Japanese Orthopedic Association (JOA) score, bone grafting fusion, and complications were recorded.

Results

All patients were followed up for 35-52 months and achieved good clinical outcomes. There were no differences between the two groups in the operative time, intraoperative blood loss, JOA score, bone grafting fusion, and complications. However, there was a significant difference between the two groups in VAS scores for incision pain on the 1st day and 3rd day after surgery. At the last follow-up, JOA scores were significantly improved in both groups compared to the preoperation.

Conclusion

This retrospective study confirmed that both the affected-vertebra CBT screw fixation and PS fixation for lumbar TB via posterior and anterior approaches could achieve satisfactory outcomes, while the former resulted in better improvement for postoperative VAS scores.

Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit

BACKGROUND

A combined anterior decompression and stabilization followed by posterior instrumented fusion promotes fusion of the affected segment of spine and prevents further progression of deformity. The objective of this study is to report on outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity who underwent single-stage anterior corpectomy and fusion and posterior decompression with instrumented fusion.

METHODS

A total of 49 patients (29 males, 20 females) with varying grades of neurological deficit due to tuberculosis of the spine (thoracic, thoracolumbar, and lumbar) were included in this prospective study. The diagnosis of tubercular infection was established after clinical, hematological, radiological, and histological specimens taken at surgery. All were treated with combined anterior and posterior decompression, debridement, and stabilization with direct autologous bone grafting or wrapped bone graft in mesh or expandable cages. Neurological status and visual analog scale (VAS) pain score were recorded at each visit. X-rays, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function were evaluated at 3, 6, and 12 months after surgery and then once a year thereafter. Results were analyzed in terms of neurological recovery (Frankel grade), bony union time, and correction of kyphotic deformity.

RESULTS

The mean age was 37.8 years (range, 2-65 years). Mean preoperative VAS scores improved from 5.6 to 1.5. The average ESR and CRP returned to normal within 6 months in all patients. The mean time to fusion was 8.4 months for the whole group. The neurological deficit in 42 of 49 patients had excellent or good clinical outcome (P < .0001). A total of 10 of 17 patients improved from Frankel A and B to Frankel E (normal activity). Three patients each in the thoracic and thoracolumbar groups improved to Frankel D. Radiological measurements showed the mean kyphotic correction was 61%, 66%, and 67% in the thoracic, thoracolumbar, and lumbar/lumbosacral spine, respectively.

CONCLUSIONS

Combined single-stage anterior decompression and stabilization followed by posterior instrumented fusion is safe and effective in the treatment of tuberculous spondylitis with neurological deficit in the thoracic and lumbar spine. This procedure helps to correct and maintain the deformity, abscess clearance, spinal-cord decompression, and pain relief as well as return to normal motor function. Bony fusion prevents further progression of deformity.

LEVEL OF EVIDENCE

2.

Efficacy of surgery via the single anterior and single posterior approaches for treatment of thoracic spinal tuberculosis

Objective

The type of surgical treatment that should be adopted for thoracic tuberculosis (TB) remains controversial. This study was performed to compare the clinical efficacy of surgery via the single anterior and single posterior approaches for treatment of thoracic spinal TB.

Methods

Seventy-eight patients with thoracic TB undergoing surgical treatment were divided into two groups on the basis of the surgical methods employed: Group A (single anterior debridement + bone graft fusion and internal fixation) and Group B (single posterior debridement + bone graft fusion and internal fixation). Results of clinical and imaging examinations were analysed and compared between the two groups.

Results

The surgical duration and mean hospital stay were significantly longer and the perioperative bleeding volume was significantly higher in Group A than B. At the last follow-up, changes in the American Spinal Injury Association grade showed no obvious differences between the two groups. Before and after the surgery and at the last follow-up, no significant differences were detected in the Cobb angle change or correction rate between the two groups.

Conclusion

Surgery via the single anterior and single posterior approaches achieved good clinical efficacy in the treatment of thoracic spinal TB.

Biomechanical Evaluation and the Assisted 3D Printed Model in the Patient-Specific Preoperative Planning for Thoracic Spinal Tuberculosis: A Finite Element Analysis

Posterior fixation is superior to anterior fixation in the correction of kyphosis and maintenance of spinal stability for the treatment of thoracic spinal tuberculosis. However, the process of selecting the appropriate spinal fixation method remains controversial, and preoperative biomechanical evaluation has not yet been investigated. In this study, we aimed to analyze the application of the assisted finite element analysis (FEA) and the three-dimensional (3D) printed model for the patient-specific preoperative planning of thoracic spinal tuberculosis. An adult patient with thoracic spinal tuberculosis was included. A finite element model of the T7−T11 thoracic spine segments was reconstructed to analyze the biomechanical effect of four different operative constructs. The von Mises stress values of the implants in the vertical axial load and flexion and extension conditions under a 400-N vertical axial pre-load and a 10-N⋅m moment were calculated and compared. A 3D printed model was used to describe and elucidate the patient’s condition and simulate the optimal surgical design. According to the biomechanical evaluation, the patient-specific preoperative surgical design was prepared for implementation. The anterior column, which was reconstructed with titanium alloy mesh and a bone graft with posterior fixation using seven pedicle screws (M+P) and performed at the T7–T11 level, decreased the von Mises stress placed on the right rod, T7 pedicle screw, and T11 pedicle. Moreover, the M+P evaded the left T9 screw without load bearing. The 3D printed model and preoperative surgical simulation enhanced the understanding of the patient’s condition and facilitated patient-specific preoperative planning. Good clinical results, including no complication of implants, negligible loss of the Cobb angle, and good bone fusion, were achieved using the M+P surgical design. In conclusion, M+P was recommended as the optimal method for preoperative planning since it enabled the preservation of the normal vertebra and prevented unnecessary internal fixation. Our study indicated that FEA and the assisted 3D printed model are tools that could be extremely useful and effective in the patient-specific preoperative planning for thoracic spinal tuberculosis, which can facilitate preoperative surgical simulation and biomechanical evaluation, as well as improve the understanding of the patient’s condition.

Pathologic characteristics of spinal tuberculosis: analysis of 181 cases

OBJECTIVE

This study aimed to provide a basis for the diagnosis of spinal TB by analyzing its pathologic characteristics.

METHODS

The data of 181 patients with spinal TB who underwent surgery from January 2013 to January 2019 at the General Hospital of Ningxia Medical University were retrospectively analyzed. The participants comprised 80 men and 101 women with an average age of 45.1 ± 16.5 (range: 14-78) years. Based on the assessment of tissue samples, five patients had cervical TB, 49 had thoracic TB, 86 had lumbar TB, 22 had thoracolumbar TB, and 19 had lumbosacral TB. Tuberculous granulation tissue, sclerotic bone, sequestrum, and intervertebral disc tissue were collected for hematoxylin and eosin staining. The proportion of patients with atypical and typical pathologic characteristics was identified and compared for statistical analysis.

RESULTS

The typical pathologic characteristics included tubercles, granulomas, caseous necrosis, multinuclear giant cells, infiltration of acute inflammatory cells, sequestration, and fibroblastic proliferation. A total of 119 patients had caseous necrosis, 95 had multinuclear giant cells, 68 had granulomatous inflammation, and 21 had tubercles. Moreover, 46 (25.4%) patients had at least three pathologic characteristics and only 12 (6.6%) exhibited all the pathologic characteristics. Of the 35 (19.3%) patients with atypical pathologic characteristics, 17 had lymphocyte infiltration, 10 had fibroblastic proliferation, 2 had hyaline changes, 1 had local hemorrhage, 1 chronic inflammatory change, 2 had sequestration, 1 had dilated and congested vessels, and 1 had acute suppurative inflammation.

CONCLUSIONS

The most common pathologic characteristics were caseous necrosis, multinuclear giant cells, granulomatous inflammation, and tubercles. Moreover, multiple pathologic characteristics were observed in patients with spinal TB and one type of these characteristics was dominant. However, atypical pathologic characteristics were also noted. Thus, both pathologic examination and clinical analysis must be performed to improve the diagnostic rate of spinal TB.

Role of local streptomycin in prevention of surgical site infection in TB spine

PURPOSE

Surgical site infection (SSI) continues to be one of the most common post-operative complications in most spine surgeries. Patients with tuberculosis (TB) of spine are more at risk of developing this complication due to a number of reasons. This adds to significant morbidity and economic burden on patients adversely affecting the mental status and quality of life of patients. The aim of this study was to investigate the role of local streptomycin in preventing SSI in patients undergoing surgical management of spinal TB.

METHODS

In total, 56 patients who underwent surgical management for radiologically proven TB spine divided into two groups were included in the study. Group A included 30 patients with no local streptomycin administered intraoperatively, while group B included 26 patients operated in the later part of study with the use of local streptomycin intraoperatively. The two groups were compared and the outcome criteria analysed were SSI rate, length of hospital stay, duration of post-operative antibiotics and need for debridement.

RESULTS

Length of hospital stay (group A: 18.4 ± 6.9 days; group B: 9.7 ± 3.9 days) and duration of post-operative antibiotics (group A: 8.1 ± 1.6 days; group B: 6.2 ± 2.1 days) were significantly higher in group A when compared with group B. SSI rate (group A: 13.34%; group B: 3.84%) and need for debridement (group A: 10%; group B: 3.84%) were higher in group A, but the difference was not statistically significant.

CONCLUSION

Intraoperative administration of local streptomycin significantly reduces the length of hospital stay and duration of antibiotic administration in post-operative period in patients undergoing surgery for TB spine.

Efficacy, safety and prognosis of treating neurological deficits caused by spinal tuberculosis within 4 weeks' standard anti-tuberculosis treatment: A single medical center's experience

The present study aimed to retrospectively analyze the safety and efficacy of the early surgical management of thoracic tuberculosis (TB) in patients with neurological deficits. The medical data of patients with thoracic TB exhibiting neurological deficit in the Chest Hospital of Hebei Province were retrospectively reviewed. A total of 234 cases, including 123 males and 115 females, were recruited in the present study. Their pre- and postoperative neurological deficit and pain levels were assessed using the 2002 American spinal injury association (ASIA) impairment scale and visual analog scale, respectively. Patients were divided into two groups according to whether their preoperative standardized anti-TB treatment time was ≥4 weeks or <4 weeks. There was no difference in blood loss and operation time between the two groups. The erythrocyte sedimentation rate was higher in patients receiving standard anti-TB <4 weeks prior to and 1 month following surgery compared with the ≥4 weeks group, but the difference was not significant 6 months following surgery. ASIA scale scores all increased significantly 1 month following surgery in the <4 weeks group compared with the ≥4 weeks group (P=0.001) though there was no difference between the scores prior to surgery. ASIA scale scores improved to 4.4±0.5 and 4.5±0.4 in patients with anti-TB treatment times of ≥4 weeks and <4 weeks, respectively, 24 months following surgery (P=0.0895). The present study demonstrated that for patients with thoracic TB exhibiting neurological deficit, early surgical management following <4 weeks' standard anti-TB treatment is recommended. It may relieve spinal cord compression and also benefit the early recovery of neurological function in these patients.

Anterior versus posterior instrumentation for treatment of thoracolumbar tuberculosis : A meta-analysis

BACKGROUND

To compare clinical and functional outcomes of anterior versus posterior debridement and spinal fixation for surgical treatment of thoracolumbar tuberculosis.

METHODS

A computer-based online search of the Cochrane Library, PubMed, EMBase, Wanfang, VIP, and the CNKI database was performed. The methodological quality of included studies was evaluated, and data analyses were performed using RevMan 5.0 software (The Nordic Cochrane Centre, The Cochrane Collaboration Copenhagen, Denmark).

RESULTS

Eleven trials were studied, with eight performed in China, two in Egypt, and one in India. The results showed significant differences between the two operative approaches in terms of correction of kyphotic angle and intraoperative blood loss, but not in terms of operation time, hospital stay, fusion time, and loss of correction at the final follow-up.

CONCLUSION

The anterior and posterior approaches are equally good methods for treatment of thoracolumbar tuberculosis. The anterior approach results in less blood loss, whereas posterior instrumentation is better suited for correction of kyphotic angle.

Late diagnosis of multidrug-resistant tuberculosis in a child at Dr George Mukhari Academic Hospital, Ga-Rankuwa, South Africa: A case report

Introduction

South Africa has one of the top ten tuberculosis burdens in the world, only lagging behind countries with significantly larger populations. Increased awareness of extrapulmonary tuberculosis, specifically spinal tuberculosis, is necessary, because of the HIV epidemic.

Case presentation

This report describes the case of a 9-year-old male patient who was suspected of having multidrug-resistant (MDR) tuberculosis, based on failure to recover clinically and radiologically after 6 months on first-line anti-tuberculosis treatment. Pus samples were sent to an accredited academic laboratory for histopathology, microscopy, culture, line-probe assay (MTBDRplus assay) and phenotypic MGIT 960 drug susceptibility tests. Second-line MDR tuberculosis treatment was introduced. Clinical, radiological, physical processes and more laboratory tests were conducted to document whether or not there was improvement in the patient.

Management and outcome

After laboratory diagnosis of MDR tuberculosis, the patient was started on MDR tuberculosis treatment. The patient started improving remarkably after the introduction of anti-tuberculosis treatment and rehabilitation, although he also required surgery to stabilise the spine. Neurological improvement was observed in the patient and he fully recovered.

Discussion

Although the diagnosis of spinal MDR tuberculosis may not be achieved easily by culture, the well-known gold standard method of tuberculosis diagnosis, it is of great importance to rapidly initiate an effective anti-tuberculosis treatment of drug-resistant strains to reduce the deformity of the spine.

Sample sizes and statistical methods in interventional studies on individuals with spinal cord injury: A systematic review

AIM

Prevalence and incidence of spinal cord injury (SCI) are low. However, sample sizes have not been systematically examined yet, although this might represent useful information for study planning and power considerations. Therefore, our objective was to determine the median sample size in clinical trials on SCI individuals. Moreover, within small-sample size studies, statistical methods and awareness of potential problems regarding small samples were examined.

METHODS

We systematically reviewed all studies on human SCI individuals published between 2014 and 2015, where the effect of an intervention on one or more health-related outcomes was assessed by means of a hypothesis test. If at least one group had a size <20, the study was classified as a small sample size study. PubMed was searched for eligible studies; subsequently, data on sample sizes and statistical methods were extracted and summarized descriptively.

RESULTS

Out of 8897 studies 207 were included. Median total sample size was 18 (range 4-582). Small sample sizes were found in 167/207 (81%) studies, resulting limitations and implications for statistical analyses were mentioned in 109/167 (65%) studies.

CONCLUSIONS

Although most recent SCI trials have been conducted with small samples, the consequences on statistical analysis methods and the validity of the results are rarely acknowledged.

Comprehensive treatment algorithm for management of thoracic and lumbar tubercular spondylodiscitis by single-stage posterior transforaminal approach

BACKGROUND

Surgery in tubercular spondylodiscitis involves radical debridement and fusion by combined anterior and posterior or all posterior approaches with a posterolateral window with its associated morbidities. This study evaluates the outcome of a comprehensive treatment algorithm for thoracic and lumbar tubercular spondylodiscitis by a single-stage posterior transforaminal approach.

METHODS

One hundred and twenty-six patients with tubercular spondylodiscitis between T1 and S1 who underwent posterior surgery with/without fusion by transforaminal approach with a minimum follow-up of 2 years were analyzed. Radiological outcome was assessed by documenting healing with magnetic resonance imaging/computed tomography and radiographical fusion, while clinical outcome was assessed by visual analog score (VAS) for pain and Frankel grading for neurological recovery.

RESULTS

Of the 114 patients available for follow-up with a mean age of 53 years, complete radiological healing was observed in all patients (100%) with radiographical fusion in 97.4% and neurology recovered to Frankel E in all 37 patients with deficit. The preoperative VAS score of 9.2 improved significantly to 1.7 postoperatively, and all patients returned to their preoperative occupational activities at the final follow-up.

CONCLUSION

This comprehensive treatment algorithm of single-stage posterior surgery by transforaminal approach in thoracic and lumbar tubercular spondylodiscitis provided good clinical and radiological outcomes. It aids in achieving the same surgical goals, obviating the need for extensive posterior or combined surgical approaches.

Five-year outcomes of posterior affected-vertebrae fixation in lumbar tuberculosis patients

BACKGROUND

Posterior instrumentation after deformity correction is an important method for reconstruction of spinal stability in the management of lumbar tuberculosis (TB). However, the commonly used methods include both long- and short-segment fixation of normal motor units. There has been no report regarding affected-vertebrae fixation of lumbar TB.

METHODS

Data from 135 patients with lumbar TB who underwent posterior instrumentation and either affected-vertebrae fixation or short-segment fixation using a combined posterior and anterior approach were retrospectively reviewed. Among these patients, 71 cases were treated with affected-vertebrae fixation, and 64 cases were treated with short-segment fixation. Debridement, bone grafting, deformity correction, and decompression were performed within all affected segments. Operative times, intra-operative blood loss, TB cure rates, bone graft fusion rates, degree of deformity correction, neurological function, pain recovery, and complications were analyzed.

RESULTS

Comparing affected-vertebrae fixation vs. short-segment fixation groups, respectively, the number of the affected segments was 107 vs. 98; average number of affected segments was 1.51 vs. 1.53; total number of fixed segments was 107 vs. 226; average number of fixed segments was 1.51 vs. 3.53; average blood loss was 726.2 ml vs. 948.5 ml; average operative time was 210.4 min vs. 270.3 min; and average hospitalization costs were 29,000 RMB vs. 42,000 RMB (all p values < 0.05). In the affected-vertebrae fixation vs. short-segment fixation groups, respectively, TB cure rates were 82.61% vs. 84.62% at 6 months after operation and 97.83% vs. 97.44% at 5 years after operation; bone fusion rates were 86.96% vs. 87.18% at 6 months after operation and 97.83% vs. 97.66% at 5 years after operation; average number of degrees of Cobb's angle correction were 13.1° vs. 13.7°; average correction losses were 1.9° vs. 1.4°; and complication rates were 12.04% vs. 12.97% (all p values > 0.05).

CONCLUSION

Under strict surgical indications, posterior instrumentation on affected-vertebrae is a safe, effective, and feasible fixation method in the treatment of lumber TB.

Unusual circumstances to diagnose cervical Pott's disease

Tuberculous spondylodiscitis usually affects the dorso-lumbar spine, and its cervical location is a rare condition that can mimic other diseases and consequently cause treatment delays. We report a case of tuberculous spondylodiscitis of the lower cervical spine discovered under unusual circumstances in a patient with severe polytrauma involving a cranio-cerebral trauma, a non-displaced fracture of the two laminæ and the spinous process of the C6 vertebrae as well as fibular and tibial shaft fractures. The patient underwent static tibial nailing, and a collar with occipital and chin supports was applied. At 2-month follow-up, the patient presented with severe neck pain without neurologic deficits. Plain and dynamic cervical radiographs showed a stable C6-C7 subluxation and C7 superior endplate collapse. The CT scan also outlined prevertebral soft tissue swelling. The MRI showed a C6-C7 spondylodiscitis associated with a prevertebral abscess with am 8-cm major axis. The diagnosis of C6-C7 Pott's disease was confirmed by a CT-guided biopsy. The patient received 12 months of antituberculous chemotherapy, after which the paravertebral abscess completely disappeared, and the patient has had no functional sequelae. The diagnosis of cervical spine tuberculosis is difficult and requires a high level of attention. Delays in establishing the diagnosis and starting the appropriate treatment result in severe complications such as spinal cord compression and spinal deformity, which are difficult to manage.

Débridement and Reconstruction Improve Postoperative Sagittal Alignment in Kyphotic Cervical Spinal Tuberculosis

BACKGROUND

Cervical spinal tuberculosis is relatively common in some developing countries. It erodes vertebrae and discs, which sometimes results in cervical kyphosis and myelopathy. However, to our knowledge, no studies have evaluated improvements to patient-reported outcomes among patients who undergo surgical cervical sagittal realignment after kyphotic cervical spinal tuberculosis has been treated by débridement and reconstruction.

QUESTIONS/PURPOSES

(1) Can a spine with kyphotic cervical spinal tuberculosis be returned to normal alignment and fused successfully? (2) Will patient-reported outcomes be improved with this intervention? (3) Are patient-reported outcomes correlated with realignment?

METHODS

Forty-six patients with kyphotic cervical spinal tuberculosis were evaluated in this retrospective study. We generally performed surgery on patients with this condition when patients with cervical spinal tuberculosis presented with cervical kyphosis with or without neurologic deficits. Patients who did not meet these criteria were treated with other surgical procedures during the study period. Study patients were evaluated with cervical imaging, patient-reported outcomes questionnaires (Neck Disability Index [NDI], and the Japanese Orthopaedic Association [JOA] score), and physical examinations. Scores were collected by fellows preoperatively and at followup. No patient died during the followup. The mean followup was 26.8 months (range, 20-35 months). Preoperative and 2-year followup radiologic parameters were measured, including C0-2 Cobb angle, C2-7 Cobb angle, C2-7 sagittal vertical axis, center of gravity (CG) to C7 sagittal vertical axis (CG-C7 sagittal vertical axis), thoracic inlet angle, T1 slope, and neck tilt. The correlations between cervical alignment and the NDI and JOA score were analyzed. Factors correlated with the NDI and JOA score improvements were identified by multiple stepwise regression analysis. CT was used to assess bone fusion after surgery.

RESULTS

All 46 patients showed bone fusion on CT scans. The preoperative C0-2 Cobb angle improved after surgery (mean difference, 5.0°; 95% CI, 2.3°-7.7°; p = 0.0068), as did C2-7 Cobb angle (mean difference, -33°; 95% CI, -35° to -31°; p = 0.0074), C2-7 sagittal vertical axis (mean difference, -28 mm; 95% CI, -30 mm to -26 mm; p = 0.0036), CG-7 sagittal vertical axis (mean difference, -26 mm; 95% CI, -28 mm to -24 mm; p = 0.0049), T1 slope (mean difference, 6.0°; 95% CI, 3.7°-8.3°; p = 0.0053) and the thoracic inlet angle (mean difference, 8.0°; 95% CI, 3.7°-12°; p = 0.0072). With the numbers available, the neck tilt angle did not improve (mean difference, -0.2°; 95% CI, -1.0° to 0.6°; p = 0.079). The preoperative NDI of 34 ± 5.1 decreased to 17 ± 4.6 (p = 0.0096) at followup. Improvements in NDI were correlated with the magnitude of correction of the cervical deformities, including C0-2 Cobb angle (r = -0.357, p = 0.007), C2-7 Cobb angle (r = 0.410, p = 0.002), T1 slope (r = -0.366, p = 0.006, thoracic inlet angle (r = -0.376, p = 0.005), C2-7 sagittal vertical axis (r = 0.450, p = 0.001), and CG-C7 sagittal vertical axis (r = 0.361, p = 0.007). The JOA score improved to 13 ± 2.6 from 7.2 ± 1.9, which did not correlate with postoperative cervical realignment. After controlling for potential confounding variables like Cobb angles and T1 slope, we found C2-7 sagittal vertical axis was the most influential factor correlated with NDI improvement (r = 0.450, p = 0.002).

CONCLUSION

When treating kyphotic cervical spinal tuberculosis by débridement, decompression, and reconstruction, more attention should be drawn to realigning the cervical spine, in particular to restoring the C2-7 sagittal vertical axis. However, how best to restore the C2-7 sagittal vertical axis and cervical alignment in a kyphotic cervical spine needs further study.

LEVEL OF EVIDENCE

Level III, therapeutic study.