Bombay Hospital and Medical Research Centre, 12, New Marine Lines, Mumbai - 400 020, Maharashtra, India.
*Corresponding Author: Saijyot Raut, Bombay Hospital and Medical Research Centre, 12, New Marine Lines, Mumbai - 400 020, Maharashtra, India.
Citation: Saijyot Raut, (2022). Spinal Tuberculosis Recent Trends of Surgical Management in Modern Era. J. Clinical Orthopedics and Trauma Care, 4(2); DOI:10.31579/2694-0248/021
Copyright: © 2022 Saijyot Raut, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 08 December 2021 | Accepted: 31 December 2021 | Published: 11 January 2022
Keywords: spinal tuberculosis; modern era; percutaneous pedicle screw
Abstract
Tubercle bacilli has been known to live in symbiosis with mankind since centuries. Tubercle bacilli mainly causes pulmonary disease but extra pulmonary manifestations are fairly common with spine being the most common site
Introduction
Tubercle bacilli has been known to live in symbiosis with mankind since centuries. Tubercle bacilli mainly causes pulmonary disease but extra pulmonary manifestations are fairly common with spine being the most common site [1]. Amongst the bone and joint tuberculosis, spinal tuberculosis requires special attention because it not only affects the biology and mechanics but also the neurology. Treatment principles of spinal tuberculosis have changed rapidly over the years with the improvement in socioeconomic status, development of BCG vaccine and effective anti-tubercular drugs, hand in hand neumerous controversies have also emerged over the treatment protocol. The whole idea of surgical management of spinal tuberculosis is changing today with the advent of minimally invasive spine surgery (MISS), tubular/endoscopic decompression and percutaneous pedicle screw (PPS) fixation.
Discussion
Tuberculosis is epidemic in many parts of the world and with spinal tuberculosis being the most important and most common extrapulmonary tuberculosis site. It is always necessary for a shrewd spine surgeon to be well versed with the latest principles and trends in the management of on eof the most unintelligible disease known to mankind. The 2 most important milestones in the history that had a great impact on the treatment of spinal tuberculosis is the development of ATT and results of MRC trials. Before the advent of ATT, treatment was mainly a watchful observation and emphasis for good sanitation and nutrition. The ultimate goal was to achieve ankyloses in least disabling position by the application plaster cast immobilization for 2-3years [1-6]. Because of the unpredictable and unsatisfactory results of this orthodox treatment surgeons opted to surgically excise the diseased bones and joints by targeting the pathological area [7, 8]. This lead to increased morbidity and mortality. But with the advent of ATT and its remarkable results [14] led to the development of the middle path regieme which changed the principles of radical surgical debridement to optimal surgical debridement mainly focusing on prevention of neurology and deformity. The MRC trials concluded that drug treatment group, debridement group and debridement with anterior spinal fusion group has similar outcomes over 15years [16] except that the fusion group had quicker pain relief and decreased tendency for deformity progression. The landmark results of Oga et.al. [17] Showed that tubercle bacilli do not adhere to metal and neither form biofilms, thus releasing the anxiety to use instrumentation for immediate stability amongst spine surgeons. Thus the modern principles of fusion and bone to bone contact for effective results were laid down. Modern day indications and principles of surgical treatment of spinal Tuberculosis is well defined. Indications include severe and rapidly progressive neurological deficit,significant destruction causing mechanical instability and deformity, large abscess causing pressure symptoms and lack of response to ATT. Similarly surgical principles include optimum debridement and decompression, adequate bone to bone contact for fusion, providing immediate stability for early mobilization with an approach which causes least morbidity couples with effective ATT. Radical debridement is not recommended nowadays and decompression and debridement is restricted to removal of sequestered disc, loose pieces of bone wit drainage of pus to allow spinal canal decompression. In children, injury to thr growth plates must be avoided by limited debridement [18]. Anterior coloumn reconstruction is obtained by anterior or posterior approaches using strut grafts (autograft/allograft) or titanium mesh cages. Immediate stability is provided with adequate instrumentation. Graft related complications and loss of correction of kyphosis [20, 21] has been described after isolated arthrodesis. Upadhyay et.al. Reported dislodgment of graft after anterior fusion in 10 out of 104 patients and increase in kyphosis by 20 degrees in one year [22]. Primary stabilization provide immediate pain relief, promoted healing and neurological recovery, enhances fusion rates and allows early mobilization. These principles can be achieved with anterior alone, posterior alone or combined approaches. Tuberculosis is always a medical disease, so without effective ATT any surgery performed by above principles in mind can fail. Apart from the traditionally used anterior, posterior, combined anterior posterior approach, recently minimal invasive spine surgery (MISS) is playing a significant role in surgical management of tuberculosis. MISS has proven its might with regards to better patient outcomes less postoperative stay, less blood loss, less postoperative pain, smaller insicions and early return to work in degenerative spine pathologies [44, 45]. But in the management of spinal tuberculosis its use is restricted to procure specimens for culture, drainage of epidural abscess, percutaneous debridement of early discitis, anterior transforaminal debridement and reconstructions followed by percutaneous screw fixation.
Applications of MISS are a boon in immunocompromised and elderly morbid patients. Ashizwa et al [46] performed percutaneous transpedicular biopsies and found 92
Conclusion
Tuberculosis has been known to coexist with human species since ages. Principles of treatment has changed drastically over the years, with advances in medical management with ATT use and gradually increasing use of MISS surgical techniques there is always a wide scope for treatment of spinal tuberculosis to achieve more better outcomes in coming times.
References
- Tuli SM. 3rd ed. New Delhi: Jaypee Brothers; 2004. Textbook- Tuberculosis of the skeletal system (Bones, Joints, Spine and Bursal sheaths).
View at Publisher |
View at Google Scholar
- Barnes PF, Barrows SA. Tuberculosis in the 1990s. Ann Intern Med. 1993;119:400-10.
View at Publisher |
View at Google Scholar
- Patel S, Collins DA, Bourke BE. Don’t forget tuberculosis. Am Rheum Dis. 1995;54:174-5.
View at Publisher |
View at Google Scholar
- Duraiswami PK, Tuli SM. 5000 years of orthopaedics in India. ClinOrthopRelat Res. 1971;75:269-80.
View at Publisher |
View at Google Scholar
- Scott JE, Taor WS. The changing pattern of bone and joint tuberculosis. J Bone Joint Surg Am. 1969;51:1331-42.
View at Publisher |
View at Google Scholar
- Bick KM. Classics of Orthopaedics. Philadelphia, PA: JB Lippincott Co.; 1976.
View at Publisher |
View at Google Scholar
- Dobson J. Tuberculosis of spine. J Bone Joint Surg Br. 1951;33:517-31.
View at Publisher |
View at Google Scholar
- Seddon HJ. Pott’s paraplegia, prognosis and treatement. Br J Surg. 1935;22:769-99.
View at Publisher |
View at Google Scholar
- Albee FH. The bone graft operation for tuberculosis of spine. JAMA. 1930;94:1467-71.
View at Publisher |
View at Google Scholar
- Hibbs RA, Risser JC. Treatment of vertebral tuberculosis by the spine fusion operations. J Bone Joint Surg. 1928;10:805-14.
View at Publisher |
View at Google Scholar
- Mercer W. Then and now: the history of skeletal tuberculosis. J R CollSurgEdinb. 1964;10:243-54.
View at Publisher |
View at Google Scholar
- Andre T. Studies on the distribution of tritium-labelled dihydrostrptomyem and tetracycline in the body. ActaRadiol. 1956;46:1-89.
View at Publisher |
View at Google Scholar
- Barclay WR, Ebert RH, Le Roy GV, et al. Distribution and excretion of radioactive isoniazid in tuberculosis patients. JAMA. 1953;151:1384-8.
View at Publisher |
View at Google Scholar
- Stevenson FH, Manning CW. Tuberculosis of the spine treated conservatively with chemotherapy, series of 72 patients collected 1949-1954 and followed to 1961. Tubercle. 1962;43:406-11.
View at Publisher |
View at Google Scholar
- Hodgson AR, Stock FE. Anterior spinal fusion for the treatment of tuberculosis of the spine. J Bone Joint Surg Am. 1960;42:1147-56.
View at Publisher |
View at Google Scholar
- Konstam PG, Konstam ST. Spinal tuberculosis in southern Nigeria with special reference to ambulant treatment of thoracolumbar disease. J Bone Joint Surg Br. 1958;40:26-32.
View at Publisher |
View at Google Scholar
- Oga M Arizono T, Takasita M, et al. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis: clinical and biologic study. Spine. 1993;18:1890-4.
View at Publisher |
View at Google Scholar
- Rajasekaran S. The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br. 2001;83(7):954-962.
View at Publisher |
View at Google Scholar
- Zaveri G. The role of posterior surgery in spinal tuberculosis. Argo Spine News J. 2011;23(3);112-119.
View at Publisher |
View at Google Scholar
- H L Bailey, M Gabriel, A R Hodgson, J S Shin. Tuberculosis of the spine in children. Operative findings and results in one hundred consecutive patients treated by removal of the lesion and anterior graftingJ Bone Joint Surg Am. 1972;54(8):1633-57.
View at Publisher |
View at Google Scholar
- Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg Am. 1989;71:1314-23.
View at Publisher |
View at Google Scholar
- Upadhyay SS, Sell P, Saji MJ, et al. 17-year prospective study of surgical management of spinal tuberculosis in children. Hong Kong operation with debridement surgery for short and long-term outcome of deformity. Spine (Phila Pa 1976). 1993;18:1704-11.
View at Publisher |
View at Google Scholar
- Upadhyay M, Patel J, Kundnani V, Ruparel S, Patel A. Drug sensitivity patterns in Xpert-positive spinal tuberculosis: an observational study of 252 patients.Eur Spine J. 2020;29(7):1476-1482.
View at Publisher |
View at Google Scholar
- Dai LY, Jiang LS, Wang W, Cui YM. Single-stage anterior autogenous bone grafting and instrumentation in the surgical management of spinal tuberculosis. Spine (Phila Pa 1976) 2005;30:2342–2349.
View at Publisher |
View at Google Scholar
- Zhao J, Lian XF, Hou TS, Ma H, Chen ZM. Anterior debridement and bone grafting of spinal tuberculosis with one stage instrumentation anteriorly or posteriorly. IntOrthop 2007;31:859–863.
View at Publisher |
View at Google Scholar
- Cui X, Li LT, Ma YZ. Anterior and posterior instrumentation with different debridement and grafting procedures for multi-level contiguous thoracic spinal tuberculosis. Orthop Surg. 2016;8(4):454–61.
View at Publisher |
View at Google Scholar
- Dunn RN, Ben HM. Spinal tuberculosis. Bone Joint J. 2018;100-B(4):425–31.
View at Publisher |
View at Google Scholar
- Li W, Liu Z, Xiao X, Zhang Z, Wang X. Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults. BMC Musculoskeletal Disorders. 2019;20:570.
View at Publisher |
View at Google Scholar
- Huang QS, Zheng C, Hu Y, Yin X, Xu H, Zhang G, Wang Q: One-stage surgical management for children with spinal tuberculosis by anterior decompression and posterior instrumentation. IntOrthop 2009;33:1385-1390.
View at Publisher |
View at Google Scholar
- Talu U, Gogus A, Ozturk C, Hamzaoglu A, Domanic U. The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases. J Spinal Disord Tech. 2006;19(8):554-9.
View at Publisher |
View at Google Scholar
- Garg B, Kandwal P, Nagaraja UB, Goswami A, Jayaswal A. Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: a retrospective analysis. Indian J Orthop. 2012;46(2):165-70.
View at Publisher |
View at Google Scholar
- Liu J, Wan L, Long X, Huang S, Dai M, Liu Z. Efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal tuberculosis: a meta-analysis. World Neurosurg. 2015;83(6):1157-1165.
View at Publisher |
View at Google Scholar
- Lonstein JE. Cord compression. In: Bradford DS, Lonstein JE, Ogilvie JW et al. (Eds). Moe’s textbook of scoliosis and other spinal deformities, 2nd edition. Philadelphia:WB Saunders;1987.pp540-7.
View at Publisher |
View at Google Scholar
- Dalvie SS, Laheri VJ. Closed-wedge spinal osteotomy for thecorrection of post-tubercular kyphosis in children. J Bone Joint Surg Br. 2000;82:283-284.
View at Publisher |
View at Google Scholar
- Kanna RM, Shetty AP, Rajasekaran S. Surgical management of Pott’s spine induced kyphosis in older children or adults. CurrOrthopPract. 2017;28:15-22.
View at Publisher |
View at Google Scholar
- Bezer M, Mucukdurmaz F, Guven O. Transpediculardecancellation osteotomy in the treatment of post-tubercular kyphosis. J Spinal Disord Tech. 2007;20:209-15.
View at Publisher |
View at Google Scholar
- Kalra KP, Dhar SB, Shetty G, et al. Pedicle subtraction osteotomy for rigid post-tubercular kyphosis. J Bone Joint Surg Br. 2006;88:925-7.
View at Publisher |
View at Google Scholar
- Deng Y, Lv G, An HS. En bloc spondylectomy for the treatment of spinal tuberculosis with fixed and sharply angulated kyphotic deformity. Spine (Phila Pa 1976). 2009;34:2140-6.
View at Publisher |
View at Google Scholar
- Kawahara N, Tomita K, Baba H, et al. Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine (Phila Pa 1976). 2001;26:391-402.
View at Publisher |
View at Google Scholar
- Gertzbein SD, Harris MB. Wedge osteotomy for the correction of post-traumatic kyphosis. A new technique and a report of three cases. Spine (Phila Pa 1976). 1992;17:374-9.
View at Publisher |
View at Google Scholar
- Kanna RM, Shetty AP, Rajasekaran S. Surgical management of Pott’s spine induced kyphosis in older children or adults. CurrOrthopPract. 2017;28:15-22.
View at Publisher |
View at Google Scholar
- Patel A, Ruparel S, Dusad T, Mehta G, Kundnani V.Posterior-approach single-level apical spinal osteotomy in pediatric patients for severe rigid kyphoscoliosis: long-term clinical and radiological outcomes. J NeurosurgPediatr. 2018;21(6):606-614.
View at Publisher |
View at Google Scholar
- Wang K, Wang N, Wang Y, et al. Anterior versus posterior instrumentation for treatment of thoracolumbar tuberculosis : A meta-analysis.Orthopade. 2019 Mar;48(3):207-212.
View at Publisher |
View at Google Scholar
- Schwender JD, Holly LT, Rouben DP, Foley FT. Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF): Technical Feasibility and Initial Results. J Spinal Disord Tech. 2005;18 Suppl:S1-6.
View at Publisher |
View at Google Scholar
- Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and Radiological Outcomes of Open Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion. Eur Spine J. 2012;21(11):2265-70.
View at Publisher |
View at Google Scholar
- Ashizawa R, Ohtsuka K, Kamimura M, et al. Percutaneous transpedicular biopsy of thoracic and lumbarvertebrae--method and diagnostic validity. Surg Neurol. 1999;52:545-51.
View at Publisher |
View at Google Scholar
- Jayaswal A, UpendraB, Ahmed A, et al. Video-assisted tharacoscopic anterior surgery for tuberculous spondylitis. ClinOrthopRelat Res. 2007;460:100-107.
View at Publisher |
View at Google Scholar
- Tong YJ, Liu JH, Fan SW, et al. One-stage Debridement via Oblique Lateral Interbody Fusion Corridor Combined with Posterior Pedicle Screw Fixation in Treating Spontaneous Lumbar Infectious Spondylodiscitis: A Case Series. Orthop Surg. 2019 Dec;11(6):1109-1119.
View at Publisher |
View at Google Scholar
- Jayaswal A, UpendraB, Ahmed A, et al.Video-assisted thoracoscopic anterior surgery for tuberculous spondylitis.ClinOrthopRelat Res. 2007 Jul;460:100-7.
View at Publisher |
View at Google Scholar
- Kapoor SK, Agarwal PN, Jain BK Jr, et al. Video-assisted tharacoscopic decompression of tubercular spondylitis: clinical evaluation. Spine (Phila Pa 1976). 2005;30:E605-E610.
View at Publisher |
View at Google Scholar
- Kandwal P, Garg B, Bn U, et al. Outcome ofminimally invasive surgery in the management of tuberculous spondylitis. Indian J Orthop. 2012;46(2):159-64.
View at Publisher |
View at Google Scholar
- Hu W, Zhang X, Yu J, et al. Vertebral column decancellation in Pott's deformity: use of Surgimap Spine for preoperative surgical planning, retrospective review of 18 patientsBMC MusculoskeletDisord. 2018;19(1):13.
View at Publisher |
View at Google Scholar