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ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 98-103

Surgical management of tuberculosis of dorsal spine and dorsolumbar spine: Anterior versus posterior approach


Department of Neurosurgery, Andhra Medical College, King George Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Vijaya Prasad Balda
Department of Neurosurgery, Andhra Medical College, King George Hospital, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.185433

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  Abstract 

Background: Approach for surgical treatment of thoracolumbar tuberculosis (TB) has been controversial. The aim of the study is to compare the clinical, radiological and functional outcome of anterior versus posterior debridement and spinal fixation for the thoracic and thoracolumbar TBs.
Materials and Methods: Thirty-four patients with dorsal spinal TB treated surgically between September 2011 and December 2013 were included in this study. Sixteen patients (Group 1) with a mean age of 34.5 years underwent anterior debridement, decompression, and instrumentation by anterior transthoracic, transpleural, and /or retroperitoneal diaphragm cutting approaches. Eighteen patients (Group 2) with a mean age of 35.4 years underwent posterolateral (extracavitary) decompression/posterior decompression and posterior instrumentation. Various parameters such as neurological recovery, improvement of symptoms, and prevention of kyphosis progression were compared. Neurological outcome is assessed by Nurick grade and Frankel grade. The mean follow-up is 12 months.
Results: In the present study, 87.5% of the patients had neurological improvement in Group 1 and 61% had improvement in Group 2. In Group 1, 93% of the patients had reduction of back pain and in Group 2, 83% of the patients had reduction of back pain. In follow-up, both groups had equal fusion rates, and no implant displacement on x-rays. Except for one patient in Group 2, no patient had a worsening of deformity.
Conclusion: Anterior approach is better for debridement and decompression of the spinal cord and stabilization than posterior approach.

Keywords: Anterior approach, posterior approach, thorasic and thoracolumbar TBs


How to cite this article:
Balda VP, Satyavaraprasad K. Surgical management of tuberculosis of dorsal spine and dorsolumbar spine: Anterior versus posterior approach. J NTR Univ Health Sci 2016;5:98-103

How to cite this URL:
Balda VP, Satyavaraprasad K. Surgical management of tuberculosis of dorsal spine and dorsolumbar spine: Anterior versus posterior approach. J NTR Univ Health Sci [serial online] 2016 [cited 2022 Jan 19];5:98-103. Available from: https://www.jdrntruhs.org/text.asp?2016/5/2/98/185433


  Introduction Top


  • Of all the patients suffering from tuberculosis (TB), nearly 5% have the skeletal system involved.
  • Vertebral TB constitutes about 50% of all cases of skeletal TB. [1],[2],[3],[4],[5],[6],[7],[8]
  • 60% of the world's spinal TB is from India.
  • Although medical treatment is the mainstay of therapy, surgery is required in certain situations.
  • In addition, with an increase in sophistication of the instrumentation, indications of surgery have gained a wider spectrum of usage, not just to correct or prevent neurological deficits but also to correct deformities. [8],[9],[10],[11],[12],[13],[14],[15],[16]
  • On combining medical and surgical treatments, the results are excellent. [17]


Indications for surgery are: [18],[19],[20],[21]

  1. Neurological signs not improving or worsening within 4 weeks of adequate conservative treatment.
  2. Progressive neurological deficits even on adequate treatment.
  3. Recurrence of neurological signs after improvement.
  4. Rapid-onset paraplegia.
  5. Late-onset paraplegia.


The approach for surgical treatment of thoracolumbar TB has been controversial.

The goals of surgery in Pott's spine are adequate decompression, adequate debridment, maintenance and reinforcement of stability and correction, and prevention of deformity.

The aim of the study is to compare the clinical, radiological, and functional outcome of anterior versus posterior debridement and spinal fixation for the thoracic and thoracolumbar TBs.


  Materials and methods Top


Thirty-four patients with confirmed dorsal spinal TB (20 males and14 females, with a mean age of 34.5 years and range of 18-65 years) were treated surgically between 2011 and 2013.

All these patients were prospectively analyzed into two groups on the basis of surgical approach.

Group 1: Sixteen patients with a mean age of 34.5 years underwent anterior debridement, decompression, and instrumentation by anterior transthoracic, transpleural approach for dorsal lesions and transthoracic retroperitoneal diaphragm cutting approach for thoracolumbar disease (patients with lesion below D3 are considered for anterior approach).

Group 2: Eighteen patients with a mean age of 35.4 years underwent posterolateral (extracavitary) decompression/posterior decompression and posterior instrumentation.

The indications for surgery in both these groups were the same.

Preoperatively, all these patients were evaluated neurologically by the Medical Research Council (MRC) grading for power, Nurick grading, and Frankel grading for neurological status.

Plain x-ray and magnetic resonance imaging (MRI) studies were conducted in all these patients before surgery.

All the patients were given standard antituberculosis with four drugs (HRZE).

The operative techniques for each group are as follows:

Group 1

All 16 patients underwent single-stage anterior radical debridement, decompression, autogenous bone grafting, and instrumentation.

Anterior transthoracic, intrapleural approach used for dorsal lesions and transthoracic retroperitoneal diaphragm cutting approach was used for thoracolumbar lesions. Pus and necrotic tissue were removed as much as possible until normal bleeding bone was reached. Neural decompression was carried out with subtotal or complete corpectomy of the involved vertebrae. The titanium cages packed with autogenous rib were used for reconstruction. Anterior instrumentation in the form of rod-screw construct was used following debridement in 13 patients. None of these patients had undergone supplementary posterior instrumentation.

Group 2

Posterolateral extrapleural approach was used to decompress the cord in five patients. The necrotic material within the body and disc was removed using curettes and the paraspinal abscess was drained. An autograft was used from one side to reconstruct the defect. Posterior laminectomy was performed in 13 patients to decompress the cord.

Posterior instrumentation using transpedicular screw and rod system was performed in 12 patients and Hartshill instrumentation was performed in four patients.

Immediately after surgery, routine lateral and anterior-posterior (AP) x-rays were obtained to assess the extent of decompression and placement of graft and instrumentation. The neurological status of the patient was assessed.

All patients were seen at 1 month, 3 months, 6 months, 9 months, and 12 months after

surgery.

At each follow-up, neurological examination and x-ray were obtained in a standing position to determine fusion status, development or progression of deformity after surgery, and instrument failure.

All patients continued their standard antitubercular treatment postoperatively.














  Results Top


Out of 34 patients, six patients presented with paraplegia of >2 months duration.

Paraplegia (Nurick grade 5)

Out of six patients, three underwent anterior approach and three underwent posterior approach.

In anterior approach patients, one patient is able to work normally (Nurick grade 1) and two patients had improvement of power (Nurick grade 2).

In posterior approach patients, one patient had improvement of power (Nurick grade 3) and two patients had no improvement (Nurick grade 5).

Paraparesis

  • Anterior approach-13 patients.
  • Posterior approach-15 patients.
  • 11 patients had improvement in power in anterior approach and 10 patients had improvement in power in posterior approach.
  • Two patients remain static in anterior approach and four patients in posterior approach.
  • One patient had decreased power in posterior approach.




Back pain

All patients had back pain. Sixteen patients were treated by anterior approach and 18 patients were treated by posterior approach. In Group 1, 93.7% of the patients had a reduction of back pain and in Group 2, 83% of the patients had a reduction of back pain.

Kyphosis

In the present study, significant correction of spinal deformity was not performed; straightforward placement of instrumentation was performed. The idea was to provide optimal stabilization and prevent future progression of deformity for early mobilization [Figure 1] and [Figure 2].
Figure 1: (a) Preoperative x-ray case 1 (b) Preoperative MRI 1 (c) Preoperative MRI t1-case 1 (d) Postoperative x-ray case 1 (e) Postoperative x-ray case 1

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Figure 2: Intraoperative cage image case 2

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In one patient for whom posterolateral decompression without instrumentation was performed, there was worsening of kyphosis for which instrumentation was performed.

In follow-up, both groups had equal fusion rates, and no implant displacement on x-rays. Except for one patient in Group 2, no patient had worsening of deformity.


  Discussion Top


Spinal TB primarily affects the anterior structures and anterior approach is considered to be the gold standard for debridement and decompression in Pott's spine, which was popularized by Hodgson [22] in 1960. Recent literature seems to echo the fact that posterolateral approach is a safe and effective method in the management of TB of the spine. [23],[24],[25],[26],[27] In the present study, 87.5% of the patients had neurological improvement in Group 1 and 61% had improvement in Group 2.

In Group 1, 93% of the patients had a reduction of radicular pain and in Group 2, 83% of the patients had a reduction of pain by posterior approach.

In our present study, six patients presented with paraplegia (>2 months duration), three patients in Group 1 had an overall improvement in power [Figure 3] while one out of three in Group 2 had improvement in power. Overall, four out of six patients had an improvement by surgery. It was consistent with the observation made by Sai Kiran et al. [4] who reported a remarkable improvement in all five patients with paraplegia of >2 months duration, with motor function improving to Frankel grade D/E. Similar findings were reported by Moula et al. [28]
Figure 3: (a) Preoperative photo case 3 (b) Preoperative MRI case 3 (c) Postoperative x-ray case 3 (d) Postoperative photo case 3

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So, late presentation with paraplegia should not preclude surgery.

In the present study, 19 patients presented with bladder symptoms; in Group 1, all patients had improvement while in Group 2, 94% of the patients had improvement.

Yilmaz et al. [29] believe that anterior instrumentation is more effective than posterior instrumentation for reducing deformity and stabilizing the vertebral column in patients who have kyphosis related to TB of the spine.

Dai et al. [30] have shown that anterior instrumentation in the dorsolumbar spine is associated with high fusion rate, low complication rate, and increased correction of kyphosis.

In the present study, a significant correction of spinal deformity was not performed; straightforward placement of instrumentation was performed [Graph 1 [Additional file 1]]. The idea was to provide optimal stabilization and prevent future progression of deformity for early mobilization; this was in accordance with Tuli's paper, [31] which has shown a significant development in the management of spinal TB of the spine.


  Conclusion Top


Spinal TB often involves the anterior and medial aspects of the vertebral column. In cases of great vertebral destruction and compression of the spinal canal by granulation tissue and abscess, thorough decompression of the cord by anterior approach (including abscess drainage, debridement of infected osseous and disc, decompression of spinal column) followed by segmental fusion with strut graft and instrumentation has resulted in the improvement of symptoms and prevention of subsequent collapse compared to posterior approach.

Anterior procedures help in the opening of loculated and contained cavities of tuberculous abscesses. This helps in better penetration of chemotherapeutic drugs and a better response to medical treatment.

Decompression followed by fusion and instrumentation has resulted in better results than without instrumentation.

Instrumentation helps in early mobilization, prevents graft displacement, and prevents progression of deformity.

For patients presenting at a late stage, i.e., paraplegia, surgery should be offered because surgical results are good in these group too.

The advantages of anterior approach are:

  • Directly deal with pathology.
  • Wide exposure and direct visualization across the midline.
  • Anterior reconstruction can be performed more efficiently.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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