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

ABSTRACT 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.

[1]  R. Hurtado,et al.  Challenges and controversies in the treatment of spinal tuberculosis , 2020, Journal of clinical tuberculosis and other mycobacterial diseases.

[2]  Haiping Liu,et al.  Efficacy of surgery via the single anterior and single posterior approaches for treatment of thoracic spinal tuberculosis , 2020, The Journal of international medical research.

[3]  R. Garg,et al.  Spinal Tuberculosis: Still a Great Mimic , 2019, Neurology India.

[4]  N. Marathe,et al.  Does Mesh Cage Subsidence Have any Effect on Functional Outcome in Spinal Tuberculosis? , 2019, Asian journal of neurosurgery.

[5]  T. Hou,et al.  Surgical treatment of thoracolumbar spinal tuberculosis—a multicentre, retrospective, case-control study , 2019, Journal of Orthopaedic Surgery and Research.

[6]  S. Rajasekaran,et al.  Spinal Infections: From Prevention to Cure Spinal Tuberculosis: Current Concepts , 2018 .

[7]  Jun Liu,et al.  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 , 2018, BMC Surgery.

[8]  Yang-hui Jin,et al.  Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation , 2017, Medical science monitor : international medical journal of experimental and clinical research.

[9]  X. Cui,et al.  Anterior and Posterior Instrumentation with Different Debridement and Grafting Procedures for Multi‐Level Contiguous Thoracic Spinal Tuberculosis , 2016, Orthopaedic surgery.

[10]  K. Phan,et al.  Surgery for spinal tuberculosis: a multi-center experience of 582 cases. , 2015, Journal of spine surgery.

[11]  Qiang Zhou,et al.  Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach , 2015, Journal of Orthopaedic Surgery and Research.

[12]  Qixin Zheng,et al.  Anterolateral Radical Debridement and Interbody Bone Grafting Combined With Transpedicle Fixation in the Treatment of Thoracolumbar Spinal Tuberculosis , 2015, Medicine.

[13]  Chun-yang Fang,et al.  [Surgical treatment of lumbosacral tuberculosis by anterior debridement,bone graft,and posterior pedicle screw-rod internal fixation]. , 2014, Zhongguo gu shang = China journal of orthopaedics and traumatology.

[14]  B. Tosun,et al.  Surgical treatment of thoracolumbar tuberculosis: a retrospective analysis of autogenous grafting versus expandable cages , 2014, European Spine Journal.

[15]  X. Pang,et al.  One-stage anterior debridement, bone grafting and posterior instrumentation vs. single posterior debridement, bone grafting, and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis , 2014, European Spine Journal.

[16]  Zili Wang,et al.  Anterior debridement and bone grafting with posterior single-segment internal fixation for the treatment of mono-segmental spinal tuberculosis. , 2013, Injury.

[17]  A. Jain,et al.  Tuberculosis of spine: neurological deficit , 2013, European Spine Journal.

[18]  Mingxing Tang,et al.  One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series , 2013, Archives of Orthopaedic and Trauma Surgery.

[19]  V. Rahimi-Movaghar,et al.  Spinal tuberculosis: diagnosis and management , 2012, Asian spine journal.

[20]  Yi-bing Bai,et al.  Outcomes of anterior and posterior instrumentation under different surgical procedures for treating thoracic and lumbar spinal tuberculosis in adults , 2012, International Orthopaedics.

[21]  Xiaobin Wang,et al.  Single-stage posterior instrumentation and anterior debridement for active tuberculosis of the thoracic and lumbar spine with kyphotic deformity , 2012, International Orthopaedics.

[22]  Wei Hu,et al.  One-Stage Anterolateral Surgical Treatment for Lumbosacral Segment Tuberculosis , 2012, International Orthopaedics.

[23]  Qiang Zhou,et al.  A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis , 2012, International Orthopaedics.

[24]  Licia K. Gaber-Baylis,et al.  Perioperative Morbidity and Mortality After Anterior, Posterior, and Anterior/Posterior Spine Fusion Surgery , 2011, Spine.

[25]  Zhuojing Luo,et al.  One-stage surgical management for thoracic tuberculosis by anterior debridement, decompression and autogenous rib grafts, and instrumentation. , 2011, The spine journal : official journal of the North American Spine Society.

[26]  R. Riesenburger A New Thoracic Reconstruction Technique “Transforaminal Thoracic Interbody Fusion”: A Preliminary Report of Clinical Outcomes , 2011 .

[27]  Cheng-Mao Ho,et al.  Spinal tuberculosis in non-HIV-infected patients: 10 year experience of a medical center in central Taiwan. , 2010, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[28]  Y. Yukawa,et al.  A New Thoracic Reconstruction Technique “Transforaminal Thoracic Interbody Fusion”: A Preliminary Report of Clinical Outcomes , 2010, Spine.

[29]  A. Jain Tuberculosis of the spine: a fresh look at an old disease. , 2010, The Journal of bone and joint surgery. British volume.

[30]  K. Shimizu,et al.  Surgical Outcome of 2-stage (Posterior and Anterior) Surgical Treatment Using Spinal Instrumentation for Tuberculous Spondylitis , 2010, Journal of spinal disorders & techniques.

[31]  S. Mehta,et al.  Surgical Treatment of Lumbar Tuberculous Spondylodiscitis by Transforaminal Lumbar Interbody Fusion (TLIF) and Posterior Instrumentation , 2009, Journal of spinal disorders & techniques.

[32]  A. Jain,et al.  Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. , 2008, The Journal of bone and joint surgery. British volume.

[33]  J. Chen,et al.  One-stage Surgical Management for Multilevel Tuberculous Spondylitis of the Upper Thoracic Region by Anterior Decompression, Strut Autografting, Posterior Instrumentation, and Fusion , 2007, Journal of spinal disorders & techniques.

[34]  A. Mahapatra,et al.  Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients. , 2007, Journal of neurosurgery. Spine.

[35]  Xiaofeng Lian,et al.  Anterior debridement and bone grafting of spinal tuberculosis with one-stage instrumentation anteriorly or posteriorly , 2007, International Orthopaedics.

[36]  N. Schlesinger,et al.  Tuberculosis of the Spine: Experience in an Inner City Hospital , 2005 .

[37]  Hao Zhang,et al.  One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis , 2004, European Spine Journal.

[38]  M. Kış,et al.  Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis , 2003, European Spine Journal.

[39]  N. Prabhu,et al.  Spectrum of MR imaging findings in spinal tuberculosis. , 2002, AJR. American journal of roentgenology.

[40]  A. Jain Treatment of tuberculosis of the spine with neurologic complications. , 2002, Clinical orthopaedics and related research.

[41]  A. Nene,et al.  Lumbar and lumbosacral tuberculous spondylodiscitis in adults. Redefining the indications for surgery. , 2002, The Journal of bone and joint surgery. British volume.

[42]  V. Laheri,et al.  Single stage decompression, anterior interbody fusion and posterior instrumentation for tuberculous kyphosis of the dorso-lumbar spine , 2001, Spinal Cord.

[43]  M. Turgut Spinal tuberculosis (Pott’s disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients , 2001, Neurosurgical Review.

[44]  J. Darbyshire,et al.  Five-year assessment of controlled trials of short-course chemotherapy regimens of 6, 9 or 18 months’ duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery , 1999, International Orthopaedics.

[45]  O. Güven Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines. , 1996, Spine.

[46]  Y. Sugioka,et al.  Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. , 1993, Spine.

[47]  J. Louw Spinal tuberculosis with neurological deficit. Treatment with anterior vascularised rib grafts, posterior osteotomies and fusion. , 1990, The Journal of bone and joint surgery. British volume.

[48]  T. Shanmugasundaram,et al.  Prediction of the angle of gibbus deformity in tuberculosis of the spine. , 1987, The Journal of bone and joint surgery. American volume.

[49]  S. Fountain,et al.  Progressive kyphosis following solid anterior spine fusion in children with tuberculosis of the spine. A long-term study. , 1975, The Journal of bone and joint surgery. American volume.

[50]  J. Dobson Percivall Pott. , 1972, Annals of the Royal College of Surgeons of England.

[51]  A. Hodgson,et al.  Anterior spinal fusion the operative approach and pathological findings in 412 patients with pott's disease of the spine , 1960, The British journal of surgery.