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Tuberculous
spondylitis, surgical vs non-surgical treatment
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INTRODUCTION
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The incidence of tuberculous (TB) spondylitis varies considerably throughout the world. Tuberculous affection of the spine occurs in 50% of patients with bone involvement.9 There has been an increasing incidence of tuberculosis throughout the world over the past three decades.1
In North America and Saudi Arabia the disease primarily affects adults.3,4 Neurologic deficit as well as deformity such as kyphosis is a frequent sequelae of the disease.
The best method of choice for treatment is still debatable. Radical excision and fusion is advocated by many authors.1,4,6 However, medical treatment is still an alternative.8 In this paper we report our experience in treating TB spondylitis both medically and surgically.
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PATIENTS
AND METHODS
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During the period 1983–1999, 1195 patients were treated for TB at our hospital. One-hundred and forty-two patients had bony involvement (Fig. 1). Of these 142 patients, 110 had TB spondylitis, 42 females and 68 males (Fig. 2). Fifty-nine patients were treated with anti TB alone for nine months. The regimen that we used was Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. In addition, all patients received Pyridoxine. The rest of the patients, in addition to the same chemotherapy regimen, received radical surgery using the modified Hong-Kong procedure (Fig. 3).7
There were 36 males and 23 females in the non-surgical group, whereas there were 32 males and 19 females in the surgical group. The mean age was 47.1 (range 2-89 years) (Fig. 4). The follow-up period ranged between 1-15 years.
The thoraco-lumbar affection constitutes 90% of cases and the rest were cervical and lumbosacral (Fig. 5). Of 110 patients, 44 had neurological deficit.
The neurological deficit in non-surgical group was 23 patients and 21 in the surgical group (Fig. 6). Follow-up was done by plain radiography, MRI and ESR in addition to clinical examination at six weeks, three months, six months and then yearly.
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| Figure 1 - Spinal involvement over the years |
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| Figure 2 - TB spine | Figure 3 - Surgical approach |
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| Figure 4 - Age distribution | Figure 5 - Spinal level of involvement |
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| Figure 6 - Neurological damage |
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RESULTS
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Erythrocyte sedimentation rate (ESR) values dropped rapidly in the surgical group compared to the non-surgical group, thus indicating that drainage of abscess and de-bridement clears the infection faster than chemotherapy alone.
No complication occurred with anti TB treatment. One patient had anterior decompression followed by stabilisation with Hartshill rectangle two weeks later. Immediately follow-ing the surgery the patient was un-able to move her feet and the metal was removed. The patient had full recovery after three months. This was the only complication that occurred due to surgery of mainly posterior stabilisation. Resistant organism was encountered in one patient only. Complete bony fusion, as assessed radiologically, was ob-tained in all patients.
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DISCUSSION
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The controversy regarding surgical treatment or medical treatment of
tuberculous spondylitis continues.2, 6,8
The reports of the Medical Research Council suggested that the overall
outcome was the same for both modalities.5-7 However, consideration for
those patients who had neurological deficit or the existence of facilities
for surgical treatment, especially in developing countries, should be
addressed. Our non-surgical group were treated before the establishment
of our Spinal Unit. Surgical treatment is our standard method in patients
with selected criteria.
Patients with neurologic deficit, abscess, kyphosis or intractable pain,
in our view, required radical surgery. The other important factor was
availability of facilities for performing major surgery and the experience
of surgeons. This is one of the major factors that dictate the modality
of treatment in developing countries.
Our results, using both treatment modalities, are in agreement with the
published reports.6-8 The advantage of surgical treatment over medical
treatment alone was early ambulation of the patient, less hospitalisation
time, early neurologic recovery, less deterioration of the angle of kyphosis,
and this is due to the ability to correct kyphosis if an additional posterior
approach is used. However, even with only anterior approach and strut
graft, kyphotic deformity is less. Apart from that, the overall outcome
is almost the same at the latest follow-up. In our series we did not use
combined anterior and posterior approach except in one patient because
most of our patients did not have kyphosis deformity that merited correction.
The patient who had posterior instrumentation had loss of power in the
lower limb immediately after surgery and the instrumentation was removed
(Fig. 8a and b) The reason for this was that the patient had the posterior
approach two weeks after the anterior approach due to increase of kyphosis.
After two weeks there was more adhesion and the attempt to correct the
kyphosis led to transient compromise of blood supply. This patient recovered
completely within three months.
At follow-up there was an increase of the angle of kyphosis by 8-100 compared
with the immediate post-operative x-rays (Fig. 8c and d). This was mainly
due to collapse of the graft as most of the patients were elderly and
had an osteoporotic bone. This is statistically significant if compared
with increase of the kyphotic deformity in the non-surgical group. Although
this was a significant increase of kyphosis radiologically, clinically
there was no obvious deformity. The question of instrumentation in all
patients is still unresolved. Also, whether we should use anterior approach
combined with posterior stabilisation to reduce this increase in kyphosis.
Recently, we have started to combine the anterior approach with anterior
instrumentation in an effort to reduce the increase in kyphotic angle
due to collapse of the graft and avoid posterior surgery either at the
same time or later. The results of this will be available when we have
sufficient data.
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Figure 7a
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Figure 7b
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| Figure 7a - Lateral x-ray of patient treated medically showing a degree of kyphosis of 200 | Figure 7b - Lateral x-ray of the same patient after 2 years showing increase of the degree of kyphosis 35 degrees |
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Figure 8a
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Figure 8b
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| Figure 8a - MRI of patient showing the extent of destruction and pressure on the cecal sac. | Figure 8b - Immediate post-operative x-ray of the patient. The posterior stabilisation device was removed because of immediate deterioration of neurological status. |
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Figure 8c
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Figure 8d
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| Figure 8c - Lateral x-ray of patient showing angle of kyphosis of 150 at few weeks post-operatively | Figure 8d - Lateral x-ray of the same patient 5 years post-operatively showing a degree of kyphosis of 20 degrees |
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CONCLUSION
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REFERENCES
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| 1. | Leong JCY: Editorial. Tuberculosis of the spine. JBJS 1993, 75B: 173-175 |
| 2. | Leong JCY: Treatment: Tuberculous bone and joint infection. Current Ortho 1988, 2: 86-89 |
| 3. | Lifeso RM, Weaver P, Harder EH: Tuberculous Spondylitis in adults. JBJS 1985, 67A: 1405-1413 |
| 4. | Martin NS: Tuberculosis of the spine. A study of the results of treatment during the last twenty-five years. JBJS 1970, 52B: 613-628 |
| 5. | Medical Research Council Working Party on TB of the spine. A 10-year assessment of controlled trial of inpatient and outpatient of POP, jacket for TB of the spine in children on standard chemotherapy. Study in Mason, Pusan and Korea. JBJS 1985, 63: 103-110 |
| 6. | Medical Research Council Working Party on tuberculosis of the spine. A comparison of 6 months and 9 months course regimen of chemotherapy in patients receiving ambulatory treatment or undergoing radical surgery for TB of the spine. Indian J of Tuberculosis (Suppl) 1989, 36: 1-29 |
| 7. | Medical Research Council Working Party on tuberculosis of the spine. A controlled trial of anterior spinal fusion and debridement in surgical management of tuberculosis of the spine in patients on standard chemotherapy. A study in Hong-Kong BJ Surg 1974, 611: 853-866 |
| 8. | Parthasarathy S, Srivane K, Santha T, Prabhakar R, et al: Short-course chemotherapy for tuberculosis of the spine. A comparison between ambulant treatment and radical surgery – ten-year report. JBJS 1999, 81B: 464-471 |
| 9. | Tuli SM, Srivastava TP, Varma BP, Sinha GP: Tuberculosis of spine. Acta Orthop (Scand) 1967, 38: 445-458 |
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