Orthopedics

Feature Article 

One-stage Posterior Surgical Treatment for Lumbosacral Tuberculosis With Major Vertebral Body Loss and Kyphosis

Lin Sun, MD; Yueming Song, PhD; Limin Liu, MD; Quan Gong, MS; Chunguang Zhou, MD

Abstract

The treatment goals of tuberculous spondylitis are to eradicate infection and to prevent or treat instability, deformity, and neurologic deficit. The purpose of this study was to evaluate the clinical outcomes following chemotherapy with 1-stage posterior debridement, correction, and instrumentation and fusion for the treatment of lumbosacral tuberculosis with major vertebral body loss and kyphosis. Fourteen patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis underwent 1-stage posterior surgery. Clinical assessments included low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores, neurologic deficit, erythrocyte sedimentation rate, and C-reactive protein level. Radiographic parameters included kyphosis angle, anteroposterior translation, local scoliosis, lumbar lordosis, pelvic parameters, sagittal offset, and fusion. Thorough debridement was performed. Patients were followed for an average of 39.3 months. Constitutional symptoms, low back ache, and functional outcome improved in all patients postoperatively. At final follow-up, Frankel Grade improved by 0 to 2 grades, mean kyphosis angle improvement was 44.3°, and satisfactory spinopelvic and sagittal balance were achieved. Spinal posterolateral fusion was obtained in all patients and no fixation loosening was found at 2-year follow-up. Differences existed between the pre- and postoperative radiographic parameters (P<.05). Correction loss at last follow-up was not statistically significant (P>.05). No surgical complications or infection recurrence occurred. Tuberculosis can be cured and effective correction of kyphosis can be achieved for lumbosacral tuberculosis with major vertebral body loss and kyphosis by performing 1-stage posterior surgery and chemotherapy.

The authors are from the Department of Orthopedics, West China Hospital, Sichuan University, Chendu; and the Department of Orthopedics (LS), Shanxi Academy of Medical Sciences, Xhanxi Da Yi Hospital, Taiyuan, China.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Limin Liu, MD, Department of Orthopedics, West China Hospital, Sichuan University, Guoxuexiang No. 37, Wuhouqu, Chendu 610041, China (liulimin_9999@163.com).

Abstract

The treatment goals of tuberculous spondylitis are to eradicate infection and to prevent or treat instability, deformity, and neurologic deficit. The purpose of this study was to evaluate the clinical outcomes following chemotherapy with 1-stage posterior debridement, correction, and instrumentation and fusion for the treatment of lumbosacral tuberculosis with major vertebral body loss and kyphosis. Fourteen patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis underwent 1-stage posterior surgery. Clinical assessments included low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores, neurologic deficit, erythrocyte sedimentation rate, and C-reactive protein level. Radiographic parameters included kyphosis angle, anteroposterior translation, local scoliosis, lumbar lordosis, pelvic parameters, sagittal offset, and fusion. Thorough debridement was performed. Patients were followed for an average of 39.3 months. Constitutional symptoms, low back ache, and functional outcome improved in all patients postoperatively. At final follow-up, Frankel Grade improved by 0 to 2 grades, mean kyphosis angle improvement was 44.3°, and satisfactory spinopelvic and sagittal balance were achieved. Spinal posterolateral fusion was obtained in all patients and no fixation loosening was found at 2-year follow-up. Differences existed between the pre- and postoperative radiographic parameters (P<.05). Correction loss at last follow-up was not statistically significant (P>.05). No surgical complications or infection recurrence occurred. Tuberculosis can be cured and effective correction of kyphosis can be achieved for lumbosacral tuberculosis with major vertebral body loss and kyphosis by performing 1-stage posterior surgery and chemotherapy.

The authors are from the Department of Orthopedics, West China Hospital, Sichuan University, Chendu; and the Department of Orthopedics (LS), Shanxi Academy of Medical Sciences, Xhanxi Da Yi Hospital, Taiyuan, China.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Limin Liu, MD, Department of Orthopedics, West China Hospital, Sichuan University, Guoxuexiang No. 37, Wuhouqu, Chendu 610041, China (liulimin_9999@163.com).

Tuberculosis is a common infection in developing nations, and active immunization has significantly reduced the disease burden in many countries.1 The involvement of bones and joints develops in approximately 10% of patients with tuberculosis, of whom half have tuberculous spondylitis.2 For patients with tuberculous spondylitis, the infection causes collapse and loss of vertebral body, leading to kyphosis and sagittal imbalance.2

The treatment goals of tuberculous spondylitis are to eradicate infection and prevent or treat instability, deformity, and neurologic deficit. The options of treatment are chemotherapy or chemotherapy with surgery.3,4 For tuberculosis spondylitis of the lumbosacral segment (L3 and lower levels5), various methods of debridement and fusion have been reported, including debridement with anterior fusion, posterior fusion, single-stage anterior and posterior fusion, and posterior fusion followed by anterior fusion.3,6–9 Posterior debridement with instrumentation and fusion is an effective procedure for treating lumbosacral tuberculosis without major vertebral body loss.7–9 However, few reports have been published on performing 1-stage posterior surgery to treat lumbosacral tuberculosis with major vertebral body loss and kyphosis.

In this retrospective series of 14 patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis who underwent chemotherapy, posterior debridement, correction, and short-segment instrumentation and fusion, the authors describe their experience and evaluate its results in terms of pain relief, improvement in function, and correction of kyphosis and sagittal balance.

Materials and Methods

This study was approved by the institutional review board. Written informed consent was obtained from all patients preoperatively. Between November 2007 and August 2010, fourteen patients with lumbosacral tuberculosis, major vertebral body loss, and kyphosis were enrolled in this retrospective study. Inclusion criteria were progressive tuberculosis spondylitis at L3 and lower levels; major vertebral body loss; kyphosis angle more than 10° at a lumbosacral segment; and previous posterior debridement, correction, and short-segment instrumentation and fusion. Exclusion criteria were previous lumbosacral surgery or trauma at L3 and lower levels, history of adolescent scoliosis or kyphosis, ankylosing spondylitis, and failure to comply with standard postoperative chemotherapy. The diagnosis of tuberculosis spondylitis was guided by symptoms, elevation of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, computed tomography (CT), and magnetic resonance imaging (MRI). The final diagnosis was confirmed via the postoperative pathological studies. A senior spine surgeon (L.L.) performed all surgeries. Data were collected by 2 independent spinal surgeons (Q.G., C.G.) who were not involved in surgery or patient management, and the means were obtained. Interobserver reliability was good (κa=0.71∼0.93).

Chemotherapy was started immediately after the diagnosis of tuberculous spondylitis. Indications for surgery were pronounced instability with major vertebral body loss and spinal kyphosis, neurologic deficit, and huge abscess. Clinical and radiologic assessments were performed preoperatively, postoperatively, and during regular follow-up but were reviewed retrospectively for study purposes. Clinical assessments included constitutional symptoms, low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores,10 and neurologic deficit. Constitutional symptoms mainly included general fatigue, night sweats, and fever with weight loss. The measurement of low back ache used a pain visual analog scale with a score of 0 to 10. The Oswestry Disability Index score was the sum of the points from the answers to 10 questions on disability (each received 0 to 5 points).11 Neurologic deficit was assessed according to Frankel classification.8 Erythrocyte sedimentation rate and CRP level were obtained for all patients.

Radiographs and CT scans of the lumbosacral spine and the entire spine (standing) were obtained for all patients. Vertebral body loss was measured on sagittal CT scans. Each vertebra was divided into 10 equal parts based on the vertical height, and the loss of height on each vertebra was added to find the amount of vertebral loss.5,7 Major vertebral loss was defined as more than 5 parts on the summation.7

The kyphosis angle at the lumbosacral segment was measured on lateral radiographs. Lines were drawn along the posterior border of the first normal vertebra above the level of lesion and the posterior border of the sacrum (Figure 1A). The posterior angle was expressed as a plus (+) sign and the anterior angle as a minus (−) sign.

Lateral radiograph showing the kyphosis angle (angle between the lines along the posterior border of the first normal vertebra above the level of the lesion and the posterior border of sacrum) (A). Sagittal computed tomography scan showing the anteroposterior translation measurement method using the following formula: (a/b×100%) (B). Anteroposterior radiograph showing local scoliosis measured by drawing 2 lines: 1 on the superior margin of the upper first uninvolved vertebra and the other correcting both sides of the posterior inferior iliac spine (C).

Figure 1: Lateral radiograph showing the kyphosis angle (angle between the lines along the posterior border of the first normal vertebra above the level of the lesion and the posterior border of sacrum) (A). Sagittal computed tomography scan showing the anteroposterior translation measurement method using the following formula: (a/b×100%) (B). Anteroposterior radiograph showing local scoliosis measured by drawing 2 lines: 1 on the superior margin of the upper first uninvolved vertebra and the other correcting both sides of the posterior inferior iliac spine (C).

Anteroposterior translation was measured by determining the ratio between the slipped posterior distance of the first cephalad-involved vertebral body and the anteroposterior diameter of the top of the last caudal-involved vertebral body as seen on sagittal CT scans (Figure 1B).

Local scoliosis was measured by drawing 2 lines: 1 on the superior margin of the upper first uninvolved vertebra and the other connecting both sides of the posterior inferior iliac spine on anteroposterior radiographs (Figure 1C). Global lumbar lordosis (Cobb’s angle from the L1 upper endplate to the S1 upper endplate on the lateral radiographs) was also measured. Pelvic parameters included pelvic incidence, sacral slope, and pelvic tilt.12 Global lumbar lordosis and pelvic parameters were not analyzed for patients with S1 vertebral body loss. Sagittal offset was measured between the C7 sagittal plumb line and the posterior-superior corner of the normal sacrum on lateral radiographs of the entire spine, with a plus (+) sign indicating anterior displacement and a minus (−) sign indicating posterior displacement. Anterior interbody fusion and posterolateral fusion were assessed on CT scans of the lumbosacral spine.

Surgical Technique

After placing the patient in a prone position on the operating table, which was flexed in a reverse V shape, the posterior midline approach was used while the patient was under general anesthesia. Intraoperatively, while under C-arm guidance, pedicle screws were inserted in 1 or 2 segments above and below the involved bodies and partly in 1 involved body if the pedicle screw channel of the involved body was not destructed and the screw hold in the body was strong enough. Complete laminectomy was performed at the involved levels. Temporary fixation with a unilateral rod was performed on 1 side. Facetectomy was then performed at the involved levels on the other side. If the pedicle was free from the involved vertebral body, the transverse process and pedicle were excised at their bases. The pus was drained, and the sequestra, infected disk, endplates, and soft tissue were thoroughly debrided. The sclerotic bone of the residual vertebral body was curetted, but no additional osteotomy of the vertebral body was performed. These materials were sent for histopathologic examination and antibiotic sensitivity testing. Then, posterior debridement was performed on the other side. After completing the posterior debridement, the cavities between the residual bodies were irrigated. The anterior two-thirds of the space was packed with iliac cancellous bone autograft mixed with streptomycin (1000 mg), and gelatinous sponges were used to prevent the morselized bone from moving into the spinal canal.

Three steps were performed to correct the kyphosis, including extending the operating table slowly to the neutral position, using a cantilever beam technique to introduce the rods, and performing instrumental compression. A temporary titanium rod was alternated from side to side during correction to avoid translation at the osteotomy site. C-arm fluoroscopy was used to examine the consequence of correction. After correction, shortening of the spine was permitted. Pedicle screws were then fixed to precontoured rods on both sides, and 1 cross-link was used between 2 rods. For spinal fusion, the authors performed strict iliac cancellous bone autografting after posterolateral spinal element decortications at the fixation segments.

Postoperatively, all patients were placed on strict bed rest for 3 weeks. A lower lumbar orthosis was given to all patients, which was continued for an average of 6 months postoperatively. All patients received a 4-drug chemotherapy regimin of isoniazid (5 mg/kg), rifampicin (10 mg/kg), pyrizinamide (25 mg/kg), and streptomycin (20 mg/kg) for 2 months. This was followed by the 3-drug chemotherapy regimen of isoniazid (5 mg/kg), rifampicin (10 mg/kg), and pyrizinamide (25 mg/kg) for another 10 months.

The paired t test was used for the analysis of the preoperative and final follow-up clinical assessments. Mann-Whitney U test was used to evaluate the differences in the Scoliosis Research Society-22 scores. Repeated analysis of variance test was used to compare the preoperative, postoperative, and final follow-up values of the radiologic assessments, and the Bonferroni test was used when the P value was less than .05. A P value less than .05 was considered statistically significant.

Results

Five men and 9 women with an average age of 34.3 years (range, 10–50 years) were included in the analysis. The clinical characteristics of the included patients are shown in Table 1.

Patient Characteristics and Instrumented Fusion Levels

Table 1: Patient Characteristics and Instrumented Fusion Levels

Surgery was successful for all patients, and no large vessel injury or spinal nerve injury occurred. Mean±SD operative time was 283±62 minutes, and mean±SD estimated intraoperative blood loss was 1264±527 mL. Thorough debridement of the tuberculosis lesion was performed. The range of instrumented fusion levels and patient clinical data are shown in Table 1. Two patients had caudal instrumentation at only 1 level (S1) because 1 was a child and the other had difficulty during screw placement at S2. A bicortical fixation technique at S1 was provided for the 2 patients. Histopathologic examination results suggested tuberculosis in all patients. The organism was isolated and antibiotic sensitivity was performed in 9 of 14 patients. Average follow-up was 39.3 months (range, 24–56 months) (Figures 27).

Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), T1- (D) and T2-weighted (E) sagittal magnetic resonance images, and anteroposterior (F) and lateral (G) radiographs of the entire spine showing that the L5 vertebral body was destroyed. Preoperatively, the kyphosis angle was 13.39°, anteroposterior translation was 68.00%, local scoliosis was 19.5°, and sagittal offset was 31.21 mm.

Figure 2: Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), T1- (D) and T2-weighted (E) sagittal magnetic resonance images, and anteroposterior (F) and lateral (G) radiographs of the entire spine showing that the L5 vertebral body was destroyed. Preoperatively, the kyphosis angle was 13.39°, anteroposterior translation was 68.00%, local scoliosis was 19.5°, and sagittal offset was 31.21 mm.

Images of a 24-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and sagittal computed tomography scan (C) showing a kyphosis angle of 225.89°, anteroposterior translation of 6.71%, and local scoliosis of 4.38°.

Figure 3: Images of a 24-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and sagittal computed tomography scan (C) showing a kyphosis angle of 225.89°, anteroposterior translation of 6.71%, and local scoliosis of 4.38°.

Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), and anteroposterior (D) and lateral (E) radiographs of the entire spine at final follow-up 36 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, anteroposterior translation, local scoliosis, and a sagittal offset of 4.93 mm.

Figure 4: Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), and anteroposterior (D) and lateral (E) radiographs of the entire spine at final follow-up 36 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, anteroposterior translation, local scoliosis, and a sagittal offset of 4.93 mm.

Images of a 22-year-old woman with lumbosacral tuberculosis. Preoperative anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), sagittal magnetic resonance image (D), and anteroposterior (E) and lateral (F) radiographs of the entire spine showing loss of vertebral body height at L4 (loss of 4 parts), L5 (loss of 10 parts), and S1 (loss of 8 parts), a kyphosis angle of 52.61°, local scoliosis of 5.76°, and sagittal offset of 61.40 mm.

Figure 5: Images of a 22-year-old woman with lumbosacral tuberculosis. Preoperative anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), sagittal magnetic resonance image (D), and anteroposterior (E) and lateral (F) radiographs of the entire spine showing loss of vertebral body height at L4 (loss of 4 parts), L5 (loss of 10 parts), and S1 (loss of 8 parts), a kyphosis angle of 52.61°, local scoliosis of 5.76°, and sagittal offset of 61.40 mm.

Images of a 22-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and transverse (C) and sagittal computed tomography scans (D) showing a kyphosis angle of 213.12° and local scoliosis of 2.04°.

Figure 6: Images of a 22-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and transverse (C) and sagittal computed tomography scans (D) showing a kyphosis angle of 213.12° and local scoliosis of 2.04°.

Images of a 22-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, transverse (C) and sagittal (D) computed tomography scans, and anteroposterior (E) and lateral (F) radiographs of the entire spine at final follow-up 39 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, local scoliosis, and a sagittal offset of 18.32 mm.

Figure 7: Images of a 22-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, transverse (C) and sagittal (D) computed tomography scans, and anteroposterior (E) and lateral (F) radiographs of the entire spine at final follow-up 39 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, local scoliosis, and a sagittal offset of 18.32 mm.

Constitutional symptoms, low back ache, and postoperative functional outcome improved in all patients. The visual analog scale, Oswestry Disability Index, and Scoliosis Research Society-22 scores were significantly different at final follow-up compared with preoperatively (P<.05) (Table 2). Frankel Grade improved by 0 to 2 grades at final follow-up. Eight patients with preoperative neurologic deficit had complete recovery of neurological function within 6 months postoperatively. One patient with Frankel Grade A had no recovery; he underwent surgery for an L1 fracture with paraplegia 7 years previously. Two other patients with preoperative Frankel Grade C only recovered to Frankel Grade D at final follow-up. Erythrocyte sedimentation rate normalized within 3 months in 6 patients and within 6 months in 8 patients postoperatively, and CRP returned to normal levels for all patients within 3 months postoperatively. Significant differences were found in ESR and CRP levels between the preoperative and final follow-up values (Table 2). No recurrent infection occurred and no multidrug-resistant bacillus types were observed in this series.

Clinical Assessmenta

Table 2: Clinical Assessment

Postoperatively, average shortening of the lumbosacral spine was 1.5 vertebral bodies (range, 0.9–2.3 vertebral bodies) and 1.7 intervertebral disks (range, 0–2 intervertebral disks). Average kyphosis angle improvement was 45.8° (range, 34.9°–53.1°). Complete spinal posterolateral fusion was obtained in all patients and no loosening or breakage of the pedicle screws was found at 2-year follow-up, but interbody fusion was not obtained (solid anterior fusion rate, 0). Although some correction loss (average reduction, 2.1°) occurred at last follow-up, it was not statistically significant (P>.05). Satisfactory spinopelvic balance and sagittal balance were achieved. Preoperative, postoperative, and final follow-up kyphosis angle, AP translation, local scoliosis, global lumbar lordosis, pelvic incidence, sacral slope, pelvic tilt, and sagittal offset were noted (Table 3). Significant differences existed in these pre- and postoperative values (P<.05), except in the pelvic incidence. These parameters were well maintained at final follow-up (P>.05).

Radiologic Assessment

Table 3: Radiologic Assessment

Postoperative complications consisted of 1 wound infection and 1 bed sore that was not severe. The wound infection was cured with no additional antibiotic therapy, and the bed sore was treated with local wound care.

Discussion

Tuberculosis spondylitis preferentially affects the anterior structures of the vertebral column in more than 90% of patients with lumbosacral tuberculosis.13 Collapse and major vertebral body loss causes spinal instability and kyphosis. Tuberculous spondylitis is a main cause of kyphosis in the developing world.14 Lumbosacral region involvement occurs in 10% to 15% of all patients with tuberculous spondylitis.7 Stability and lordosis of the lumbar and lumbosacral spine are necessary for normal spinal biomechanical function. Instability leads to low back pain and disability.

Kyphosis in the lumbosacral region presents several biomechanical disadvantages. These patients often cannot stand erect despite compensatory hip extension, knee flexion, and overwork of the erector spinal musculature. The results are muscle fatigue and low back pain. Studies have also shown a direct correlation between decrease in lordosis of the lumbar and lumbosacral spine with the severity of low back pain.5 Spinal tuberculosis causes pus to accumulate in the prevertebral and paravertebral spaces. Pus accumulation can lead to pressure over the cauda equina and the cauda equina nerve roots, and the neurologic deficit is further aggravated by the kyphosis.

In the current series, patients had major vertebral body loss of the lumbosacral spine. More than 9 parts of loss were observed on CT scans in accordance with the method reported by Rajasekaran et al5 in which each vertebra was divided into 10 equal parts based on the vertical height and the kyphosis angle was more than 10°. The paravertebral abscess was present in all patients, and neurologic deficit was found in 10 (71%) patients. Major vertebral body loss of the lumbosacral spine, a kyphosis angle greater than 10°, paravertebral abscess, and neurologic deficit are indications for surgery and the difficulties faced intraoperatively.

Various approaches have been reported for lumbosacral tuberculosis.3,8,15 Song et al16 reported that an average improvement of 9.5° in the lumbosacral angle and that bone fusion could be obtained for lumbosacral tuberculosis by performing anterolateral surgery. Surgery via an anterior approach has the advantage of direct access to the site of inflammation and rapid bony union but is associated with approach-related morbidity.3 An anterior paramedian transperitoneal approach carries the risk of morbidity to major neurovascular structures. It is difficult to decompress the cauda equina nerve roots via anterior approaches. Moreover, anterior instrumentation is not advisable at the L4–L5 and L5-S1 segments, and anterior decompression usually requires supplementation with posterior instrumented stabilization.8 Average operative time, blood loss, and length of stay following the 2-stage procedure are greater than those following the 1-stage approach.7,15

Posterior surgery could effectively treat lumbosacral tuberculosis without major vertebral body loss.7,8 Bezer et al7 reported that by performing transpedicular drainage with posterior instrumentation and fusion, debridement was obtained and average kyphosis decreased to 5.4° postoperatively from the preoperative value of 17.5° for lumbosacral tuberculosis without major vertebral body loss. Bezer et al17 also reported that posterior transpedicular decancellation osteotomy effectively corrected posttuberculosis kyphosis (average kyphosis angle improvement, 17.7°).

The current authors analyzed the feasibility of the current 1-stage posterior surgery performed as follows: (1) the posterior approach is relatively easier and safer; (2) debridement via a posterior approach is relatively complete because the destruction and loss of the vertebral body usually leads to vertebral posterior wall damage and freeing of the pedicle; (3) the satisfactory correction of kyphosis could be achieved via osteotomy of the spinal rear structure with no need for additional osteotomy of the involved body for the preoperative major vertebral body loss; (4) the posterior instrumentation and fusion at L4-S1 could be effectively achieved; and (5) the nerve roots are continuously visible during debridement, decompression, and kyphosis correction. Thorough debridement, satisfactory kyphosis correction (average kyphosis angle improvement at final follow-up, 44.3°), and satisfactory spinopelvic balance and sagittal balance were achieved for all patients.

The ultimate goal of spinal deformity reconstructive surgery is to obtain solid fusion at the instrumented segments. Zaveri and Mehta8 reported that 13 patients with lumbar tuberculous spondylodiskitis had definitive fusion and 2 patients had probable fusion after undergoing posterior transforaminal debridement, interbody fusion, and instrumentation. Kim et al18 reported that complete bony fusion was obtained for 23 patients with tuberculosis of the lower lumbar spine who underwent posterior instrumentation and anterior interbody arthrodesis. Karaeminogullari et al19 reported good restoration and maintenance of lumbar lordosis by using combined posterior and anterior fusion for lumbar tuberculosis.

In the current study, cancellous autograft from the iliac crest was used in preference to a structural tricortical graft due to irregularity of the vertebral surface, the desire to preserve as much of the viable bone that remained after debridement as possible, and the technical difficultly associated with placing a structural graft at this level. Although solid anterior fusions may not be evident in all patients, solid posterolateral fusion was achieved in all patients, and no correction loss or implant failure occurred.

Similar to most of the studies reported,4,7,8,15,18,20–22 the current authors obtained an encouraging cure rate of tuberculosis spondylitis and improvement in neurologic status postoperatively. Patients had satisfactory recovery of neurological deficit (Frankel Grade improvement, 0–2 grades) and healing of the tuberculosis spondylitis (100%). Standard chemotherapy regimens are vital to the complete cure of tuberculosis spondylitis.

The sample size in the current study was relatively small; a larger study is needed to further assess the effects of the surgery. Also, a longer follow-up time is needed to determine how well the corrections are maintained in these patients.

Conclusion

Tuberculosis cure and effective kyphosis correction can be successfully achieved by performing 1-stage posterior debridement, osteotomy correction, and short-segment instrumentation and fusion and chemotherapy in patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis.

References

  1. Dye C, Lonnroth K, Jaramillo E, Williams BG, Raviglione M. Trends in tuberculosis incidence and their determinants in 134 countries. Bull World Health Organ. 2009; 87:683–691. doi:10.2471/BLT.08.058453 [CrossRef]
  2. Rajasekaran S. The problem of deformity in spinal tuberculosis. Clin Orthop Relat Res. 2002; (398):85–92. doi:10.1097/00003086-200205000-00012 [CrossRef]
  3. Klockner C, Valencia R. Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine (Phila Pa 1976). 2003; 28:1036–1042. doi:10.1097/01.BRS.0000061991.11489.7F [CrossRef]
  4. Kotil K, Alan MS, Bilge T. Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study. J Neurosurg Spine. 2007; 6:222–228. doi:10.3171/spi.2007.6.3.222 [CrossRef]
  5. Rajasekaran S, Shanmugasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty D. Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy. Spine (Phila Pa 1976). 1998; 23:1163–1167. doi:10.1097/00007632-199805150-00018 [CrossRef]
  6. Moon MS, Moon YW, Moon JL, Kim SS, Sun DH. Conservative treatment of tuberculosis of the lumbar and lumbosacral spine. Clin Orthop Relat Res. 2002; (398):40–49. doi:10.1097/00003086-200205000-00007 [CrossRef]
  7. Bezer M, Kucukdurmaz F, Aydin N, Kocaoglu B, Guven O. Tuberculous spondylitis of the lumbosacral region: long-term follow-up of patients treated by chemotherapy, transpedicular drainage, posterior instrumentation, and fusion. J Spinal Disord Tech. 2005; 18:425–429. doi:10.1097/01.bsd.0000171627.11171.6f [CrossRef]
  8. Zaveri GR, Mehta SS. Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar interbody fusion (TLIF) and posterior instrumentation. J Spinal Disord Tech. 2009; 22:257–262. doi:10.1097/BSD.0b013e31818859d0 [CrossRef]
  9. Arora S, Kumar R, Batra S, Nath R. Transpedicular drainage of presacral abscess and posterior decompression of acute cauda equina syndrome in caries spine: a case series of 3 patients. J Spinal Disord Tech. 2011; 24:E26–E30. doi:10.1097/BSD.0b013e3181ecf873 [CrossRef]
  10. Rodriguez-Olaverri JC, Zimick NC, Merola A, et al. Comparing the clinical and radiological outcomes of pedicular trans-vertebral screw fixation of the lumbosacral spine in spondylolisthesis versus unilateral transforaminal lumbar interbody fusion (TLIF) with posterior fixation using anterior cages. Spine (Phila Pa 1976). 2008; 33:1977–1981. doi:10.1097/BRS.0b013e31817ecc01 [CrossRef]
  11. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000; 25:2940–2952. doi:10.1097/00007632-200011150-00017 [CrossRef]
  12. Barrey C, Jund J, Perrin G, Roussouly P. Spinopelvic alignment of patients with degenerative spondylolisthesis. Neurosurgery. 2007; 61:981–986. doi:10.1227/01.neu.0000303194.02921.30 [CrossRef]
  13. Murrey DB, Brigham CD, Kiebzak GM, Finger F, Chewning SJ. Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976). 2002; 27:2338–2345. doi:10.1097/00007632-200211010-00006 [CrossRef]
  14. Kawahara N, Tomita K, Baba H, Kobayashi T, Fujita T, Murakami H. Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine (Phila Pa 1976). 2001; 26:391–402. doi:10.1097/00007632-200102150-00016 [CrossRef]
  15. He Q, Xu J. Comparison between the anteroposterior and anterior approaches for treating L5-S1 vertebral tuberculosis. Int Orthop. 2012; 36:345–351. doi:10.1007/s00264-011-1307-6 [CrossRef]
  16. Song JF, Jing ZZ, Chen B, Ai ZS, Hu W. One-stage anterolateral surgical treatment for lumbosacral segment tuberculosis. Int Orthop. 2012; 36:339–344. doi:10.1007/s00264-011-1378-4 [CrossRef]
  17. Bezer M, Kucukdurmaz F, Guven O. Transpedicular decancellation osteotomy in the treatment of posttuberculous kyphosis. J Spinal Disord Tech. 2007; 20:209–215. doi:10.1097/01.bsd.0000211271.89485.f1 [CrossRef]
  18. Kim DJ, Yun YH, Moon SH, Riew KD. Posterior instrumentation using compressive laminar hooks and anterior interbody arthrodesis for the treatment of tuberculosis of the lower lumbar spine. Spine (Phila Pa 1976). 2004; 29:E275–E279. doi:10.1097/01.BRS.0000129027.68574.06 [CrossRef]
  19. Karaeminogullari O, Aydinli U, Ozerdemoglu R, Ozturk C. Tuberculosis of the lumbar spine: outcomes after combined treatment of two-drug therapy and surgery. Orthopedics. 2007; 30:55–59.
  20. Jin D, Qu D, Chen J, Zhang H. One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J. 2004; 13:114–121. doi:10.1007/s00586-003-0661-5 [CrossRef]
  21. Guzey FK, Emel E, Bas NS, et al. Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases. J Neurosurg Spine. 2005; 3:450–458. doi:10.3171/spi.2005.3.6.0450 [CrossRef]
  22. Christodoulou AG, Givissis P, Karataglis D, Symeonidis PD, Pournaras J. Treatment of tuberculous spondylitis with anterior stabilization and titanium cage. Clin Orthop Relat Res. 2006; (444):60–65. doi:10.1097/01.blo.0000201175.87635.28 [CrossRef]

Patient Characteristics and Instrumented Fusion Levels

Patient No./Sex/Age, yLevelMedical HistoryConstitutional SymptomsaLow Back AcheFrankel ClassificationVertebral Body LossbParavertebral AbscessInstrumented Fusion Level
1/M/42L4–L5NoNoYesDL4:6; L5:8YesL2–L3, S1–S2
2/F/44L5-S1L1 fracture with paraplegiaYesYesAL5:9; S1:2YesL3–L4, S1–S2
3/F/50L3–L4Pulmonary tuberculosisYesYesDL3:9; L4:8YesL1–L2, L5, S1
4/F/10L4–L5Patent ductus arteriosusYesYesEL4:6; L5:9YesL2–L3, S1
5/F/24L5NoNoYesDL5:10YesL3–L4, S1
6/F/36L3–L5Pulmonary tuberculosisNoYesCL3:5; L4:10; L5:4YesL1–L2, S1–S2
7/M/28L5-S1NoYesYesEL5:10; S1:1YesL3–L4, S1–S2
8/F/22L4-S1NoYesYesDL4:4; L5:10; S1:8YesL2–L3, S1–S2
9/F/27L4–5Pulmonary tuberculosisNoYesCL4:2; L5:8YesL3–L4, S1–S2
10/M/41L3–L5NoYesYesDL3:2; L4:10; L5:7YesL2–L3, S1–S2
11/F/34L4-S1NoYesYesCL4:2; L5:10; S1:1YesL3–L4, S1–S2
12/M/47L4–L5Digestive tuberculosisYesYesDL4:6; L5:7YesL2–L3, S1–S2
13/F/37L4NoNoYesDL4:9YesL2–L3, L5, S1
14/M/38L3–L4Pulmonary tuberculosisYesYesEL3:1; L4:8YesL2–L3, L5, S1

Clinical Assessmenta

Clinical AssessmentPreoperativeFinal Follow-upP
Low back ache visual analog scale7.43±0.760.50±0.53.000
Oswestry Disability Index, %b81.14±5.6124.57±5.74c.000
Erythrocyte sedimentation rate, mm/h26.45±16.5710.21±4.82c.016
C-reactive protein, mg/L25.83±28.683.18±1.34c.007
Scoliosis Research Society-22 scoresb
  Function and activity1.81±1.23.73±1.47c.001
  Pain2.44±1.794.50±1.76c.017
  Self-image and appearance2.25±2.084.02±1.27c.028
  Mental health3.55±.0.834.36±1.29.143
  Satisfaction with managementNA4.44±1.97NA

Radiologic Assessment

Radiologic AssessmentMean±SD
P
PreoperativePostoperativeFinal Follow-up
Kyphosis angle, deg21.68±9.77−24.16±8.72a−22.67±8.32.000
AP translation, %47.87±29.103.75±5.97a4.80±6.32.000
Local scoliosis, deg10.57±6.612.38±1.30a3.04±1.60.001
Global lumbar lordosis, deg6.16±28.2723.98±14.67a26.13±13.73.046
Pelvic incidence, degb50.32±9.3450.41±8.7350.58±10.49NA
Sacral slope, degb6.58±22.7429.82±8.56a28.96±10.45.003
Pelvic tilt, degb43.76±17.9319.84±7.39a20.68±9.64.000
Sagittal offset, mmc48.24±11.28NA9.74±5.72a.000

10.3928/01477447-20130724-28

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