Neurological Improvement after Decompression for Dorsal Spine Tuberculosis (TB)

Objectives: To assess the neurological improvement after decompression for dorsal spine tuberculosis in terms of Frankel grading. Materials and Method: Prospective study was done in the Neurosurgery department, Prime Teaching Hospital Peshawar from 2018 to 2021. Patients of both genders aged between 18 to 60 years were selected while those unfit for surgery or requiring conservative management were excluded from the study. After clinical examination and radiological findings, the patients were diagnosed with dorsal spine tuberculosis requiring surgery. All patients were followed for 3 months post-operatively. Neurological improvement was measured by comparing pre and post-op Frankel grading. Complications were also documented. Results: Out of 38 patients included in the study, 16 (42%) were male and 22 (58%) were female. The mean age of presentation was 34 ± 5. The distribution for age groups was 18 – 30 (08), 31 – 40 (13), 41 – 50 (11), and 51 – 60 (06). Level of disease D4 – D8 were 17 (44.8%) and D9 – D12 was 21 (55.2%). Pre-operative neurological status of the patients was (5.2%) Frankel A, (10.5%) Frankel B, (47.3) Frankel C, (22%) Frankel D, and (7.8%) Frankel E while Post-operative grading was (2.6%) Frankel A, (5.2%) Frankel B, (23.6%) Frankel C, (47.3%) Frankel D and (18.4) Frankel E. 3 patients experienced worsening of neurology, 2 patients bleeding and CSF leak and 1 patient died as a complication of the surgery. Conclusion: Surgical option involving decompression of spine TB followed by stabilization is utilized in a majority of patients with neurological deficits. It is very effective and the results are good. The main advantage is thorough debridement and achievement of spinal stabilization.


INTRODUCTION
Worldwide 10 million people were infected with tuberculosis with the second number in South East Asia prevalence. 1 It is primarily a disease of the lungs, but extra pulmonary involvement is not uncommon. The most common second type of extra-pulmonary tuberculosis is spine tuberculosis. 2 The most common site of involvement in the thoracolumbar spine followed by lumber and then the cervical spine. 3 Spinal TB presents a variety of symptoms, but its nature is always insidious in onset, and its progress at a slow pace. 4 The manifestation depends on the severity, duration, site, and complications (abscess, sinuses, deformity, and neurological deficit) caused by the disease. The neurological deficit can occur in both the early disease process and also in the late healed stage. In the active stage, it is direct compression of the spinal cord by abscess, sequestrum, inflammatory tissue, or the spinal column instability which results in neurological compromise. In the healed stage, it is the stretching of the spinal cord over the gibbus or rarely ossification of the ligamentum flavum proximal to the kyphosis which causes the neurological compromise. 5 Tuberculosis and human beings have a symbiotic relationship and with advancements in medical sciences, the goal of treatment has changed. In the pre-era of antibiotics, they were treated with a high protein diet, rest, and fresh air hoping for natural quiescence of disease. 6 Historically the treatment for spine tuberculosis was conservative such as body cast and a good nutrition diet while later W.H.O was under the agenda to provide better treatment presented with anti-tuberculosis therapy which changed the lives of affected patients. 7 The thoracic spine is the most affected region; MRI has changed the era by providing better-advanced diagnosis which has helped the treatment with conservative management, surgery, and Anti-tuberculosis therapy. [8][9][10] The purpose of this study is to focus on the results of spinal decompression in patients with spine TB. Not all patients are candidates for anti-TB drugs and surgery becomes the mainstay of management in those patients.

Study Design and Setting
This prospective study was conducted after approval from the ethical committee from June 2018 to June 2021 at the department of neurosurgery, Prime teaching hospital Peshawar.

Sampling
Patients who were clinically and radiologically (through MRI dorsal spine) diagnosed with spine tuberculosis were enrolled in the study through consecutive non-probability sampling.

Inclusion Criteria
Inclusive criteria for patients were aged from 18 -60 years of either gender. Patients who were having deteriorating neurology, Para spinal abscess/cord compression, and refractory to conservative therapy were included in the study.

Exclusion Criteria
Patients which were not fit for surgery, improved with conservative management, and were not willing for study/surgery were excluded.

Clinical Management
The main procedure followed was decompression ± fusion through lateral thoracotomy and patients were followed for at least three months post-operatively. Results were analyzed through SPSS-VER 26.0.

Age and Gender Distribution
A total of 38 patients were enrolled in this study that underwent a surgical procedure. Total percentages which were obtained from the study for males were 42% (16) and 58% (22) for females. The mean age of presentation was 34 ± 5.

Clinical Information
The main procedure followed was decompression ± fusion through the lateral thoracotomy approach. There was a neurological improvement in 35 patients while 3 patients experienced worsening neurological symptoms. 2 patients were complicated by excessive intraoperative bleeding and postoperative CSF leak which were managed successfully. 1 patient expired as a result of a complication of the surgical procedure.

DISCUSSION
Spinal tuberculosis is considered a medical condition till the patient has a neurological deficit and surgery is required for decompression despite ongoing anti-tuberculosis therapy. [11][12] There are no straightforward guidelines for the diagnosis and treatment of spinal tuberculosis. 13 Studies show that anti-tuberculosis therapy and conservative treatment have shown successful medical results in patients without surgery. [14][15] Certain conditions necessitate surgical options over medical treatment alone. These are lack of improvement or recurrence following medical treatment, severe weakness in the lower limbs at presentation, and static structural or functional instability in the form of incapacitating pain or deformity. 16 Early diagnosis and treatment are necessary to prevent permanent neurological disability and minimize spinal deformity. 17 In our study, there were 38 patients in which 42% (16) were male and 58% (22) female with a mean age of 34 years, which was compared to the previous study. [18][19] Neurological complications seen in our study were three patients which is less than in another study. 20 Studies have shown results of neurological improvement in Frankle grading following surgery which is similar to our result. [21][22] As can be seen from the results of our study, post-operatively highest number of patients falls into Frankle D (17/38) and Frankle E (10/38) which is the neurological grade of a healthy individual as for motor in the limbs is concerned. Complications are part of surgery and the ratio of our study was compared to another study which was more than our result. 23

CONCLUSION
Anti-TB drugs have revolutionized the treatment of tuberculosis and remain the 1 st choice of management. However, in complicated cases, especially with patients having neurological deficits due to spinal TB, surgery is a useful alternative. Surgery remains the preferred mode of treatment, especially for complicated spine tuberculosis. Functional outcomes are affected by pain and spinal cord compression.