Anterior Decompression and Fixation with a Reconstruction Plate in Cervical and Cervicodorsal Spinal Tuberculosis: A Study of 39 Cases
Abstract
Objective: To evaluate the efficacy of anterior instrumentation in patients with subaxial and cervicodorsal spinal tuberculosis in reconstruction of the spine, providing pain relief, neurological recovery and prevention of deformity.
Patients and Methods: This is a hospital based reteospective study conducted at Departments of Neurosurgery, Lahore General Hospital and Jinnah Hospital Lahore. Medical records of all the patients operated for subaxial cervical and cervicodorsal (C3-D2) spinal tuberculosis treated by anterior approach during January 2004 to December 2009 were reviewed and analysed. A five drug antituberculous regimen were used for 15-18 months. The follow up ranged from 2 years to 4 years. Clinical and radiological assessment was carried out at intervals.
Results: Between January 2004 and December 2009, 39 patients of subaxial cervical and cervico-dorsal (D1, 2) Spinal tuberculosis has been operated by anterior approach. Three patients with involvement of D 1 and D2 vertebrae had a similar approach without excision of medial end of clavicle or manubrium sterni. The age ranged from 18-55 years with a mean age of 32.5 years. There were 26 male and 13 female patients with a male to female ratio of 2:1. Patients presented with Fever and weight loss 10 patients (25.6%), Pain 36, (92.3%), Dysphagia, 3 (7.6%), Motor deficit, 36 (92.3%), Small muscle wasting in hand, 6, (15.3%), Sensory deficit, 32 (82%), Sphincter involvement, 16 (41%), Cervical deformity, 30 (76.9%), Spasticity, 32 (82%). The mean duration between onset of symptoms and clinical presentation in our series was 9.3 months (range3 to 20 month). Cervical x-rays were carried out immediately post op and then at 3, 6, 12, and 24 months. Pain improved in 32 patients (88.8%). Motor deficit improved in all 36 patients. Degree of improvement was less in patients with severe motor deficit preoperatively. Spasticity improved in 28 patients out of 32 (87.5%).Sensory Deficit slowly improved in all 32 cases. Sphincter involvement improved in all 16 cases. Spinal deformity improved in 26 patients out of 30 (86.6). Small muscle wasting of hands present in 6 patients preoperatively didn’t recover in 2 patients. The results were classified as excellent (Grade 5/5 power on last follow up, no pain or deformity, 28 patients 71.7%), good (motor power Grade 4/5, mild pain, residual wasting but no functional sequale, 8 patients, 20.5%) and fair (persistent disability in 4 patients 7.7%). A satisfactory relief of pain and neurological improve-ment was seen in 36 patients (92.3%).
Conclusions: Anterior reconstruction using titanium reconstruction plates and iliac bone graft for stabilization of the subaxial and cervicodorsal region tuberculosis is a very useful adjunct in improving neurological deficit, relieving pain and preventing kyphotic deformity. A satisfactory segmental stability and fusion is achieved by this technique
References
2. Davidson PT, Horowitz I. Skeletal tuberculosis: Am J Med 1970; 48: 72-84.
3. Fang D, Leong J, Fang H. Tuberculosis of the upper cervical spine. J Bone Joint Surg Br 1983; 65: 47-50.
4. Govender S, Charles R. Tuberculosis of the cervical spine. Neuro Orthopedics 1991; 11: 101-7.
5. Alvarez S, McCab WR: Extrapulmonary tuberculosis revisited: a review of experience at Boston city and other hospitals. Medicine (Baltimore) 1984: 625-55.
6. Levin MF, Vellet AD, Munk PL, et al. tuberculosis of the odontoid bone: a rare but treatable cause of quadri-plegia. Can Assoc Radiol J 1992; 43: 199-202.
7. Slater RR Jr, Beale RW, Bullitt E. Pott’s disease of the cervical spine. South Med J 1991; 84: 521-523.
8. Wurtz R, Quader Z, Simon D, et al. Cervical tubercu-lous vertebral osteomyelitis: case report and discussion of the literature. Clin Infect Dis 1993; 16: 806-808.
9. Hodgson AR, Stock FE: Anterior spinal fusion. A preli-minary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. British J Surg 1956; 44: 266-275.
10. Hodgson AR, Stock FE: Anterior spinal fusion for the treatment of tuberculosis of the spine. J Bone Joint Surg Am 1960; 42: 295-310.
11. Medical Research Council Working Party on tubercu-losis of the spine : A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemo-therapy: a study in Hong Kong. Br J Surg 1974; 61: 853-866.
12. Mehta JS, Bhojraj SY: tuberculosis of the thoracic spine. A classification based on the selection of the sur-gical strategies. J Bone Joint Surg Br 2001; 83: 859-863.
13. Perronne C, Saba J, Behloul Z, Salmon-Ceron D, Leport C, Vild JL, et al. Pyogenic and tubercolous spo-ndylodiskitis (vertebral osteomyelitis) in 80 adult pati-ents. Clin Infect Did 1994; 19: 746-50.
14. Rezai AR, Lee M, Cooper OR, Errico TJ, Koslow M. Modern management of spinal tuberculosis. Neurosur-gery 1995; 36: 87-97.
15. Moskocich R, Benson D, Zhang ZH, Kabins M. Extra-coelomic approach to the spine. J Bone Joint Surg Br 1993; 75: 886-93.
16. Chen WJ, Wu CC, Jung CH, Chen LH, Niu CC, Lai PL. Combined anterior and posterior surgeries in the treatment of spinal tuberculous spondylitis. Clin Orthop 2002; 398: 50-59.
17. Govender S. The outcome of allografts and anterior ins-trumentation in spinal tuberculosis. Clin Orthop 2002; 398: 60-6.
18. Mehta JS, Bhojraj SY: tuberculosis of the thoracic spi-ne. A classification based on the selection of the surgi-cal strategies. J Bone Joint Surg Br 2001; 83: 859-863.
19. Mukhtar AM, Farghaly MM, Ahmed SH. Surgical tre-atment of thoracic and lumbar tuberculosis by anterior interbody fusion and posterior instrumentation. Med Princ Pract 2003; 12: 92-6.
20. Korkusuz F, Islam C, Korkusuz Z. Prevention of post-operative late kyphosis in Pott’ disease by anterior de-compression and intervertebral grafting. World J Surg 1997; 21: 524-8.
21. Ramani PS, SharmaA, Jituri S, Muzumdar DP. Anterior instrumentation for cervical spine tuberculosis: An ana-lysis of surgical experience with 61 cases. Neurology India 2005; 53: 83-89.
22. Maiuri F, Iaconetta G, Gallicchio B, Manto ABriganti F. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine 1997; 22: 1741-6.
23. Colmenero JD, Jimenez-Mejies ME, Sanchez-Lora FJ, Reguera JM, Palomino-Nicas J, Martos F, et al. Pyo-genic, tubercular and brucellar vertebral osteomyelitis: A descriptive and comparative study of 219 cases. An Rheum Dis 1997; 56: 709-15.
24. Cotton A, Flipo RM, Dronot MH, Maury F, Chastanet P, Duquesnoy B, et al. Spinal tuberculosis. Study of cli-nical and radiological aspects from a series of 82 cases. J Radiol 1996; 77: 419-26. French.
25. Leibert E, Schluger NW, Bonk S, Rom Wn. Spinal tub-erculosis in patients with immunodeficiency virus infe-ction. Clinical presentation, therapy and outcome. Tuber Lung Dis1996; 77: 329-34.
26. Nussbaum ES, Rocks GL, Bergman TA, Erickson DL, Seljeskog GL. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg 1995; 83: 243-7.
27. Lin GC, Chon MS, Tsai TC, Lin SY, Shen YS. MR evaluation of tubercolous spondylitis. Acta Radiol 1993; 34: 554-8.
28. Ahmadi J, Ahmadi J, Bajaj A, Destion S et al. Spinal tuberculosis: A typical observation at MR imaging. Radiology 1993; 189: 489-493.(s)
29. Al-Mulhim FA, Ibrahim EM, El-Hassan AY, Mohar-ram HM: Magnetic Resonance Imaging of tuberculous spondylitis. Spine 1995; 20: 2287-2292.(s)
30. Desai SS. Early diagnosis of Spinal tuberculosis by MRI. J Bone Joint Surg Br 1994; 76: 863-9.
31. Arizono T, Oga M, Shiota E, Honda K, Sugioka K, Dif-ferentiation of vertebral osteomylitis and tubercolous spondylitis by magnetic resonance imaging. Int Orthop 1995; 19: 319-22.
32. Kim NH, Lee HM, Suh JS. Magnetic Resonancme Iag-ing for the diagnosis of tubercolous spondylitis. Spine 1994; 19: 2451-5.
33. Lanzzieri C. Magnetic Resonancme Imaging of infec-tions of the spine. In: Haaga JR, Lanzzieri C F, Gilke-son RC, editors. CT and MR imaging of the whole body. 4th ed. St. Louise: Missouri, EUA; 2003: P 809-10.
34. Gupta RK, Agarwal P, Rastagi H, et al. Problems in distinguishing Spinal tuberculosis from neoplasia on MRI. Neyroradiology 1996; 38 [suppl 1]: 97-104.(s)
35. Pattison RR. Pott’s paraplegia: An account of the tre-atment of 89 consecutive patients. Paraplegia 1986; 24: 77-91.(s)
36. Hoffman EB, Grosier JH< Cremin BJ: Imaging in chil-dren with Spinal tuberculosis. A comparison of radio-graphy, computed tomography and magnetic resonance imaging. J Bone Joint Surg Br 1993; 75: 233-239.(s)
37. Al-Mulhim FA, Ibrahim EM, El-Hassan AY, Mohar-ram HM: Magnetic Resonance Imaging of tuberculous spondylitis. Spine 1995; 20: 2287-2292.(s)
38. Ahmadi J, Bajaj A, Destion S et al. Spinal tuberculosis: A typical observation at MR imaging. Radiology 1993; 189: 489-493.(s)
39. Lindahl S, Nyman RS, Brismar J, Hugosson C, Lund-stedt C. Imaging of tuberculosis, spinal manifestations in 63 patients. Acta Radiol 1996; 37: 506-11.
40. Hayes AJ, Chokesy M, Barnes N, Sparrow OC. Spinal tuberculosis in developed countries. Difficulties in dia-gnosis. J R Coll Surg Edin1996; 41: 192-6.
41. Azzam NI, Tammawy M, tuberculous spondylitis in adults. Diagnosis and treatment. Br J Neurosurg 1988; 2: 85-91.
42. Jain R, Sawhney S, Berry M. Computed Tomography of cerebral tuberculosis. Patterns of bone destruction. Clin Radiol 1993; 47: 196-9.
43. Moon MS, Woo YKLee KS, Ha KY, KimSS, Sun DH. Posterior instrumentation and anterior interbody fusion for tubercolous kyphosis of dorsal and lumbar spines. Spine 1995; 20: 1910-6.
44. Guven O, Kumano K, Yalcin S, Karahan M, Tsuji S, A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of Spinal tubercu-losis. Spine 1994; 19: 1039-43.
45. Sundararaj GD, Behera S, Ravi V, Vankatesh K, Che-rian VM, Lee V. Role of posterior stabilization in themanagement of tuberculosis of dorsal and lumbar spine. J Bone Joint Surg Br 2003; 85: 100-6. 46. Fuster S, Sala P, Prat S, Carles MJ, Colomer J, Susu s. Spinal tuberculosis : early surgical treatment combined with medical treatment. Med Clin (Bare) 2001; 117: 457-9. (Spanish language). 47. Jain AK. Treatment of tuberculosis of the spine with neurological complications. Clin Orthop 2002; 398: 75-85.
48. Rajasekaran S. The problem of deformity in spinal tuberculosis. Clin Orthop and Related Research 2002; 398: 85-92.
49. Sundaresan N, Shah J, Foley KM, Rosen G. An anterior surgical approach to upper thoracic vertebrae. J Neuro-surg 1984; 61: 686-90.
50. Sar C, HamzaogluA, Talu U, Domanic U. An anterior approach to the cervicothoracic junction of the spine (modified osteomy of the manubrium sterni and clavi-cle). J Spinal Disord1999; 12: 102-6.
51. Chatterjee S, Basu S. Trans-sternal decompression de-compression of postlaminectomy caries of the upper dorsal spine. Br J Neurosurg 2003; 17: 270-1.
52. Hsu LC, Leong JC. Tuberculosis of the lower cervical spine (C2- C7). A report on 40 cases. J Bone Joint Surg Br 1984; 66: 1-5.
53. Lifeso RM, Weaver P, Harder EH, tuberculous spon-dylitis in adults. J Bone Joint Surg Am 1985; 67: 1405-13.
54. Loembe PM, Mwanyombet-Ompounga L, Assengone-Zeh Y, Kengue-Lechiombeka PR. Early anterolateral surgery for the tuberculosis of the lower cervical spine with neurological complications in adults. Our expe-rience in Gabon. Neurocherurgie 2000; 46: 541-8. (French).
55. Yilmaz C, Selek HY, Gurkan I, Erdemli B, Korkusuz Z. Anterion instrumentation for the treatment of spinal tuberculosis. J Bone Joint Surg Am 1999; 81: 1261-7.
56. Dharmalingam M. Tuberculosis of the spine-the Sabah experience, Epidemiology, treatment and results. Tube-rculosis (Edin) 2004; 84: 24-8.
57. Hassan MG. Anterior plating for lower cervical spine tuberculosis. Int Orthop 2003; 27: 73-7.
58. Li L, Cui SQ, Wang H. Clinical application of anterior cervical locking plate systems and analysis of compli-cations as well as their countermeasures. Zhonngguo Xiu Fu Chong Jian Wai Ke Za Zhi 2004; 18: 28-30. (Chinese).
59. Oga M, Arizono T, Takasita M, Sugioka Y. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine 1993; 18: 1890-4.
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