Clinical study of radiological outcome and improvement in neurological status after surgical treatment of tuberculosis of spine

 

Aamir Hussain Chowdhary¹, Subham Surmal^2*, Farid Hussain Malik³, Shazia Bashir⁴

 

Abstract              Background: Osteoarticular tuberculosis accounts for 11% of EPTB, spondylitis or Pott disease, represents 50% of all cases. Early operative intervention for tuberculous spine with the goals of early decompression and protection of neural elements, correction and maintenance of deformity and early pain free mobilization. In present study, we aimed to study radiological outcome and improvement in neurological status after surgical treatment of tuberculosis of spine. Material and Methods: Present study was hospital based, prospective, observational study, conducted in patients 21-70 years age, either gender, had clinical and radiographic evidence of tuberculosis of any vertebral body from C1 to S1, with evidence of activity of the disease clinically and or radiographically, underwent surgical treatment for tuberculosis of spine. Results: In present study most common age group was 31-40 years (34 %) followed by 21-30 years (32 %). There was almost equal distribution in males and females (male 56 and female 44%). The level of lesion most commonly affected was lower thoracic including thoracolumbar junction (70%). The mean preoperative ESR value was 114.9 and mean postoperative value was 20.26. Preoperative mean kyphotic deformity was 26.36 percent and postoperative after correction mean kyphotic deformity was 7.72 as calculated by cobbs angle in postoperative X-ray‘s. Neurological function preoperative, postoperative and on subsequent follow up was graded according to Frankel et al., grading. Preoperatively 9 patients were classified under grade B, 40 patients graded under grade C and 1 patient under grade D. Postoperatively 35 patients improves to grade E , 13 patients to grade D, 1 patient under grade C, and 1 patients remains unchanged to grade B. Conclusion: Operative intervention in Pott’s spine is associated with improved radiological outcome, improvement in neurological status, correction of deformity.

Keywords: Operative intervention, Pott’s spine, radiological outcome, neurological status.

 

INTRODUCTION

Tuberculosis is ubiquitous in distribution. Tuberculosis mostly affects adults. However, all age groups are at risk. Over 95% of cases and deaths are in developing countries. The risk factors of tuberculosis are HIV, undernutrition, alcohol use and tobacco smoking. The most frequently affected extra pulmonary organs are the liver, the spleen, the lymph nodes, the meninges, the bone marrow and the adrenal glands. Osteoarticular tuberculosis accounts for 11% of EPTB forms according to published series.¹ Although it can affect any bone, spondylitis or Pott disease, represents 50% of all cases. ² Spinal tuberculosis can lead to neurological complications with incidence about 10 -43%.³ With the advent of chemotherapy drugs medical treatment remains the mainstay treatment, but in order to deal with residual disease chemotherapy alone is insufficient and thus the role of surgical intervention is required in to eradicate the foci for better delivering of drugs, neurological decompression, radical debridement, deformity correction and stabilization to prevent further neurological trauma.⁴ Jacob R,⁵ suggested the early operative intervention for tuberculous spine with the goals of early decompression and protection of neural elements, correction and maintenance of deformity and early pain free mobilization. In present study, we aimed to study radiological outcome and improvement in neurological status after surgical treatment of tuberculosis of spine.

              

MATERIAL AND METHODS

Present study was hospital based, prospective, observational study, conducted in department of orthopedic surgery, at GMC, Jammu. Study was approved by institutional ethical committee. Fifty patients of spinal tuberculosis were taken for study from March 2019 to December 2020.

Inclusion criteria

• Patients 21-70 years age, either gender, had clinical and radiographic evidence of tuberculosis of any vertebral body from C1 to S1, with evidence of activity of the disease clinically and or radiographically, willing to participate in study and for follow up.

Exclusion criteria

• Total destruction equivalent to six or more vertebral bodies.
• Tuberculosis of the spine associated with tuberculoma brain/ meningitis / tuberculous arthritis of other joints.
• Serious non- tuberculous disease likely to prejudice the response to treatment or its assessment.
• Any contra- indication to any of the methods of treatment under comparison.

Study was explained in local language and a written informed consent was taken for participation in study. Detailed history, clinical examination findings were noted in case record for. For all the patients included in study standard AP and Lateral radiogram and MRI spine, routine blood investigations, ESR, CRP, Mantoux test, sputum for AFB needs to be performed pre operatively. All patients are to be given appropriate bed rest, analgesics, bowel bladder care, and 4 drugs anti-tubercular treatment according to appropriate regime for 3 weeks before surgery except those with progressive neural deficit and kyphotic deformity greater than 40 degree requiring urgent decompression patients shall be followed up at 3, 6 and 12 months. Postoperatively standard chemotherapy consisting of isoniazid (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg), and pyrazinamide (25 mg/kg) was administered for 3 months after the operations. Subsequently, a regimen of rifampicin, isoniazid, and ethambutol was continued for at least 9 months. All patients were X‐rayed, and the erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) levels, hepatic functions, and other parameters were examined at regular follow up the patients were mobilized as early as possible with crutches and spinal braces. At each follow-up evaluation, plain radiographic studies were obtained in standing position to determine the fusion status, development or progression of deformity after surgery and instrumentation failure. Patients will be evaluated for radiological parameters like improvement in local kyphosis. Data was collected and compiled using Microsoft Excel and statistical analysis was done using descriptive statistics.

DISCUSSION

Spinal tuberculosis generally starts in vertebral bodies and intervertebral discs and is so called as spondylodiscitis. The common site of lesion is paradiscal followed by central thus causing anterior column destruction and resulting into kyphotic deformity.⁶ Other less commonly types include anterior, appendical and synovial. Approximately 40% of the cases of tuberculosis of the spine with paraplegia show recovery with antituberculosis treatment, rest, and/or traction. The treatment of tuberculosis of spine consists of conservative methods or surgical management. Conservative method comprises Bed rest with or without Plaster casts, Chemotherapy, Supervision with Imaging and blood markers every 3 months followed by resumption of activity with braces. However, with proper indications, surgical procedures are superior in the prevention of neurological deterioration, maintenance of stability, prevention of deformity, early recovery and early mobilization.^7,8,9The goals of surgery in Tuberculosis of spine are adequate decompression, adequate debridement, maintenance and reinforcement of stability and correction and to stop the progression of kyphosis.¹⁰ The mean ESR noted in our study was 114.9 preoperatively. Erythrocyte sedimentation rate (ESR) is a sensitive marker of infection and can be used to monitor therapeutic response, but its low specificity is a concern. Usually in TB, ESR is >20 mm/h and decreases as healing progresses. Wang et al.,¹¹ noted that mean ESR of the patients at the initial hospitalization was 96.4 ± 20.8 mm/h. Similar findings were noted in present study. The mean kyphosis as calculated by cobbs angle was 26.36 preoperative and after corrective surgery mean kyphosis was 7.72. In a study conducted by Xu Cui et al.,¹² the kyphotic deformities were corrected from 32.1° ± 10.3° to 10.2° ± 2.1° in the anterior group and from 33.8° ± 11.7° to 12.6° ± 2.7° in the posterior group. The mean preoperative kyphosis was 27.2° (50-16) and mean postoperative kyphosis was 9.0° (20-0) in a study conducted by Saurabh Singh et al.,¹³There is marked correction in deformity by operative measures which leads to reversal of neurological complication, better cosmetic appearance and helps in preventing complications like sinus formation, bed sores DVT.In presents study, 80 % patients falls in grade C, 18 % in grade B and 2 % in grade D preoperatively and post operatively there is significant improvement in neurological status and by the end of one year follow up 70 % patients improves to grade E, 26 % to grade D, 2 % patient to grade C and 2 % patient remains in grade B. In a study by Xu Cui et al.,¹² the neurologic statuses of the 23 patients with preoperative neurologic deficits improved in each group. Thus, there is excellent improvement in neurological status of patients who gets operative treatment in Pott’s spine.

Among the various types of decompression, Anterior approach is considered the gold standard for debridement and decompression in Pott‘s spine. Anterior radical surgery was popularized by Hodgson and Stock¹⁴. Advantages of the traditional anterior approach are ability to directly access the disease and perform decompression, better correction of deformity, less muscle dissection and the ability to place a graft. The disadvantages of anterior approach are morbidity and mortality associated with the transpleural and retroperitoneal approach like atelectasis, chest infection, pneumothorax and postoperative ileus, increase in spinal instability after surgical decompression in the immediate postoperative period. The rib grafts are readily available after thoracotomy but they are structurally weak and does not contain cancellous bone.¹⁵ The stability of anterior instrumentation may not provide adequate fixation as there is concomitant inflammation associated with infection and the anterior bones are hyperemic and porotic. Implant holding is a problem and there might be risk of graft subsidence and graft slippage. Posterior instrumentation with anterior decompression and fusion can be performed in one or two stages.¹⁶ This surgery is more radical but recurrence rate is low. The posterior approach on the other hand has a special advantage in that the instrumentation avoids contact with the infectious focus, helps in correcting pre-existing kyphosis effectively and it can provide good fixation through posterior elements as the disease pathology is anterior. Considerable number of patients recovers following conservative medical treatment when they start treatment early. But as most of the patients present late with significant neurological complication and kyphotic deformity medical management at that stage isn‘t of much value in treatment.

 

CONCLUSION

Operative intervention in Pott’s spine is associated with improved radiological outcome, improvement in neurological status, correction of deformity is also achieved in desired manner and overall complication of Pott’s spine will be minimized.

 

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