Transthoracic Evacuation and Anterior Spinal Fusion in Pott s Paraplegia

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1 THE ANNALS OF THORACIC SURGERY Journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association VOLUME 4 NUMBER 4 OCTOBER 1967 Transthoracic Evacuation and Anterior Spinal Fusion in Pott s Paraplegia W. A. Cook, M.D.,# R. R. Shaw, M.D., W. R. Webb, M.D., W. K. Clark, M.D., and H. H. Shah, M.B., B.S. T hrown from his horse en route to Lock Hospital in January, 1756, Dr. Percival Pott suffered a compound fracture of the leg. A prolonged convalescence marked the beginning of his medical writing [3]. One article, entitled Remarks on That Kind of Palsy of the Lower Limbs Which Is Associated With a Curvature of the Spine, is the classic description of the paraplegia secondary to the tuberculous spinal disease which bears his name [151. It is likely that man and Mycobacterium tuberculosis have been associated for several million years, and the antiquity of gibbus and paraplegia is documentably 6,000 years old [14]. The deformity has been notable throughout history; foul, bunch-backed Richard I11 of England is still remembered for his appearance rather than his ability to rule [ 181. To this historical mistrust of cripples is added the modern stigma of tuberculosis with its psychological impact of lost health, work, and freedom. From the Division of Thoracic and Cardiovascular Surgery and the Division of Neurosurgery, The University of Texas Southwestern Medical School, Dallas, Tex. Aided by Grant No. HE from the National Institutes of Health, U.S. Public Health Service. Accepted for publication June 2, *Present address: Department of Surgery, Albert Einstein College of Medicine, Fastchester Road and Morris Park Avenue, Bronx, N.Y Reprint requests to Dr. Webb. VOL. 4, NO. 4, OCT.,

COOK, SHAW, WEBB, CLARK, AND SHAH Streptomycin, para-aminosalicylic acid, and isoniazid have reduced the bed allocation for orthopedic tuberculosis from 250 to 75 and the deaths from 20 to 8 a year

2 COOK, SHAW, WEBB, CLARK, AND SHAH Streptomycin, para-aminosalicylic acid, and isoniazid have reduced the bed allocation for orthopedic tuberculosis from 250 to 75 and the deaths from 20 to 8 a year at Seaview Hospital, N.Y., but worldwide the disease is still a crippling killer [16]. This is reflected by a survey of the world literature on Pott s paraplegia for 1964, showing 25 articles in the Russian, 14 in the French, 10 in the British, but none in the American literature. Even in the United States the emergence of atypical and drug-resistant tuberculosis prevents complacency. One of the authors (R. R. S.), faced with the treatment of Pott s paraplegia in Afghanistan, utilized Hodgson and Stock s transthoracic approach to drain the abscess, evacuate the destroyed bone, and graft the bony spine [l 11. His Afghanistan experience was attended by success, and upon return to the United States additional cases were undertaken by this approach. The satisfying results of our first 6 cases and a desire to emphasize this surgical approach prompt this report. CLINICAL MATERIAL We have treated 6 patients with Pott s paraplegia by transthoracic evacuation and anterior fusion. One patient with a 20-year-old calcified tuberculous empyema had concomitant decortication. The patients ranged in age from 11 to 54 years. Three were males, and 3 were females. There were 2 American Negroes, 1 American Caucasian, 1 Afghan, and 2 Nicaraguan nationals. All had x-ray evidence of vertebral body involvement and unequivocal neurological deficit, the duration of which ranged from 24 hours to 1 year. All patients had positive skin tests for typical tuberculosis and x-ray evidence of pulmonary involvement, and all were treated throughout their course with streptomycin, para-aminosalicylic acid, and isoniazid. OPERA TIVE METHOD All patients were operated upon as emergencies as soon as diagnosed to prevent the progress of their gibbus and paraplegia. The chest was opened on the side of presentation of the Pott s abscess through the bed of the rib lying adjacent to the involved vertebra (Fig. 1). This rib was resected from the costochondral junction to the articulation with the transverse process and set aside for future use. For additional support the head of the rib was preserved unless it was badly diseased or was obstructing decompression of the cord. The pleura overlying the abscess was incised through a T-shaped incision, with one limb running parallel to the vertebral column and the other along the bed of the resected rib. The lung and mediastinal structures were retracted, and, if necessary, an intercostal artery above and below the lesion was di- 292 THE ANNALS OF THORAClC SURGERY

3 Pott s Paraplegia FIG. 1. Operative approach. The rib is resected to the area of abscess and destroyed bone. FIG. 2. Operative field. The pleura is incised and the lung and aorta retracted. Following debridement of destroyed bone and abscess, the patient is hyperextended with the aid of a Cloward separator, as shown. The spine is now ready for grafting. vided to facilitate retraction of the aorta (Fig. 2). All purulent material was evacuated from the abscess cavity, and all destroyed bony elements and intervertebral discs were resected. The resection extended to grossly normal vertebral bone above and below the lesion and posteriorly to the spinal ligament. The pedicles were preserved when not destroyed by the tuberculous process. VOL. 4, NO. 4, OCT.,

4 COOK, SHAW, WEBB, CLARK, AND SHAH FIG. 3. Completed repair. Three rib struts, one placed on each side and one anteriorly, form a compartment for bone chips, correct the spinal angulation, and encourage early bone fusion. The patient was then hyperextended on the operating table, in 2 cases with the aid of a Cloward spreader. The distance between the normal vertebral bodies was measured and the previously resected rib cut into three struts of that length. The first strut was inserted on the far side of the intervertebral space and the second anteriorly, forming a compartment between the vertebral bodies (Fig. 3). The excess rib was cut into small chips and inserted into this compartment. The final strut was then inserted on the near side of the intervertebral space and the mediastinal structures and pleura allowed to fall back into position, thereby forming a pocket for the grafts. The pleura over the abscess was left open, the pleural space drained with two large tubes, and the chest closed with absorbable sutures. Postoperatively the patients were nursed supine on a regular hospital bed for periods ranging from 12 to 16 weeks; then they were allowed gradually progressive activity and ambulation with a back brace. Intensive physical therapy was given throughout. RESULTS Case 1. A 25-year-old Afghan man with collapse of T8 and 9 had been paraplegic for 1 year. Eight months following operation he was ambulatory with the aid of a cane. Case 2. A 53-year-old white woman with a 20-year history of tuberculous empyema had rapid onset of paraplegia with collapse of T6 and 7 (Fig. 4). She was treated nonsurgically at another institution for 41 days without improvement. When -transferred to our care her trapped lung was decorticated, drainage of the abscess was carried out, and strut grafts were inserted. She was ambulatory in 15 weeks and able to garden that summer. Case 3. An 11-year-old Nicaraguan boy with involvement of T4 through 9 had been paraplegic for one month. Treatment was drainage and anterior 294 THE ANNALS OF THORACIC SURGERY

A 29-year-old Nicaraguan man with collapse of T8 and 9 had a rapid onset of paraplegia 2 to 3 days prior to surgery.

5 Pott s Paraplegia FIG. 4. Case 2. Chest x-ray shows chronic calcific tuberculous empyema and bulging Pott s abscess. strut grafting; he began to move his legs on the afternoon of surgery and went on to complete recovery. Case 4. A 29-year-old Nicaraguan man with collapse of T8 and 9 had a rapid onset of paraplegia 2 to 3 days prior to surgery. Following the transthoracic operation the patient was rapidly regaining normal motor function, but he was lost to follow-up by departure of the surgeon (R. R. S.) from S.S. Hope. Case 5. A 46-year-old Negro woman became paraplegic from collapse of T7 24 hours prior to surgery (Fig. 5). All of her neurological deficit disappeared FIG. 5. Case 5. The chest laminagram shows the extent of the Pott s abscess and the collapsed vertebral body. VOL. 4, NO. 4, OCT.,

6 COOK, SHAW, WEBB, CLARK, AND SHAH within 12 hours of operation, and she was ambulatory four months after surgery. Case 6. A 54-year-old Negro woman with a 10- to 15-year history of pulmonary tuberculosis was paralyzed by collapse of T9. She was admitted to another hospital and 48 hours later had a posterior laminectomy of T9, 10, and 11. Three weeks following this she had no symptomatic improvement and was transferred to the Woodlawn Chest Disease Hospital. On the following day, 25 days from the onset of paraplegia, the patient had transthoracic evacuation of her Pott s abscess and anterior strut grafting. This patient is the only one in the group who failed to improve neurologically following this procedure. Her initial postoperative course was otherwise satisfactory, and after three months she was transferred to the Chronic Disease Unit where she initially did well. A month and a half later she died of renal and adrenal insufficiency and drug intoxication. At autopsy the patient was found to have complete bony fusion of the vertebral bodies. The spinal cord showed marked degeneration at the level of the lesion, but there was no residual mechanical compression. DZS C USSI 0 N Tuberculosis of the spine most often affects the thoracic vertebrae. The spinal canal in the thoracic region has a relatively small diameter; therefore lesions in this region have a high incidence of complicating paraplegia. After destruction of the thoracic vertebral body resultant forces squeeze the destroyed bony and cartilaginous products toward the cord (Fig. 6). The anterior spinal ligament loosely confines the abscess, aggravating this pressure. Anterior pressure on the cord compresses the anterior spinal artery, producing ischemia at the level of compression. This may progress to spinal artery thrombosis and cord infarction. Septic thrombosis of the spinal arteries may also occur with permanent destruction of the cord. FZG. 6. Pathological process. The left-hand figure shows the angulation and stretching of the cord, the posterior thrust of destroyed bone and cartilage, and the compression of the anterior spinal artery. The center and right-hand figures show correction of the lesion and grafting. 296 THE ANNALS OF THORACIC SURGERY

7 Pott s Paraplegia Back pain and clonus are the most prominent early signs of Pott s paraplegia. Early recognition of these signs and prompt treatment is important, since the prognosis improves if the paraplegia is not allowed to progress to a stage of flexion or flaccid paralysis. Based on a 61.3% recovery rate in 75 late cases of Pott s paraplegia, Bosworth et al. felt that 80% of patients treated early could recover after adequate surgical fusion alone and that bony union was essential for permanent recovery [4]. Streptomycin was used in their series when it became available, but it did not alter the course of the paraplegia or the need for surgical fusion. We felt that a progressive paraplegia represents a surgical emergency which is best handled by thorough anterior decompression therapy. However, a triple drug program should be instituted, if not already in effect, and it should be guided by sensitivity cultures if possible and continued for at least two years. The various surgical procedures used for this disease are: 1. Posterior Spinal Fusion. This fails to decompress the abscess and therefore inadequately treats the cord lesion. 2. Costotransversectomy. The advantages are drainage of the abscess cavity with reduction of pressure on the cord and toxicity and minimal loss of strength in the bony spine [13]. However, total evacuation of anterior destroyed bony elements is difficult if not impossible through a posterior approach. 3. Anterolateral Decompression. This procedure, otherwise known as lateral rhachotomy, was originated in 1933 by Capener [61. The rib leading to the lesion is resected from its angle to the transverse process. The rib, transverse process and vertebral pedicle are removed to allow entry into the abscess. This has been extended to three or more ribs by other authors [I]. This procedure shares with costotransversectomy the difficulty of a posterior approach to anterior destroyed bone, which forces the surgeon to work around the spinal cord. It also contributes to the instability of the spine by destruction of the vertebral pedicle. 4. Laminectomy. We feel this procedure should be mentioned only to be condemned. It fails to relieve angulation and accomplishes only posterior decompression while the pressure on the cord is anterior. Therefore, it is not likely to improve the neurological condition. In addition, it may lead to prolongation and even permanence of paraplegia, as was the case in our only patient with a permanent neurological deficit. The spine has three general areas of longitudinal support: the column of vertebral bodies, the pedicles, and the spinous processes and lamina with their interconnecting ligaments and muscles. The lesion itself has already destroyed the anterior vertebral bodies, and laminectomy destroys the posterior area of support. Thus, the spine is further weakened without draining the abscess, decompressing the cord, or relieving angulation. In the series of Bosworth et al., 10 of 14 patients admitted with paraplegia and a previous laminectomy died, and the 4 who lived had a subsequent anterior fusion [4]. Prior to the antibiotic era, tuberculous bone involvement was frequently treated surgically. Swett et al. in 1940 reported 350 cases of Pott s disease followed 5 to 25 years with an overall bony fusion rate of 35% [22]. Posterior grafting did not improve the average result, since persistence of the abscess was associated with only 19% bony fusion. However, evacuation of the abscess raised the fusion rate to 59%.

COOK, SHAW, WEBB, CLARK, AND SHAH Since drugs have been available, the basic method of treatment for Pott s disease has generally been bed rest and triple drug therapy.

8 COOK, SHAW, WEBB, CLARK, AND SHAH Since drugs have been available, the basic method of treatment for Pott s disease has generally been bed rest and triple drug therapy. A number of authors report increased fusion and decreased mortality and relapse rates with drug therapy, but most advocate surgical intervention for paraplegia and other complications [7-10, 203. The American Thoracic Society s Committee on Therapy suggests avoiding arthrodesis and operative spinal fusion if possible but recommends emergency decompression if paraplegia develops [2]. Stevenson and Manning reported 72 patients with tuberculous spinal involvement followed 7 to 12 years with conservative treatment and chemotherapy [2 11. The average period of conservative management was 1 year, and the average length of chemotherapy was four and one-half months, which is much too short by current standards. Fifty-seven percent had bony fusion, 37.5% had fibrous union, and 7% relapsed. Falk reported 235 cases of spinal tuberculosis with 80% 5-year follow-up [9]. There were complicating abscesses in 109 (46%); 9 (3.8%) had paraplegia. All patients received at least two drugs for a year or more. Surgical fusion was done in 149 (63%); 51 (22%) had drainage of an abscess. Among the 9 paraplegics, 5 recovered with chemotherapy alone, 2 recovered with chemotherapy and drainage, and 2 were not helped by either treatment. At last assessment 77% of the entire group were working or able to work, and there had been no relapses due to spinal tuberculosis. Hodgson and his co-workers reported 100 cases of Pott s disease treated by transthoracic evacuation of the abscess and anterior bone grafting with rib struts and followed for 2 to 4 years [12]. This group showed a bony fusion rate of 93% and 1 relapse. The relapse was reexplored, and a residual abscess was drained and regrafting carried out with sound healing. Thirty-five patients were paraplegic, and of these, 74% made a complete recovery. An additional 17% made a partial neurological recovery. The authors also emphasize early decompression and grafting to prevent progression of paraplegia and gibbus, and, especially in young patients, the spread of bone involvement. This report of Hodgson et al. [12], along with that of Wilkinson in 1950 [23], has stimulated a renewed interest in surgical intervention. Since 1960 several groups of investigators employing some form of anterior decompression and bone grafting have reported cure rates for paraplegia up to loo%, with marked reduction of hospital stay and early return to ambulation [5, 17, 191. In our present series, all treated by transthoracic decompression and rib-strut grafting, all patients obtained solid bony fusion. Five regained their neurological loss. One neurological failure occurred, and that patient s definitive treatment was delayed and complicated 298 THE ANNALS OF THORACIC SURGERY

9 Pott s Paraplegia by previous laminectomy. This aggressive surgical approach to Pott s paraplegia drains the tuberculous focus, decompresses the spinal cord and its anterior artery, corrects the vertebral deformity, and hastens bony fusion, ambulation, and hospital discharge. SUMMARY Six cases of Pott s paraplegia are reported which were treated by transthoracic evacuation of the abscess and destroyed bone and insertion of rib-strut grafts in the bony defect to correct angulation and hasten bony fusion. Five of these cases are ambulatory, and there was a significant reduction in hospital stay. The sixth patient had delay of definitive treatment due to an unsuccessful laminectomy at another hospital. She failed to improve neurologically after anterior decompression and grafting and died of other causes four months postoperatively. Autopsy showed solid bony fusion with no residual mechanical compression of the spinal cord. An old transverse infarction of the cord was present. A review of surgical and medical results is presented indicating that antibiotics have made early surgical decompression of the cord and bone grafting safe and effective and that paraplegia is an indication for early use of this approach. REFERENCES 1. Alexander, G. L. Neurological complications of spinal tuberculosis. Proc. Roy. SOC. Med. 39:730, American Thoracic Societv. Subcommittee on Surgerv and Committee on Therapy. The present stitus of skeletal tuberculosk. Amer. Rev. Resp. Dis. 88:272, Beckman, F. British surgery in the 18th century. Ann. Med. His. (n.s.) 9:549, Bosworth, B. N., Della Pietra, A., and Rahilly, G. Paraplegia resulting from tuberculosis of the spine. J. Bone Joint Surg. (Amer.) 35:735, Cameron, J. A. P., Robinson, C. L. N., and Robertson, D. E. The radical treatment of Pott s disease and Pott s paraplegia by extirpation of the diseased area and anterior spinal fusion. Amer. Rev. Resp. Dis. 86:76, Capener, N. The evolution of lateral rhachotomy. J. Bone Joint Surg. (Brit.) 36:137, Chapman, P. T., Tibbits, R. S., Birkelo, C. C., and Baer, G. Skeletal tuberculosis: A retrospective study. Trans. 14th Conf. Chemother. Tuberc. 14: 111, Chofnas, I., Surrett, N. E., and Severn, H. D. Pott s disease treated without spinal fusion. Amer. Rev. Resp. Dis. 90:888, Falk, A. Results of long term chemotherapy in spinal tuberculosis. Amer. Rev. Resp. Dis. 95:1, Friedman, B. The treatment of tuberculosis of the spine in adults without surgical spine fusion. Amer. Rev. Resp. Dis. 81:940, Hodgson, A. R., and Stock, F. E. Anterior spine fusion for the treatment of tuberculosis of the spine. J. Bone Joint Surg. (Amer.) 42:295, VOL. 4, NO. 4, OCT.,

10 COOK, SHAW, WEBB, CLARK, AND SHAH 12. Hodgson, A. R., Stock, F. E., Fang, H. S. Y., and Ong, G. B. Anterior spinal fusion: The operative approach and pathological findings in 412 patients with Pott s disease of the spine. Brit. J. Surg. 48:172, Mercer, W. Orthopedic Surgery (4th ed.). Baltimore: Williams & Wilkins, Morse, D., Brothwell, D. R., and IJcko, P. J. Tuberculosis in ancient Egypt. Amer. Rev. Resp. Dis. 90:524, Pott, P. The Ciururgical Works of P. Pott. Printed for Lowndes, Johnson, Robinson, Cadell, Evans, Fox, and Hayes. London, Rheumatism and arthritis. Ann. Intern. Med. 56 (Suppl. 1):6, Risko, T., and Novoszel, T. Experience with radical operations in tuberculosis of the spine. J. Bone Joint Surg. (Amer.) 45:53, Shakespeare, W. The Tragedy of King Richard the Third. In H. Craig (Ed.), The Complete Works of Shakespeare. Chicago: Scott, Foresman, Act 4, Scene 4, Line Shaw, N. E., and Thomas, T. G. Surgical treatment of chronic infective lesions of the spine. Brit. Med. J. 1:162, Stevenson, F. H. The chemotherapy of orthopaedic tuberculosis. J. Bons Joint Surg. (Brit.) 36:5, Stevenson, F. H., and Manning, C. W. Tuberculosis of the spine treated conservatively with chemotherapy. Tubercle 43:406, Swett, P. P., Bennett, G. E., and Street, D. M. Pott s disease: The initiai lesion, the relative infrequency of extension by contiguity, the nature and type of healing, the role of the abscess, and the merits of operative and nonoperative treatment. J. Bone Joint Surg. 22:878, Wilkinson, M. C. Currettage of tuberculous vertebral disease in the treatment of spinal caries. Proc. Roy. SOC. Med. 43: 114, THE ANNALS OF THORACIC SURGERY

Preliminary Study of Tuberculosis of the Spine

Original Articles Preliminary Study of Tuberculosis of the Spine Robert C. Lifeso, MD, FRCS(C)* * Orthopedic Surgeon, Department of Surgery, King Faisal Specialist Hospital and Research Centre ABSTRACT