Long Posterior Fixation with Short Fusion for the Treatment of TB Spondylitis of the Thoracic and Lumbar Spine with or without Neurologic Deficit

Long Posterior Fixation with Short Fusion for the Treatment of TB Spondylitis of the Thoracic and Lumbar Spine with or without Neurologic Deficit Shih-Tien Wang MD, Chien-Lin Liu MD 王世典劉建麟 School of Medicine, National Yang Ming University, Taipei, Taiwan Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan 台北榮民總醫院骨科部脊椎外科

Introduction Treatment of TB spine: Conservative treatment with antituberculous chemotherapy with or without external immobilization: good to excellent clinical outcome in most of the patients although significant residual kyphosis. Surgical treatment is indicated: marked neurologic deficits J Bone Joint Surg [Br] 1998;80-B:456-62 large abscesses in whom respiratory obstruction has developed worsen neurologic deficits despite adequate chemotherapy continuing progression of kyphosis or instability despite adequate chemotherapy J Bone Joint Surg [Am] 1996; 78-A: 288-298

Surgical treatment for TB spine Anterior procedure only: Anterior radical debridement with reconstruction of the vertebral column: Hong-Kong procedure Anterior debridement with autogenous bone graft with our without instrumentation Combined anterior and posterior procedures with instrumentation posteriorly Posterior procedure only: Posterior instrumentation with transpedicle debridement with or without anterior bone graft and posterior fixation with instrumentation Posterior only procedure with posterior instrumentation and fusion with or without debridement of the abscess and infected tissue

Materials and methods A retrospective study From January, 2001 through November, 2010 51 patients: M : F = 31 : 20; T : L= 37 : 14 Age: 62.5 10.7 year-old (range, 39 to 86 year-old) Mean duration of symptoms and signs: 9.2 months(1-36 months) Surgery: Long posterior instrumentation and fusion with pedicle screws and hooks Posterior decompression if epidural abscess compress dura or spinal cord noted on MRI No anterior debridement of the infected tissue Posterior fusion or posterolateral fusion

Comorbidities Disease No. of patients Diabetes 12 Pulmonary TB 14 Diabetes and pulmonary TB 4 Pulmonary TB and TB meningitis 1 Hepatitis with cirrhosis of liver 1 Total 32

Materials and methods Pre-operative workups Plain x-ray MRI Biopsy CT guided biopsy Open biopsy Post-op management: Anti-TB chemotherapy: 12 months Bracing: 3-6 months. Ambulation: 3-4 days after operation Outcome measurements Kyphotic angle Improvement of kyphotic angle Loss of kyphotic angle Neurologic status: Frankel grading Follow-up: at least 24 months.

Results No. of patients 51 Follow-up time (months) (range) 68.8±31.9 (30 to 144) Mean preoperative kyphotic angle ( )(range) 26.1±20.5 (-18 to 62) Mean postoperative kyphotic angle ( )(range) 15.2±18.2 (-25 to 51) Mean final kyphotic angle ( )(range) 16.9±18.3 (-22 to 54) Mean loss correction angle ( )(range) 1.6±2.1 (0 to 10) Mean improved angle after operation ( )(range) 10.8±6.9 (0 to 26) Mean corrected angle ( )(range) 10.7±7.0 (0-26) Operative time (min)(range) 252.8±57(150 to 370) Estimated blood loss (ml)(range) 705±317(200 to 1500) TB proved by CT guided biopsy 14(27%) TB proved by open biopsy 37(73%) Positive rate for TB Culture or smear 8 (16%) Complications 4 Screw back out 3 Drug induced hepatitis 1

Neurologic status

A 44 y/o male, TB spine at T6-7-8 with cord compression, Frankel B with BU incontinence. Post-op 3 yr.: Frankel E, no BU incontinence Pre-op Post-op Final FU MRI Pre-op Final FU

Discussion Anterior strut graft + posterior instrumentation, one stage or two stage Good result but One day surgery long operative time Technique demanding Two stage another risk of anesthesia and operation Patient s general condition Higher complication rate of anterior approach (22%, Korjususz, Word J Surg,1997) Higher cost & longer hospitalization Posterior instrumentation only Simplicity and Shorter op time and less blood loss Low complication rate Do not influence infection control Good correction & few correction angle lost Immediate relief of pain & early mobilization Güven O, et al (Spine. 1994, Turkey)

Conclusions Posterior instrumentation only without anterior debridement of infected tissue: Good clinical outcome Rigid fixation & no loss reduction (Multiple hook fixation) Instrumentation do not interfere infection control Anterior procedure can be reserved if failure of posterior procedure

Thank you! 謝謝! None of the authors has any potential conflict of interest.