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PubMed2003

Pott's paraplegia in patients with severely deformed dorsal or dorsolumbar spines: treatment and prognosis.

STUDY DESIGN: Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. OBJECTIVES: To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. SETTING: Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. METHOD: In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2-29 years), and remained neurologically symptom free from an average of 16 years (range, 4-27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). RESULTS: In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. CONCLUSION: The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.

Adolescent↗
PubMed1997

Neural arch tuberculosis: radiological features and their correlation with surgical findings.

Radiological features of 17 cases of neural arch tuberculosis (NAT), treated surgically by the authors, are reviewed and correlated with the operative and histopathological findings. The diagnostic accuracy of different imaging modalities in the evaluation of this rare, atypical form of spinal tuberculosis was found to be very low. Thus, the initial diagnosis was in error in 15 out of 17 of our cases. Recognition of the radiological diagnostic features of NAT is important, not only because they may mimic primary or metastatic spinal neoplasms, but also because of the surgical implications. Computed tomography (CT) and magnetic resonance imaging (MRI) features correlated most closely with the surgical findings, whereas plain spinal radiographs and myelograms were found to be non-specific and non-diagnostic.

Adolescent↗
PubMedDate not supplied

A surgical revisitation of Pott distemper of the spine.

BACKGROUND CONTEXT: Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis. PURPOSE: To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted. STUDY DESIGN: A concise review of the diagnosis, management and surgical treatment of Pott disease. METHODS: A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability. RESULTS: Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity. CONCLUSIONS: Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.

Antitubercular Agents↗
PubMed1991

[Tuberculosis of the spine in the elderly and its surgical treatment].

Among the contingents with newly diagnosed spinal tuberculosis are mainly subjects aged over 50 years who have many concurrent diseases, basically associated with age, late diagnosis and advanced destructive process attended by cerebrospinal disturbances in 67.5% of cases. The characteristic features and high incidence of complications of the disease course in this category of patients call for early and complete surgical treatment. The results of treatment demonstrate a satisfactory tolerance to spinal operations by elderly patients and their high effectiveness in timely application.

Aged↗
PubMed2000

Video-assisted thoracoscopic surgery in managing tuberculous spondylitis.

The literature includes no studies on the use of video-assisted thoracoscopic surgery in the management of tuberculous spondylitis, and its role in the management of tuberculosis involving the thoracic spine remains unclear. The authors experience with 10 consecutive patients (six women, four men) who underwent video-assisted thoracoscopic surgery for the treatment of spinal tuberculosis involving levels from T5 to T11, from January 1996 to December 1997, was analyzed. Using the extended manipulating channel method (2.5-3.5 cm portal incisions), video-assisted thoracoscopic surgery was performed with a three-portal technique (seven patients) or a modified two-portal minithoracotomy technique that required a small incision for the thoracoscope and a larger incision, measuring 5 to 6 cm, for the procedures in three patients. All the patients were studied prospectively. The followup ranged from 17 to 42 months (mean, 24 months). Postoperative complications included one lung atelectasis. Pleural adhesions, owing to local inflammation or paravertebral abscess, were seen in four patients and one patient with severe pleurodesis needed an open technique for treatment. Postoperative air leaks were seen in four (40%) of 10 patients but all were transient. The average neurologic recovery was 1.1 grades on the Frankel's scale. The data from this series of patients with tuberculous spondylitis show that video-assisted thoracoscopic surgery has diagnostic and therapeutic roles in the management of tuberculous spondylitis. Technically, a combination of thoracoscopy and conventional spinal instruments to perform video-assisted thoracoscopic surgery through the extended manipulating channels, which were placed slightly more posterior than usual, was effective and safe.

Adult↗
PubMed1986

Bone tuberculosis: results and experience in Leicestershire.

Management of tuberculosis falls to the thoracic physician and includes extrapulmonary sites. We have conducted a survey of notification of bone tuberculosis in Leicestershire from 1978 to 1983 inclusive. Eighty-one cases were notified, 75 were traced and 69 confirmed tuberculosis (mean age 40.2 years, 39 male, 54 from the Indian sub-continent (ISC)). Mean length of symptoms was 8.4 months, the commonest being pain and swelling. The diagnosis was established by evidence of bone involvement plus at least one of the following: positive Heaf test (54/56), positive culture at bone sites for Mycobacterium tuberculosis (45/47), or suggestive histology (30/34). There were no resistant organisms. Chemotherapy (mean duration 16.2 months) was well tolerated. Spine was the site most often involved (37 patients, 34 ISC), with abscess formation common (17 patients). Four who presented with spinal cord compression received a mean of 8 months' bed rest, three required decompression and one died. No patient developed new neurological signs on treatment. Fourteen others received an average of 2.3 months' bed rest. In this predominantly ISC immigrant population, spinal tuberculosis is common but does not progress to cord compression on treatment. For those without cord compression the course and outcome were similar whether or not they were treated with bed rest.

Adolescent↗
PubMed2000

The results of anterior radical debridement and anterior instrumentation in Pott's disease and comparison with other surgical techniques.

Classic procedure in the treatment of vertebral tuberculosis is drainage of the abscess, curettage of the devitalized vertebra and application of antituberculous chemotherapy regimen. Posterior instrumentation results are encouraging in the prevention or treatment of late kyphosis; however, a second stage operation is needed. Recently, posterolateral or transpedicular drainage without anterior drainage or posterior instrumentation following anterior drainage in the same session is preferred to avoid kyphotic deformity. Seventy-six patients with spinal tuberculosis were operated in the 1st Department of Orthopaedics and Traumatology, Ankara Social Security Hospital, between January 1987 and January 1997. There were four children in our series. Average follow-up period was 36.1 +/- 14.5 months and the average age at the time of operation was 40.8 +/- 15.2 years. This study reports the surgical results of 45 patients with Pott's disease who had anterior radical debridement with anterior fusion and anterior instrumentation [14 patients with Z-plate and 31 patients with Cotrel-Dubousset-Hopf (CDH system)]. The results are compared with those of 8 patients who had posterolateral drainage and posterior fusion, 12 patients who had only anterior drainage and anterior strut grafting and, 11 patients who had posterior instrumentation following anterior radical debridement in the same session in terms of fusion rates, correction of kyphotic deformity, recurrence rate and clinical results. All patients had one year consecutive triple drug therapy. Preoperative 23.2 degrees +/- 12.5 degrees local kyphosis angle was lowered to 6.1 degrees +/- 6.9 degrees with a correction rate of 77.4 +/- 22.3%. When the other three groups which had been instrumented were compared, the correction rates in the local kyphosis angle values were not statistically different and the variation in loss of correction at the last follow-up was also statistically insignificant. The sagittal contour of the involved vertebra's region did not change in the uninstrumented group, while it did so in instrumented groups which had normal range values postoperatively. Overall, 27 patients had neurologic deficits preoperatively. Twenty of these (74.1%) had complete, and 5 (18.5%) had partial recovery with a combined 92.6% neurologic improvement. All the patients had a solid fusion mass at the last controls. Reactivation was not seen. Additionally, contrary to the common belief, anterior instrumentation which anterior autologous strut grafting following anterior radical debridement can be a good treatment option with low complication rate, high correction rate in acute local kyphosis, and high fusion rate.

Adolescent↗
PubMed2005

[One-stage radical eradication and wedged vertebral osteotomy through a purely posterior procedure in treating thoracic and lumbar spine tuberculosis associated with kyphosis or scoliokyphosis demormity].

OBJECTIVE: To investigate the feasibility, clinical indications and significance of one-stage radical eradication, wedged vertebral osteotomy and instrumentation in the treatment of tuberculosis of thoracic and lumbar spine associated with kyphosis or scoliokyphosis through a purely posterior procedure. METHODS: Sixteen cases with tuberculosis of thoracic and lumbar spine associated with kyphosis or scoliokyphosis were treated by one-stage radical eradication, wedged vertebral osteotomy and instrumentation fixation through posterior procedure. All patients included 12 males and 4 females, and the average age was 37.1 years (from 17 to 53 years). The preoperative average Cobb angle of kyphosis was 78.3 degrees (range from 54 degrees to 138 degrees ). There were 2 cases associated with scoliosis (the Cobb angle of scoliosis was 31 degrees and 24 degrees), and 1 case with lateral transition. Spinal cord compression were found in 7 cases. According to the Frankel's classification, 2 cases belonged to C degree, and 5 cases to D degree. There were 2 cases with caudal equina or nerve root lesions. RESULTS: The average blood loss during the operation was 1100 ml (range from 450 to 2200 ml), and the average operation time was 265 min (range from 215 to 325 min). The postoperative results were satisfactory, 14 cases were excellent and 2 cases were good. Obvious improvement was obtained in 9 cases with neurological dysfunction. The postoperative average Cobb' angle was 28.5 degrees (range from 0 degrees to 67 degrees), and the corrective rate was 63.6%. The followed-up was ranged from 14 to 52 months with an average of 26.3 months. There were no major complications related to the fixations, loss of correction and the fusion were achieved in all patients. CONCLUSIONS: One-stage radical eradication, wedged vertebral osteotomy and instrumentation is a feasible and an effective procedure in the treatment of spinal tuberculosis associated with kyphosis or scoliokyphosis. Compared with combined anterior and posterior procedure, the surgical technique may decrease injuries and has better result.

Adolescent↗
PubMed1996

Orthopaedic surgery and HIV disease in Africa.

Human immunodeficiency virus (HIV) infection has radically changed African orthopaedic practice within a decade. In Lusaka, a third of adults are infected, but most have no physical signs of the disease. Early experience showed that closed fractures healed normally, the risk of sepsis during osteosynthesis was increased and most open fractures became septic. Major orthopaedic surgery in HIV-positive patients has increased risks of sepsis which rise steeply in those with physical signs of HIV disease. Musculoskeletal infections such as tropical pyomyositis, adult haematogenous long-bone osteomyelitis, and late haematogenous infection of implants, appear as immune competence wanes. There is a dual epidemic of tuberculosis and HIV, and bone and joint tuberculosis is now common. Atypical features suggest that traditional diagnostic criteria for spinal tuberculosis may be inadequate. Rheumatoid diseases, especially reactive arthritis, are common and serious complications of HIV disease. The risk of transmission of HIV between patient and surgeon is small, especially if recommended precautions are universally applied.

Africa↗
PubMed1996

Kyphoscoliosis complicating pregnancy.

OBJECTIVE: To assess whether the outcome of pregnancies complicated by kyphoscoliosis has improved with modern obstetric and orthopedic care. METHODS: A total of 17 patients with 27 pregnancies complicated by kyphoscoliosis were identified from 91,498 pregnancies between 1980 and 1994 from the obstetric audit database. Their obstetric records and associated orthopedic records were carefully studied. RESULTS: The incidence of kyphoscoliosis complicating pregnancy in the study period was 0.029%. The mean age of these patients in their index pregnancy was 32.7 years (range 23-40), mean height 140.7 cm (range 126-163). The cause of the kyphoscoliosis included traumatic injury, spinal tuberculosis, infantile poliomyelitis and idiopathic kyphoscoliosis. Eight of the patients had previous spinal surgery. The vaginal delivery rate was high and none suffered any cardiorespiratory embarrassment. There was no maternal or perinatal mortality. CONCLUSIONS: The high maternal and perinatal risks associated with kyphoscoliosis reported in earlier literature is no longer valid. The high proportion of patients who had previous spinal surgery before pregnancy might be conducive to the avoidance of harassment and thus a favorable pregnancy outcome.

Adult↗
PubMed2006

[Elastic materials in surgery for inflammatory diseases of the vertebral column].

When 17 patients were surgically treated for spinal tuberculosis and osteomyelitis, anterior spine fusion was performed by A. Ye. Garbuz's procedure that was based on the replacement of a spinal defect by a carbon-carbonic implant that had rifampicin containers in the frontal sections, as well as by autologous bone grafts. The carbon-carbonic implants reliably fix an operated spinal portion, prevent the progression of kyphotic deformity, and create good conditions for autologous bone grafts to knit. An osteocarbonic block forms in the late postoperative period.

Adult↗
PubMed2003

[Tuberculosis of respiratory organs concomitant with tuberculosis of bones and joints in young children].

Specific features of thoracic tuberculosis were studied in children with various forms of tuberculosis of bones and joints, i.e. tuberculous spondylitis, arthritis and osteitis. Peculiarities of the clinical course and of complications of thoracic tuberculosis were detected in children with the mentioned clinical forms, which are mostly pronounced in spinal tuberculosis and tuberculosis of joints. A complicated course of thoracic process predetermines the duration of treatment and affects the choice of time for surgical intervention.

Child↗
PubMed2001

[Rare localizations of bone tuberculosis. Three case reports].

Bone and joint involvement is observed in 3 to 5 p. 100 of all cases of tuberculosis and in 15 p. 100 of extrapulmonary tuberculosis. Spinal and weight-bearing joints are most frequently involved. We report three cases of bone tuberculosis with rare localizations that raised difficult diagnostic problems. Our patients had tuberculosis of the sternum, the iliac bone and in the third case, the spine but solely in the posterior arch of the fourth cervical vertebra. X-ray evidenced bone lysis and invasion of adjacent tissues. The cold abscesses were evacuated surgically allowing bacteriological and histological diagnosis. The patients were successfully treated with anti-tuberculosis regimens. An infectious etiology should be considered in patients with bone lesions in order to obtain the samples necessary for positive diagnosis.

Adult↗
PubMed2006

Spectrum of spine infections in patients with HIV: a case report and review of the literature.

UNLABELLED: Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy. LEVEL OF EVIDENCE: Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

HIV Infections↗
PubMed2002

Spinal brace in tuberculosis of spine.

OBJECTIVE: To present our experience in the management of 22 patients with thoracolumbar spine tuberculosis (TB) using a chemotherapy regimen and locally custom-made spinal brace. METHODS: Twenty-two patients with thoracolumbar spine TB had been treated conservatively by chemotherapy and locally custom-made spinal brace and followed for 36-48 months from June 1996 to June 2000 in the Department of Orthopedics and Trauma, Algamhoria Teaching Hospital, Aden, Republic of Yemen. In 14 cases, 2 vertebrae were involved, whereas in 8 cases involvement was only of one vertebra. All had persistent back pain: 2 had neurological deficit, Frankel grade A and B (9%), and 12 (54%) had gibbus deformity. RESULTS: At the end of the observation period, all patients had no pain (based on the adjective rating scale). Fourteen thoracic and 3 psoas abscesses resolved by 18 months. Four cases (18%) had deterioration of the angle of kyphosis. Five cases (22.5%) had progressive vertebral loss. Twelve cases (84%) had bony fusion at 36 months. CONCLUSION: Chemotherapy regimen and locally custom-made spinal brace is not costly, needs neither admission nor surgical intervention that demands skills and experience and can be recommended for uncomplicated thoracolumbar spinal TB.

Adolescent↗
PubMed2005

Neurological complications of human immunodeficiency virus infection in Zimbabwe-2005.

Zimbabwe is a high prevalence area for HIV infection, and provides opportunities for studying complications of AIDS in both antiretroviral naive and treated groups of patients. Figures for HIV prevalence are among the highest in the world, but the number of people receiving treatment is very small. Economic and political factors contribute to this important health crisis. Opportunistic diseases as a whole and their relative frequencies of presentation in southern Africa are discussed, emphasizing the lead role of tuberculosis. The limited data that do exist regarding neurological complications in Zimbabwe are summarized, and combined with anecdotal experience from practicing clinicians. Opportunistic infections in the nervous system are very common, the most important being cryptococcal meningitis, causing half of all adult meningitis in the country. Tuberculous and bacterial meningitis have also become more common and carry a high mortality in HIV-infected people in Zimbabwe. Intracranial mass lesions, including tuberculoma, bacterial abscesses and toxoplasmosis encephalitis are less common and difficult to diagnose in the absence of stereotactic biopsy. Spinal tuberculosis and transverse myelitis are the most frequent causes of spinal cord opportunistic infections. Peripheral neuropathy is probably similar in presentation to that seen elsewhere, whereas dementia is less frequently recognized.

AIDS-Related Opportunistic Infections↗