Tuberculosis
In general , Rest and Nutrition
Chemotherapy
Surgery if needed .
Dorsal Spine - Approach to surgery
A bit ambiguous
Many prefer to do Anterior Transpleural. Some choose Anterolateral/posterolateral extrapleural and posterolateral approaches
Posterolateral Approach(Martin 1970)
Dura exposed by Hemilaminectomy first and then operation extended laterally to remove posterior ends of 2 to 4 ribs, corresponding transverse process and pedicles.
He thinks Anterolateral approach a very risky one.
Approach to Atlanto-occipital and Atlanto-axial joint
Numerous structures on the way anteriorly
Supine position, Neck on 5-10 degrees hyperextension ,Trachesostomy done
Transoral Anterior Approach
Uvula, Soft palate bissected , Hypopharynx packed, 5 cm long incision given, Flaps raised .
Apply stay sutures
Then anterior arch of Atlas body of axis and atlanto-axial joints exposed.
Anterior approach to C-spine
Dorsal spine - Transpleural anterior approach (Transthoracic / Trans-sternal )
Extra-pleural Anterolateral (Costo-transversectomy )
Lumbar Spine - Retroperitoneal (Renal angle, Rectus Abdominis)
Posterior
Transperitoneal (Linea Alba , peritoneum, bowel)
Posterior Approach muscles encountered
Errector Spine - Superiorly - Latissimus Dorsi
Deeply - Superiorly - Sacrospinalis,
deeply - multifidus and rotators.
Dorsal Spine choice of approach - According to Mehta and Bhojraj
Group A - Paradiscal and Central Involvement
Transpleural debridement with fusion (no instrumentation )
if Arthrodesis also required, then use transpleural approach instead of costotranseversectomy.
Group B - Group A + Deformity
Treatment like A + Instrumentation
Group C - To ill to undergo transpleural surgery
transpedicular decompression and posterior instrumentation
Group D - Posterior involvement only
posterior decompression only
Literature Review on Choice of surgery
Infact tuberculosis is a medical disease and improves with chemotherapy. However there are some indications for surgery
Failure of antituberculosis therapy
Progressive deficit despite treatment
Severe weakness
Instability
Severe pain
Deformity
Additional advantages of surgery
Provides tissue for diagnosis
Removal of infected focus
Shortening of chemotherapy
Early recovery,
Reduced recurrence
Basis of surgery
Adequate debridement/decompression
Maintenance of stability
Correction of deformity
Anterior approaches
Benefits
Access to anterior cord
Possibility of radical
debridement
Preserves the only intact bony
structure left
Risks
Steep learning curve
Pulmonary complications
Iatrogenic neurovascular injury
Result in progression of
deformity
Anterior bony insufficiency
may need additional grafting
Posterior approaches
Benefits
Easy to learn
Avoids anesthesia and pulmonary complications
Three-column fixation
Safer deformity correction
Risks
May take away the only intact
bony structure
Radical debridement may not
be possible in some cases
Recent studies advocating posterior only approaches
Zheng et al
Posterior approach better for lumbosacral
TB, especially with regards to Cobb angle at
last follow-up
Zhou et a
No difference in outcome when compared
for thoracic and thoracolumbar spinal TB.
However, surgery time and blood loss less
for posterior approaches.
Zhao et al
Microbiological outcome study showing
equal effectiveness of debridement by anterior versus posterior approaches
Muheremu et al
Meta-analysis: No significant differences
except correction of Cobb angle, which is
better in posterior approach
Liu et al
Meta-analysis: Posterior approach had same
results when compared with combined
approach but with less surgical time and
complications
Yang et al
Meta-analysis: Posterior approach had
better clinical outcome than anterior or
combined approaches
Combined Approach
useful in failed anterior surgeries and in cases of
severe destruction and deformities
Minimally Invasive Procedures
All of the posterior approaches can be made into minimally
invasive ones if only a small area needs to be exposed
Specific Circumstances
Cold Abscess
drainage is not performed nowadays even for large cold abscesses. However, if complications
such as dysphagia or respiratory distress arise, the same may
need to be drained.
Surgical drainage is only indicated when percutaneous technique fails.
Role of Debridement
Debridement alone does not improve healing or halt the progression of kyphosis.
Debridement has to be combined with
fusion or instrumentation
shift from debridement alone
to fixation with or without debridement is perhaps due to
the success of ATT
Deformity Correction
Many of the patients treated conservatively end up with a
deformity greater than 60 degrees, which can cause serious
cardiorespiratory medical complications,
“at risk signs” to identify children who are at
risk of developing severe deformity, a type which is termed
“buckling collapse
Compression of spinal cord, leading to paraplegia years after
onset of disease
The rate
of progression depends upon number of vertebrae involvement, amount of height loss, and part of the spine involved
Patients with posterior involvement along with vertebral
body loss may require fixation to prevent progression of
deformity early. There are formulas described to predict the
final deformity
Anterior approaches
Cervical 1. Transoral
2. Retropharyngeal
3. Southwick/Robinson
Occiput-C3
Occiput-C3
C2-T1
Cervicothoracic 1. Low anterior cervical
2. High transthoracic
3. Transsternal
C1-T1
C6-T4
T3/T4
Thoracic 1. Transthoracic
2 VATS
T2-L2
Thoracolumbar 1. Retroperitoneal
L1-L5
Lumbosacral junction 1. Transperitoneal
L5-S1
Posterior approaches 1. Transpedicular
2. Transfacet
3. Transforaminal
T2-S1
Both limited debridement ±
Instrumented fusion
4. Costotransversectomy
Debridement only
https://www.sciencedirect.com/science/article/abs/pii/S1878875019328803
References
Surgical Approaches in Management of Spinal
Tuberculosis. Vishal Kumar et. al
Tuberculosis of Skeletal System by Prof SM Tuli
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