Outline of Treatment of Spinal Tuberculosis

 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 


Please give your comments.  What can be improved. Your suggestions will benefit other colleagues. 

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