SPINAL

TUBERCULOSIS
TREATMENT WITH POSTERIOR

WITH
ANTERIOR OSTEOTOMIES

NEUROLOGICAL
VASCULARISED AND FUSION RIB GRAFTS,

DEFICIT

J. A. LOUW

From

Kalafong

Hospital

and

the University

ofPretoria,

Republic

ofSouth

Africa

Nineteen patients with thoracic or thoracolumbar spinal tuberculosis and neurological deficits were treated by anterior debridement, decompression and vascularised rib grafting, followed, either during the same procedure or 14 days later, by multilevel posterior osteotomies, instrumentation and fusion. Surgery was performed under cover of four-drug antituberculosis chemotherapy, given for 12 months. The average preoperative kyphotic angulation of 56#{176} was reduced to 27#{176} postoperatively and 30#{176} at the latest follow-up (3#{176} loss of correction). Radiological fusion between the vascularised rib graft and the vertebrae was seen after an average of 3.3 months. Eighteen patients (95%) had normal neurological function at 14 months, and the other could walk with the aid of crutches.

Spinal
many

tuberculosis of the human

has deformed, race for the not

paralysed past 7000 nor deformity

and

killed

years.

Anti-

tuberculous chemotherapy in the 1950s, but could arrest Research niques increase The the associated Council seem to be in kyphosis. radical grafting 1976). equally

revolutionised improve spinal reported

its treatment satisfactorily (Medical techan surgical

where 90% of patients achieved bony fusion after 60 months (Medical Research Council 1982). However, there was only a small difference between the out-patient chemotherapy group in Rhodesia (71% fusion after 36 months) and the radical surgery group in South Africa (81% fusion after 36 months) (Medical Research Council 1978a, b). with spinal treatment by at 36 and (Medical procedure, in Recovery from paraparesis in patients tuberculosis also seems to be similar whichever is used. In South Africa, radical surgery had complete months Rhodesia Research compared on Council surgical

kyphotic Many

ineffective treatment antibiotic of kyphosis

in preventing pioneered cover)was in their

surgical

in Hong

Kong
genous to give allowed

(anterior
bone

debridement,
under

decompression

and
series,

autobut

reported series of nervous

69% of patients treated neurological recovery of patients in Korea only Kalafong chemotherapy the

a 1#{176} correction

with
l978b).

73%

patients

21#{176} deterioration in a South African with spinal tuberculosis and central

ambulatory approach,

system involvement (Medical Research Council l978b, 1982). Even in Hong Kong, Jenkins et al (1975) reported a 46.4% increase in kyphosis from admission to 10-year follow-up in children managed by anterior decompression

A new

and fusion.
long though Bony been fusion of the tuberculous regarded as the surest focus in the spine has evidence of healing,

healing
alone

positive proof has never been presented. Sound is known to be slow : out-patient chemotherapy resulted in bony fusion in only 46% of patients after in Korea operation (Medical Research gave better results Council in Hong 1976). Kong,

60 months The radical

J. A. Louw,

PhD,

MMed

(Orth),
Hospital,

MBChB,
Private

Associate
Bag X396,

Professor
Pretoria 0001,

of

Orthopaedic Surgery Clinical Building, Kalafong Republic ofSouth Africa.

Fig.

1

© 1990 British
0301-620X/90/41 J Bone Joint Surg

Editorial

Society
72-B

of Bone and Joint
:686-93.

Surgery

12 $2.00 [Br] 1990;

A rib graft
vertebrae. graft.

with
Soft

its vascular
tissue has been

pedicle,
cleared

ready
for

for insertion
1 cm from each

between
end

the
of the

686

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

soon are shaped so that they can glide over and thus allow shortening to take place. either same anaesthetic (combined one-stage proce14 days later. release Owen and and a specimens had been collected for microscopy and culture. tomography. The author does not for the individual techniques. surgery sputum was performed. Hyperextension views the deformity. over vertebral levels. four-drug chemotherapy with rifampin. of the anterior strut graft acts shortening of There 1 . is (complete grade patients (range B (sensory sparing C (motor sparing. or parts destroyed by tuberculosis. The AND was METHODS spinal from that abscess into. and pyrazinamide was started. and the posterior elements posterior before as spinal urine. Sanderson under the dure)or spinal 1975 . and fusion. Rib graft sion spinal selection. Destruction vertebral bodies. a pressure sore over the greater trochanter and flexion were treated contractures of both hips and and knees. Bradford 1980). All four drugs were given as single oral doses once every 24 hours for a period of 12 months. related to tuberculosis paraplegia in four patients : three had associated pulmonary tuberculosis and one had two complications of paraplegia. average and was as the that total had number been of vertebrae. This is followed.2 three patient months had an (case function For the the anterior technique pedicle a thoracotomy to mobilise is done a rib of Bradford had been paralysed for an average 2 weeks to 36 months). At all the levels where spontaneous fusion each had 72-B. which give some indication of the extent of bone and soft tissue involvement. which aspirate column is limited by impaction of the inferior facets on a ridge below the superior facets. to the lower enddistal vertebra. the other or incomplete history. as shown on lateral tomographs. the spinous process. and radiographs. Only one deterioration ofneurological on its vascular for the bone graft and (Fig. Sixteen of6. As well as plain to prevent the patient from with the aid of crutches. A meticulous anterior and lateral release of all adhesions is therefore done before correction of the kyphosis is attempted. with an average 56). ethambutol. stomach other As VOL. Using rongeurs. There radiographs vertebral at more tech- bone scans to exclude of the entire involvement column than one and soft tissues are exposed throughout dura is exposed and decompressed both laterally. The anteriorly and at the apex of were non-contiguous Kyphosis was measured the first uninvolved proximal plate ofthe first uninvolved no false negative scans lesions were detected. so a rib criteria there was histological and that neurological confirmation involvement of spinal tuberculosis was severe enough articulates with the can be used as the transverse process of either of bone graft. This they intercostal are PATIENTS A prospective tuberculosis 1984 to 1988. The rib to be used as the pedicled for be where bone active incised is selected before and debridement tuberculosis. surgery. of was of The spine. pulling it posteriorly into the apex of the curve and preventing anterior displacement and expansion of the dura and spinal cord.9 vertebrae (range were complications as a pivot. anaesthesia arterial pressure.SPINAL TUBERCULOSIS WITH NEUROLOGICAL DEFICIT 687 is proposed to improve the results of surgical treatment of spinal tuberculosis. JULY 1990 . compression. until pus and normal debris bleeding in bone cancellous and soft bone necessitating and lateral an emergency and Anteroposterior netium-99m were obtained level. mean (1980) according grade grade A generation used using to give cephalosporin. Adhesions are frequently found the field. by posterior multilevel osteotomies. blood and densely adherent supply to the ribs lateral interrupted. Since anterior is always performed the abscess wall must vessels decompres- instrumentation claim originality proposes a new but rather longitudinally necessitates to division reach of the the affected vertebrae. 2) had had a sudden prior to admission. column the This does not alter or the torso. combination of methods. rib osteotomy pedicle and/or bone soft graft tissue (Rose. even There were five males and 14 age of 25. prophylactic Operation antibiotic ofthe is performed using under a first- cover. from the upper and no second end-plate of vertebra. because In the normal the length the anterior thoracic spine. All pathological detissue are removed tissue. The posterior procedure is performed 10 to 14 days after the anterior by operation shortening and the reduction posterior ofthe column kyphosis of the is achieved the deformity was rigid in all the patients. over the the to such study presenting The made of 19 patients with at the Kalafong Hospital for entry to the study were an incision is therefore also vessels that cross anteriorly The intercostal first uninvolved upper which these and lower vertebrae are not disturbed. anchoring the dura. to. females. a 25% reduction Hypotensive procedure. The inaccurate anterior debridement and by the technique described decompression by Hodgson are performed Stock (1956). 1). incorporated wall. recorded vertebrae.2 years (range 2 to 12 years of age or younger was patients deficit). with decompression It consists of anterior of the spinal cord debridement (Hodgson and Stock vascular 1956). on and admission : three sensory classified were seven et al (1969) Operative additional technique. No. Seven patients were walking independently. but no motor but functionally function) and nine useless). computed tomography or magnetic resonance imaging are essential to establish without doubt the first normal proximal and distal vertebrae beyond the tuberculous process. All bone and soft tissue which may prevent reduction of the kyphosis is also removed or divided. On admission a mean of three confirmed that this averaged 56#{176} (range 12#{176} to 85#{176}). 1 to 4). parts of the laminae and parts of the inferior facets are resected. three patients Neurological were to Frankel over function motor 50. 4. isoniazid.

to a Luque The one-stage the right side sandbags procedure. Some details of patients and results Neurol ogical (Frankel) status Post-op follow-up period (mth) 47 40 39 40 40 33 7 12 37 22 21 23 19 22 18 12 12 6 6 Case 1 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 Age and sex 45 35 4 14 3 36 52 35 45 35 2 23 54 56 S 12 3 3 18 F M F F F M F F F M M F F M F F F F F Levelof pathology T6 T5to8 TlOtol2 T6andl T6tolO Ll T8and9 T8and9 Tl2andLl TlandlO T7to9 T7to9 T8and9 LI and 2 L9to12 T7to9 T6and7 T6andl T8toll Hypertrophy ofnb(% of original diameter) 50 Nil 35 57 100 Nil 100 42 Nil 25 100 42 27 64 90 30 Nil 43 Nil Angula don In degrees Pre-op 60 36 67 55 80 53 45 34 60 70 85 40 12 30 85 54 68 85 46 Post-op 46 20 30 38 50 28 26 20 25 45 57 14 12 8 35 15 35 15 6 Latest 46 23 22 42 73 28 28 23 28 50 55 14 12 8 40 25 40 25 6 Pre-op B A C A C B B A C B C B B C C C C C B Last follow-up D E E E E E E E E E E E E E E E E E E Fig. The operating table is tilted from side to side to facilitate access to both wounds. after wound Fig. 2 Photographs deformity and achieved radiographs taken on by a one-stage anterior Fig. osteoand compression rectangle or Synthes internal Mersilene fixator tape instrumentation attached decompression is then carried out.688 J. Anterior debridement and The aim of the one-stage combined anterior and posterior procedure is to obtain maximum correction of the kyphosis by elongation of the anterior column and simultaneous shortening of the posterior column in such a way that the spinal cord is at the imaginary axis of rotation. but before the rib graft is inserted. 3 admission and and posterior intra-operatively procedure. tomies sublaminar in children. the posterior procedure is completed. 4 closure to show the dramatic Fig. down and The secured patient to the is positioned operating with table. great placing posterior curvature care being radiograph has been taken cephalad to align to the the iliac spine crest. The in adults. correctly An antero- by is taken to ensure that no lateral created. LOUW occurred. 5 improvement in kyphotic THE JOURNAL OF BONE AND JOINT SURGERY . A. The spinal cord is kept under constant direct vision from both anterior and posterior aspects to ensure Table I. V-shaped were closed osteotomies using either were Harrington made.

with the rib graft in position.On admission there was procedure. When wearing a spinal cast care the brace after proximally and distally. The and fusion extended from two normal the tuberculous one above focus to one to two below below in the it in other from around In the second above is callus formation between the no bridging trabeculae. trabeculae with no lytic - Fig. procedure required intensive was stable. six-monthly obtained then and at each were three-monthly thereafter. Patients were discharged when independently with the aid of crutches. rod sublaminar in four wires internal Mersilene tape and attached rod to a rectangle 1986). and compression of the posterior column.5 Three recognised. in three Abernathie in one case case (Dick was used 556 ml combined months. and the 1987). active rehabilithey could walk Follow-up was monthly year spine and for 12 months. 6a Fig. The kyphosis is reduced the by anteriorly kyphos directed posterior pressure traction on both until wounds after Postoperatively. the posterior and 878 ml for the procedure. a 30#{176} kyphosis. Figure 6a .SPINAL TUBERCULOSIS WITH NEUROLOGICAL DEFICIT 689 that the neither apex of distraction nor and compression occurs. The average follow-up bone graft were period no new the rib graft. 6c Lateral radiographs After the anterior has been reduced of a 56-year-old man. JULY 1990 . 4. No. There is bony fusion and 63% hypertrophy of the rib. Harrington was cases used (Gaines for posterior as a combined compression fixation in 10 RESULTS Details average operation.Six months to 8#{176}. their general had healed. provides a good three-point pressure system. 2 to 5). during Radiographs bony the fusion second of the was vascular dramatic (Figs improvement anterior and evident. Immediate is usual were perthe or a hyperextension a one-stage combined operation. monthly clinical until review. between graft stage there and vertebrae. sublaminar Synthes Sublaminar and a rectangle fixator in tape one alone Mersilene stages of healing of the In the early postoperative and there there but are is a lytic area stage vertebrae children for instrumentation vertebrae 14 cases five. After the posterior rib graft procedure is inserted ofthe has kyphotic been anteriorly. The posterior procedures formed in two procedure in instrumentation stages in 1 3 patients. Reduction is enhanced by using a laminectomy spreader anteriorly. one-stage was 25. and the other six. deformity completed. In the in continuity lines. The anterior cases. postoperatively Figure 6b the kyphosis - VOL. started tation. and of the blood 19 patients losses for were are given 674 ml in for Table the I. 72-B. The Luque rectangle used with sublaminar Mersilene tape for children under five years ofage and sublaminar wires for older children and adults. Figure 6c . 6b Fig. a two-stage the patients condition the patients. bone graft third is seen.

a one-stage combined Figure 7a procedure. Figure of 7c Lateral radiographs and photographs 85#{176}. spinal THE JOURNAL OF BONE AND JOINT SURGERY .The paralysed year postoperatively.Immediately after - On admission the kyphosis intact with At one year postoperatively patient there is 40#{176} angulation. A. 7e there was an angulation is reduced to 35#{176}. curve Figure at one 7d . on admission. 7c Fig. Figure 7e - bony fusion Neurologically and 90% hypertrophy a normal ofthe rib graft. 7d of a 5-year-old girl. 7b Fig. Figure 7b .690 J. - Fig. LOUW Fig. 7a Fig.

favourably to intravenous and physiotherapy . radiographs was 460.5%. angulation worse by the surgical was 26.9#{176}. of 67. 72-B. No.7#{176}) loss ofcorrection 7). Cosmetic improvement was rated by the patients parents) as excellent in 12 and good in five. had wound breakdown at the iliac site.5 to 10). 8).Pre-operative months postoperatively. 9). This was of 3. Bony in 14 (73%) 19 by at three or destruction months. At the latest a 5. JULY 1990 .6 grades neurological on the Frankel scale : 18 function 30. rib important feature of the reduction radiologists (complete) average present and earliest film which showed stage of bony healing. was the graft diameter was recorded on a lateral as used radiograph constant and used had distances the width increased by at least 25%. the thoracolumbar kyphosis was 67#{176}. No patient 88% was at nine made in 95% at 14 months. the average (Fig. but secondary wound suture was but responded donor The one-stage combined even Kalafong rigid in adults procedure kyphosis.Three near-anatomical Fig. after reduction is shown. recovery correction. six patients combined neurological months postoperatively. 8a Fig.9% average follow-up patients averaged had normal 2. and feared complication. procedure.SPINAL TUBERCULOSIS WITH NEUROLOGICAL DEFICIT 691 The independent identify radiographs senior the were separately who reviewed were by two asked to the third seen at an fusion was months.5% reduction. still leaving bronchopneumonia correction.3#{176}. Figure 9a . The At was the most recent follow-up. months and walked with the aid of crutches (case 1). 9b Lateral radiographs of a 4-year-old girl. spinal cord damage. Full recovery was achieved by 47% at three 70% at six months.6#{176} postoperatively. 9a of an 18-year-old 9b .5% follow-up. Figure 8a . and the spine was well-balanced. We 18 at six vascularised in all radiological to eliminate any of the vertebra magnification at the upper error end of evidence of erosion graft in any patient. the kyphosis was 22#{176}. antibiotics woman crest satisfactory. were minor bilateral complications in two post- (3. There was of the 10 months. procedure operation had a mean angulation and 22. the of 5. (Fig. to the while latest the The posterior fusion was complete Significant in 14 of the admission by 10 months. Figure 8b .5#{176}before a 66. a VOL. angulation of 56#{176} was (range 8#{176} to 57#{176}).6#{176} postoperatively average being Neurological 57.7% The average pre-operative reduced to 27. a 50.3#{176}) nineteenth 6). the other having only an insignificant kyphos on presentation. Figure girl. 4. allows even The the most reduction of a long-standing in the thoracic spine. 19 patients. a grossly obese of 120 kg. operatively. 8b Lateral angulation one-stage Fig. is avoided by Fig.On admission. Complications. no restoration of normal spine balance Hypertrophy ofthe rib pedicle significant when its postoperative of kyphosis (Fig. the other.3 months (range 1 . There a 61% (or two An cases : one developed treatment. a loss treated of correction with a one-stage (3.At 36 months postoperatively. angulation (see Fig. in all patients the the graft as a control hypertrophy between was seen from the serial radiographs.

early bony fusion seems to provide enough This evidence to support the use of a vascularised bone graft in spinal tuberculosis patients.8% reduction of 52% ofthe from kyphosis. was concluded that anterior debridement. Hancock DO. there may be doubt whether all the additional effort and theatre time is justified in adult patients where the cosmetic result may be less important than the paralysis. At 12 Kalafong patients had bony fusion. rigid more but fixation These and the differences are significant was produced Mantel-Cox fusion. et *1.001). Dick Anterior vascular pedicle Spine 1980. technique series. fusion in the Kalafong 10 and MRC (dash) series (see in any fusion solid. to only also with against 25% in the MRC study (Fig. rectangle allowing the spinal cord ofthe to move kyphosis. 5:318-23. but were highly group. maintain In children. ofkyphosis. THE JOURNAL OF BONE AND JOINT SURGERY . a late increase in kyphosis fusion alone is prevented by performing MRC at p used after A similar in both the allowed 15 months. available For small effective a to the latest neurological 13% of MRC and 33% < follow-up in the recovery was seen patients after (Breslow after three six months MRC study. Lifeso. Sometimes this may even render the spine more unstable than before surgery. A. months all the who had the Kalafong in only 5% at six months as against 95% respectively. and this is important enough to necessitate correction. 71% Kalafong tests). bone grafting implant for the for spine treatment surgery. adult patient with a vascularised graft after bony (continuous) at an average of 3. which also The posterior the correction until includes a posterior epiinstrumentation helps to the fusion is solid. there was no increase in the kyphotic angulation - Fig. Despite the excellent results of the Kalafong procedure. ‘I SI 40 0. LOUW meticulous attention to the during total release of all anterior and lateral forward the adhesions. 7:179-92. 95% . Frankel HL. there as against significant was a mean a mean (p < 0. 44. However. Weaver of the Harder 1985) necessitates comparison of the results present study with those for the same race and in the same part ofthe world. 12:882-900. Mersilene tape is the only column. admission compression deterioration provides a very effective three-point allows for shortening of the posterior children sublaminar after with soft immature spines. Kalafong and 50% a rectangle MRC 0. van de Werke for the evaluation ofthe radiographs. of spinal tuberculosis 1976 . In our series these advantages were gained with no significant complications. for his assistance with the statistical analysis. Bony text). Hyslop reduction in the initial management with paraplegia and tetraplegia. South African Medical Research Council. only one study in South Africa (Medical Research included patients with CNS involvement. there was an increase in kyphosis to 61#{176} over two levels. as W. as a versatile G. A. Segmental Harrington is preferred since it not system. of anterior Kalafong of the decompression method earlier because spine and more complete neurological involved recovery. bony fusion was seen postoperatively. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. since movement in and around the spinal cord was still possible in the MRC cases after anterior strut grafting alone. anterior posterior physeodesis. J . Furthermore.001 instrumentation.692 J. Becker of the Institute for Biostatistics. Complete in 47% of Kalafong and months . I further wish to acknowledge Professor P. 30 uninterrupted recovery. in the MRC study with the 19 patients operation. portion possibly of the II 90 80 10 : 0 C S 60 0. Unfortunately. Another issue which needs discussion is whether a vascularised bone graft graft has sufficient the advantages more difficult over and a non-vascularised to justify 20 ‘I I 3 6 9 12 Postoperative 15 18 period 21 24 21 31 33 36 in months longer operation. The value of postural of closed injuries of the spine Parap/egia 1969. Fourie and Dr I. The (Medical and variable Research clinical Council picture 1974. and the Mantel-Cox tests confirmed 10). and bone Comparing grafting produced 20 patients with Council l978b) it I am grateful to Dr P. Sound bony fusion is the best evidence ofhealing and 95% ofthe vascularised grafts had healed by six months as against only 5% of the patients in the older MRC group with non-vascularised grafts. the best surgical CNS involvement results. The “fixateur interne” Spine 1987.3 months postoperatively. From this decompression REFERENCES Bradford DS. Both the Breslow that the differences In the Kalafong unhindered the reduction instrumentation system. in the earlier MRC study of anterior fusion alone.

Korea. and d#{233}bridement in the surgical management of tuberculosis of Lifeso RM. 110:69-80. JM. Medical Research DEFICIT Council. 60- as a substitute for wire children. 61:853-66. on the radical treatment of Pott’s BrJSurg 1956-1957. in the surgical treatment of severe C/in Orthop 1975. of rib with J Bone Joint of a spinal blood Surg 1. A ten-year assessment of a controlled trial Medical Research Council. the management FS. Mersilene instrumentation tapes for TUBERCULOSIS WITH NEUROLOGICAL Medical Research ambulatory (Rhodesia) B:l63-77. Transposition kyphos. Owen supply for [Br] 1975. 58-B:399-4l R.SPINAL Gaines RW Jr. Weaver Bone Joint Surg P. Spine 1986. Council. Yau ACM. of the spine : studies J Bone Joint Surg [Br] in Bulawayo Hodgson AR. No. A controlled and debridement in the surgical the spine in patients on standard Kong. Hodgson AR. 59 :79-105. JULY 1990 . Rose GK. Tuberc/e 1978b. Anterior spinal fusion : a preliminary disease and of tuberculosis Kong. A five-year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis ofthe spine in children on standard chemotherapy: studies in Masan and Pusan. A controlled trial of anterior spinal fusion Stabilization tuberculosis of the spine in children. VOL. Harder [Am] EH. J Bone Joint Surg [Br] 1976. O’Mabooey spinal G. DL. Abernathie in segmental spinal 11:907-13. Seventh report of the Medical Research Council Working Party on Tuberculosis of the Spine. Dwyer AP. BrJSurg 1974. 67-A the spine in patients on standard chemotherapy : a study in two centres in South Africa. and in Hong Five-year assessments of controlled debridement and anterior spinal trials fusion 1978a 693 of in . management chemotherapy of tuberculosis : a study in Hong of comparing B :393-8. 44:266-75. trial spondylitis of anterior in adults. spine J Bone spinal fusion in the manageon [Br] standard 1982. 72-B. 4. Stock communication Pott’s paraplegia. Sanderson the stabilisation 57-B:ll2. Jenkins DHR. Medical Research Council. Tuberculous :140-13. 64- ment of tuberculosis chemotherapy in Hong in patients Joint Surg Medical Research Council. spinal fusion J 1985 . treatment. debridement and anterior of the Kong.