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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 89-92

Single-stage debridement, decompression, and circumferential reconstruction for lumbar tuberculous spondylitis: A posterior-only approach


1 Department of Orthopaedic Surgery and Trauma, National Orthopaedic Hospital, Lagos, Nigeria
2 Department of Orthopaedic Surgery and Trauma, University Of Abuja Teaching Hospital, Abuja, Nigeria

Date of Submission14-Apr-2020
Date of Acceptance05-Jun-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Adetunji M Toluse
Department of Orthopaedic Surgery and Trauma, National Orthopaedic Hospital, PMB - 2009, Igbobi, Yaba, Lagos State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_18_20

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  Abstract 


Spinal tuberculosis accounts for almost 50% of all skeletal involvements. Global reconstruction with adequate debridement and decompression, all through posterior approach alone, is one of the surgical treatment modalities in the management of this disease. A 33-year-old female presented to our facility with lumbar tuberculous spondylitis; had 8-month history of low back pain and 4-month history of progressive low back swelling with associated fever, drenching night sweat, and progressive weight loss. She had a single-stage debridement and instrumented fusion via a posterior-only approach. She is ambulant with normal gait and gaining weight by the 1-year follow-up visit, with radiologic evidence of fusion. The posterior-only approach for 360° instrumented fusion is quite rewarding in the operative care of spinal tuberculosis.

Keywords: Lumbar spine fusion, posterior approach, single stage reconstruction, spinal tuberculosis


How to cite this article:
Toluse AM, Adeyemi TO, Ogunsakin AS, Bassey AOE. Single-stage debridement, decompression, and circumferential reconstruction for lumbar tuberculous spondylitis: A posterior-only approach. Arch Int Surg 2019;9:89-92

How to cite this URL:
Toluse AM, Adeyemi TO, Ogunsakin AS, Bassey AOE. Single-stage debridement, decompression, and circumferential reconstruction for lumbar tuberculous spondylitis: A posterior-only approach. Arch Int Surg [serial online] 2019 [cited 2020 Oct 25];9:89-92. Available from: https://www.archintsurg.org/text.asp?2019/9/3/89/295920




  Introduction Top


The spine is the most common site of skeletal tuberculosis as it accounts for almost 50% of all musculoskeletal involvements amongst the rather less common extra pulmonary manifestations of the disease.[1] The lumbar spine remains the second most affected region of the vertebral column.[2]

Chemotherapy with multidrug anti-tubercular treatment is the mainstay of care in Pott's disease[3] and indications for surgery include: lack of response to chemotherapy, recurrence, static, or worsening neural deficit even after initiating chemotherapy, instability, incapacitating pain, and deformities.[4] Circumferential reconstruction alongside adequate debridement and decompression, exclusively via the posterior approach, is one of the surgical treatment modalities in the management of spinal tuberculosis.[5]


  Case Report Top


A 33-year-old female with 8-month history of low back pain and 4-month of progressive lower back swelling. The pain visual analogue scale (VAS) score was 8/10. She had associated history of low-grade fever, drenching night sweat, progressive weight loss, and unpasteurized milk ingestion. There was occasional bilateral lower limb paresthesia and difficulty in walking due to the low back pain; however, there was no history of sphincteric dysfunction.

Examination revealed a chronically ill-looking young woman with a 16 × 16 cm hemispherical mass over the left Petit's triangle, non-tender and fluctuant with no differential warmth plus midline tenderness over the lower back. There was full power in all muscle groups except both hips with MRC (Medical Research Council) Grade 4/5. A clinical diagnosis of Lumbar Tuberculous Spondylitis was made. Pain radiographs and magnetic resonance imaging [Figure 1] and [Figure 2] showed extensive destruction of entire L4 vertebral body with inferior and superior end plates of L3 and L5, respectively, plus pre- and paravertebral collections with canal and nerve root compression. Four months after commencement of multi-drug anti-tubercular regimen she had a single-stage debridement plus abscess drainage, lumbar decompression and instrumented fusion with rod-pedicle screw construct and expandable inter-body titanium cage via a posterior-only approach from L2 to S1 [Figure 3], [Figure 4], [Figure 5].
Figure 1: Pre-operative antero-posterior and lateral radiographs demonstrating osteolysis of L4 vertebra body and partial destruction of L3 and L5 vertebral bodies

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Figure 2: Pre-operative MRI scan demonstrating extensive vertebral body destruction and abscess collection in the lumbar spine

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Figure 3: Intra-operative picture demonstrating pedicles and rod in-situ on the right, with expandable cage about to be inserted

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Figure 4: Intra-operative C-arm image

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Figure 5: Post-operative radiograph showing stable reconstruction with good sagittal alignment

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The vertebral sequestrum sample for histology result further confirmed the diagnosis of Tuberculous Spondylitis. A significant clinical improvement was achieved as the Visual Analog Scale (VAS) score improved from eight (8) preoperatively to eventually zero (0) postoperatively enabling her to ambulate pain-free at 1-year follow-up [Figure 6] with radiologic evidence of stable fixation and bony fusion.
Figure 6: 1 year post-operative lateral radiograph demonstrating trabecular bone bridging posterior elements of L3, L5 and the expandable cage implant

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  Discussion Top


Surgical approach in spinal tuberculosis has evolved from anterior to posterior.[6] The anterior approach allows direct access to the infected focus and is convenient for debriding infection and reconstructing the defect.[7] Nevertheless, in the lumbar region, attainment of bony stability through anterior instrumentation alone may be inadequate due to presence of the concomitant osteoporosis associated with infection of tuberculosis that renders the vertebrae structurally weak and thereby preventing adequate fixation.[8] A combined anterior and posterior approach helps to overcome stability-related drawbacks of the anterior approach alone.[8] However, it involves two surgeries—single event or staged procedure. When performed as a single event, it is associated with increased operative time and blood loss as well as exposure of vital structures such as peritoneum in already immunocompromised tuberculosis patients, predisposing them to further infection and additional morbidity.[9]

In recent times, the posterior approach has been in the limelight because it is less invasive, allows circumferential cord decompression, and provides a strong three-column fixation via pedicle screws.[5] The functional recovery evaluated in terms of VAS score in our index case is comparable to that of other workers[10] and our patient was also pain-free during her last follow-up with radiologic evidence of stable fixation and fusion.


  Conclusion Top


Single-stage decompression and instrumented fusion via a posterior-only approach may be an effective and safe procedure for surgical treatment of lumbar tuberculous spondylitis in young adults.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rajasekaran S, Soundararajan DCR, Shetty AP, Kanna RM. Spinal tuberculosis: Current concepts. Global Spine J 2018;8:96S-108S.  Back to cited text no. 1
    
2.
Kulchavenya E. Extrapulmonary tuberculosis: Are statistical reports accurate? Ther Adv Infect Dis 2014;2:61-70.  Back to cited text no. 2
    
3.
Rajasekaran S, Khandelwal G. Drug therapy in spinal tuberculosis. Eur Spine J 2013;22(Suppl 4):587-93.  Back to cited text no. 3
    
4.
Shetty A, Kanna RM, Rajasekaran S. TB spine—Current aspects on clinical presentation, diagnosis, and management options. Semin Spine Surg 2016;28:150.  Back to cited text no. 4
    
5.
Shang H, Wang DY, Wen GH. I-Stage surgical treatment for thoracolumbar spinal tuberculosis with kyphosis. Chin Gen Pract 2010;32:42.  Back to cited text no. 5
    
6.
Jain A, Jain RK, Kiyawat V. Evaluation of outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis. Asian Spine J 2017;11:31-6.  Back to cited text no. 6
    
7.
Jain AK, Dhammi IK, Prashad B, Sinha S, Mishra P. Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. J Bone Joint Surg Br 2008;90:1477-81.  Back to cited text no. 7
    
8.
Hee HT, Majd ME, Holt RT, Pienkowski D. Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech 2002;15:149-56.  Back to cited text no. 8
    
9.
Zaveri G. The role of posterior surgery in spinal tuberculosis. Argo Spine News J 2011;23:112-9.  Back to cited text no. 9
    
10.
Akshay J, Ravikant J, Vivek K. Evaluation of outcome of posterior decompression and instrumented fusion in lumbar and lumbosacral tuberculosis. Clin Orthop Surg 2016;8:268-73.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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Abstract
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Case Report
Discussion
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