Treatment of acute tuberculous spondylitis by the spinal shortening osteotomy: a technical notes and case illustrations.

Abstract

Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encountered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treatment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurological deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening osteotomy is an alternative method for the management of tuberculous spondylitis.

Full text

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Asian Spine Journal Vol. 5, No. 4, pp 237~244, 2011
http://dx.doi.org/10.4184/asj.2011.5.4.237
Introduction
Spinal tuberculosis is most common form of extrapul-
monary tuberculosis, and it comprises approximately 50%
of all cases of skeletal tuberculosis. In general, antitubercu-
lous chemotherapy is considered the fundamental treatment
of this condition, but surgery is still necessary for the partic-
ular cases in which here is a large amount of necrotic tissue
and spinal cord compression is noted [1,2]. The principle of
operative management for spinal tuberculosis is to decom-
pressed the spinal cord by removing the necrotic tissue and
draining of any abscess, and this is follow by immobiliza-
tion. Yet the infected vertebrae are prone to collapse and
they require mechanical support to prevent progressive
deformity [3].
There is no standard method for the surgery of tubercu-
lous spondylitis. Many procedures have been described and
these consist of anterior debridement with anterior or poste-
rior spinal fixation, posterior debridement and spinal recon-
struction, as examples. These procedures require an inter-
body bone graft to restore the spinal alignment. Neverthe-
less, complications associated with interbody bone graft
placement have been reported, such as graft failure and pro-
gressive collapse [1-3].
Spinal shortening osteotomy is an alternative method for
treating spinal tuberculosis, and especially for the correction
of the sagittal balance in a late kyphotic deformity [4,5].
Received Dec 2, 2010; 1st Revised Dec 28, 2010; Accepted Jan 27, 2011
Corresponding author: Wiwat Wajanavisit, MD
Department of Orthopedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University,
240 Rama VI Road, Payathai, Ratchathewi, Bangkok 10400, Thailand
Tel: +662-2011589, Fax: +662-2011599, E-mail: Rawwj@mahidol.ac.th
Copyright � 2011 by Korean Society of Spine Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Asian Spine Journal�pISSN 1976-1902 eISSN 1976-7846
Treatment of Acute Tuberculous Spondylitis by the
Spinal Shortening Osteotomy:
A Technical Notes and Case Illustrations
Pongsthorn Chanplakorn1, Niramol Chanplakorn2, Chaiwat Kraiwattanapong1,
Wiwat Wajanavisit1, Wichien Laohacharoensombat1
1Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
2Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encoun-
tered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the
correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treat-
ment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients
who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically
treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurologi-
cal deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was
improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening
osteotomy is an alternative method for the management of tuberculous spondylitis.
KeyKey W Words ords: Tuberculosis, TB spine, Shortening osteotomy, Surgical treatment

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This technique has several advantages such as an enhanced
bony contact surface and no interbody graft placement with
the intention of restoring the sagittal spinal alignment. We
think these procedures should be superior to the former
methods in order to reduce the complications associated
with graft placement and to enhance bony healing. Howev-
er, to the best of our knowledge, there is no report on spinal
shortening ostotomy as a surgical treatment for the active
disease stage of tuberculous spondylitis without a severe
rigid angular kyphotic deformity. Thus, the aim of this
report is to present our surgical techniques and the clinical
and radiographic results of the patients treated with this pro-
cedure.
Technical Notes
Under general anesthesia the patient was turned to prone
position. The abdomen was allowed to hang free to prevent
any compression to the vena cava. Due to our limitation of
equipment, no intraoperative neuromonitoring was used
during the operation. A straight vertical midline incision
was made to extend two vertebrae above and below the
affected vertebral segment. The paraspinal muscles were
dissected and then retracted laterally. After identifying the
pathological level with an image intensifier, pedicular
screws were inserted into the pedicles of the 2 vertebrae
above and below the pathological level. After that, the dis-
section was carried out more laterally to expose the cos-
tovertebral joints of the lower affected vertebra and then
over the posterior surface of the ribs about 5 cm laterally.
After complete exposure, the osteotomy procedure was ini-
tially performed from one side of the vertebral column.
First, the rib was cut and subsequently, with gentle blunt
dissection, the parietal pleuron was dissected out with gen-
tle blunt dissection and the intercostal artery was identified
and ligated. After that, the costovertebral joint was divided
and the rib was dissected out from the intercostal muscles
and removed. A total laminectomy at the pathological level
was then performed to decompress the neural elements and
subsequently, using a high speed drill, the pars interartricu-
laris was cut laterally until reaching the lateral border of the
vertebral body. The nerve root was then identified and sac-
rificed to gaining the exposure. The pedicle of the lower
vertebral body of the affected segment was then identified
and removed to expose the diseased vertebral level (Fig. 1).
After that, the necrotic material within the disc and the ver-
tebral bodies, beneath the dural sac, were removed using
curettes and pituitary forceps. The paravertebral abscess
was then identified and drained. After adequate debride-
ment of all the infected material, the residual cortex of the
posterior parts of the vertebral bodies attached to the poste-
rior longitudinal ligament was removed. After completing
one side, the spinal plate was then applied to the ipsilateral
side of the vertebral column in order to prevent vertebral
collapse and then the operation was performed in similar
steps on the other side. However, in case 1, in addition to
the procedure described above, the left transverse process
of the T11 was also cut using a high speed drill to expose
the lower part of a large extensive anterior paravertebral
abscess for irrigation and drainage. After completing the
debridement around the dural sac, the spinal plate was then
applied and a vertebral column shortening maneuver was
238 / ASJ: Vol. 5, No. 4, 2011
Fig. 1. Case 2. The illustrative figure of the vertebral shorten-
ing osteotomy operation. After resection of the left 12th rib,
larminectomy of T11-T12 and the left T12 pedicle and pars
resection were done. The exposure (between the white arrows)
is wide enough for removal of the necrotic tissue and to drain
the abscess. The infected material beneath the dural sac can be
removed through the resected pedicle (*).
Fig. 2. Case 2. The illustrative figure shows the final step of
the vertebral shortening osteotomy procedure. After complete
removal of all the necrotic material, the dual spinal plates are
applied and adjusted for the compression of the vertebral bod-
ies (block white arrows). Kinking of the dural sac is also
observed (white star).

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then performed by adjusting the posterior instruments to
achieve bony contact (Fig. 2). The neural tissues were then
checked again for any compression that might have
occurred during the maneuver. Additionally, posteriorlateral
fusion along the instrumented area beneath the spinal plates
was then performed with local bone grafts.
1. Patients
Three patients with tuberculous spondylitis at the thoracic
spine were surgically treated with this procedure. All the
patients presented to our clinic with severe progressive back
pain. The lesions were confined in the T11-T12, T10-T11
and T7 vertebral segments, and in addition, kyphotic defor-
mity of the spinal column was detected in all the patients. A
localized paravertebral abscess was observed on the mag-
netic resonance images (MRIs) in all the patients, but in 1
patient (case 1) the abscess had extensively spread along the
anterior longitudinal ligament. Surgical intervention was
indicated as neurological deficits were detected in all the
patients. All the patients recovered from the surgery
uneventfully without further neurological deterioration. The
pathological diagnosis confirmed caseous granulomatous
inflammation in all the cases. Antituberculous chemothera-
py was prescribed for 12 months for all the patients. The
treatment regimen was as follow: isoniazid 300 mg/day plus
rifampicin 600 mg/day (for the patients who weighted more
than 50 kg) or 450 mg/day (for the patients who weighted
less than 50 kg) plus pyrazinamide 30 mg/kg/day and
ethambutol 25 mg/kg/day for 2 months and this was fol-
lowed by isoniazid plus rifampicin for the other 10 months.
The patients’ pain was dramatically improved after the
operation and all the patients remained free of pain during
the follow-up period.
2. Case illustrations
(1) Case 1
A 39-year-old male was admitted to our clinic with the
history of back pain for 3 years. The pain was located at the
Treatment of Acute Tuberculous Spondylitis by the Spinal Shortening Osteotomy / 239
Fig. 3. Case 1. The plain X-ray lateral view before the surgery (A) revealed 50% collapse of the T7 vertebra and this
resulted in a slight kyphotic deformity. After surgery (B), shortening of the vertebral column was demonstrated and
bony healing was observed (block white arrows).

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mid thoracic region. He had been diagnosed with tubercu-
lous spondylitis and he had received antituberculous
chemotherapy for 6 months, but his symptoms were not
improved. Further, he had also been treated with local
drainage of pus from his back twice in a 2 years period. The
plain X-ray revealed 50% vertebral collapse at T7, which
resulted in a slight kyphotic deformity (Fig. 3A). Unfortu-
nately, 1 month later, his symptoms progressed and acute
neurological deterioration was detected. The emergency
MRI revealed T7 vertebral collapse with a retropulsed frag-
ment compressing the dural sac. In addition, a extensive
prevertebral abscess that extended from T6 down to T12
was also identified (Figs. 4 and 5). He underwent surgical
decompression and fixation, using our presented technique,
with the drainage of the large extensive abscess by partial
transversectomy of T11. The patient recovered from the
operation uneventfully and immediate improvement of his
neurological status (ASIA score improvement from D to E)
was observed.
(2) Case 2
A 35-year-old woman came to our clinic with progressive
weakness of the lower extremities for 6 days. The motor
weakness was detected only on her right leg, but a sensory
deficit was observed on both legs below the knee. The ini-
tial X-ray revealed an erosion of the upper and lower verte-
bral endplates and destruction of the intervertebral disc of
the T11-T12 vertebral segment that result in kyphotic defor-
mity. MRI demonstrated inhomogeneous signal intensity
and destructive lesion at the T11-T12 vertebral segment,
which resulted in segmental kyphosis and caused dural sac
compression at the T11 vertebral level (Fig. 6A). Formation
of a paravertebral abscess was also detected (Fig. 6B). The
patient was scheduled for emergency surgical decompres-
sion using our presented technique (Fig. 7). The post opera-
tive course was uneventful and neurological improvement
(ASIA score improvement from C to E) was observed.
(3) Case 3
A 40-year-old woman was admitted to our clinic with
240 / ASJ: Vol. 5, No. 4, 2011
Fig. 4. Case 1. The magnetic resonance imaging sagittal view (A) revealed the increase signal intensity of the T7 ver-
tebral body. Vertebral body collapse and a retropulsed fragment that compressed the dural sac were observed. A large
extensive paravertebral abscess that extended from T6 down to T12 was demonstrated, as is indicated by the white
arrows in (B).

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back pain and progressive weakness of both legs. The X-ray
revealed superior end plate erosion at T11 and destruction
of the intervertebral disc space, which resulted in kyphotic
angulations at this vertebral segment (Fig. 8A and 8B). MRI
in this case demonstrated the destructive lesion of the T11
anterior endplate and abnormal signal intensity of the verte-
bral body with spinal canal compromise due to necrotic
material, and MRI also demonstrated abnormally increased
signal intensity of the T9 and T10 vertebrae. Vertebral
shortening osteotomy was performed at the upper half of
the T11 vertebral body using our presented technique (Fig.
9). The patient recovered from the operation uneventfully
and improvement of her neurological status (ASIA score
improvement from C to E) was observed during the follow-
up period.
Discussion
Tuberculosis of the spine is an unstable lesion that tends
to progress at least until bony union is accomplished. As a
result, kyphotic deformity usually occurs and this may
cause serious problems such as late paraplegia [1]. Anterior
radical surgery and arthrodesis have been described and
advocated in the past decade as a standard treatment for
spinal tuberculosis. The advantage of this method is direct
access to the lesion and the lesion can be eradicated by
Treatment of Acute Tuberculous Spondylitis by the Spinal Shortening Osteotomy / 241
Fig. 5. Case 1. The magnetic resonance imaging axial view at
T7 showed the degree of dural sac compression by the
retropulsed fragment and the necrotic materials (*). The
white arrows indicate the large paravertebral abscess around
the vertebral body and that extends down to T12.
Fig. 6. Case 2 The magnetic resonance imaging (MRI)
sagittal view (A) shows inhomogeneous signal intensity at
the T11-T12 intervertebral disc level. The upper end plate
of T12 was collapsed and this resulted in angulations of T11
and it caused dural sac compression (block white arrows in
[A]). The MRI axial view at the pathological level (B)
shows the degree of dural sac compromise by the necrotic
material (white star) and the local paravertebral abscess
(black arrows) is demonstrated.