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Residual deformity in spinal tuberculosis

Authors:

Abstract

Objective: nowadays there is still doubt regarding the best treatment to prevent deformities in the treatment of spinal tuberculosis. The objective of this study was to evaluate radiographically the deformities of patients under vertebral tuberculosis with different types of treatment. Methods: a retrospective evaluation of initial and final radiographs was done. The deformities were measured using the Cobb method. Twenty four patients were evaluated, seven were operated on and 17 received only antibiotics. Results: the mean focal and regional thoracic kyphosis in the beginning of the follow up was respectively 48,8° and 47,86°. There was an increase of deformity on the thoracic region, which was also the most affected, from 6,3° focal and 9,8° regional at the end of five years. Conclusion: the type of treatment has not interfered in the kyphosis progression. Patients with less than 15 years old and kyphosis greater than 30° had worse prognosis regarding the deformity progression.
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COLUNA/COLUMNA. 2008;7(1):23-26
Deformidade residual na tuberculose da coluna vertebral
Residual deformity in spinal tuberculosis
Deformidad residual en la tuberculosis de la columna vertebral
ARTIGO ORIGINAL / ORIGINAL ARTICLE
Douglas Kenji Narazaki1
Leonardo dos Santos Correia1
Marcelo Poderoso de Araújo2
Alexandre Fogaça Cristante3
Alexandre Sadao Iutaka3
Raphael Martus Marcon4
Reginaldo Perilo Oliveira5
Tarcísio Eloy Pessoa de Barros Filho6
RESUMO
Objetivo: atualmente ainda existem
controvérsias em relação à prevenção das
deformidades no tratamento da tuber-
culose da coluna vertebral. O objetivo
deste estudo é avaliar radiograficamente
as deformidades de pacientes com
tuberculose da coluna com os diferentes
tipos de tratamento. Métodos: trabalho
retrospectivo com avaliação dos pron-
tuários e das radiografias iniciais e ao
final do seguimento. As deformidades
foram medidas pelo método de Cobb.
Foram avaliados 24 pacientes, sete deles
foram operados e 17 receberam somente
antibioticoterapia. Resultados: a média de
cifose torácica focal e regional no início
do seguimento foi respectivamente 48,8o
e 47,86o. Houve aumento da deformidade
na região torácica, segmento mais
acometido, de 6,3o focal e 9,8 regional ao
ABSTRACT
Objective: nowadays there is still
doubt regarding the best treatment to
prevent deformities in the treatment
of spinal tuberculosis. The objective
of this study was to evaluate
radiographically the deformities of
patients under vertebral tuberculosis
with different types of treatment.
Methods: a retrospective evaluation
of initial and final radiographs was
done. The deformities were measured
using the Cobb method. Twenty four
patients were evaluated, seven were
operated on and 17 received only
antibiotics. Results: the mean focal
and regional thoracic kyphosis in the
beginning of the follow up was
respectively 48,8° and 47,86°. There
was an increase of deformity on the
thoracic region, which was also the
RESUMEN
Objetivo: actualmente, aún existen
muchas controversias con relación a
la prevención de las deformidades en
el tratamiento de la tuberculosis de
la columna vertebral. El objetivo de
nuestro trabajo es evaluar radiográ-
ficamente las deformidades de los
pacientes con tuberculosis de la
columna con los diferentes tipos de
tratamiento. Métodos: es un trabajo
retrospectivo con evaluación de
historias clínicas y radiografias al
inicio y al final del seguimiento. Las
deformidades fueron medidas por el
método de Cobb. Fueron evaluados
24 pacientes, siete pacientes fueron
operados y 17 recibieron solamente
antibioticoterapia. Resultados: el
promedio de la cifosis torácica focal
y regional en el inicio del seguimiento
Trabalho realizado no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
1Estagiário do Serviço de Coluna do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP -
São Paulo (SP), Brasil.
2Preceptor do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
3 Assistente do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
4Mestre em Ortopedia e Traumatologia pela Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
5Doutor; Chefe do Grupo de Coluna do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo -
USP - São Paulo (SP), Brasil.
6Professor Titular da Faculdade de Medicina da Universidade de São Paulo - USP - São Paulo (SP), Brasil.
Recebido: 11/03/2007 - Aprovado: 21/01/2008
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COLUNA/COLUMNA. 2008;7(1):23-26
24 Narazaki DK, Correia LS, Araújo MP, Cristante AF, Iutaka AS, Marcon RM, Oliveira RP, Barros Filho TEP
final de cinco anos. Conclusão: o tipo de
tratamento não influenciou na progressão
da cifose. Paciente com menos de 15 anos
e cifose maior que 30o tiveram pior
prognóstico quanto à progressão da
deformidade.
DESCRITORES: Tuberculose da
coluna vertebral/radiografia;
Doenças da coluna vertebral;
Anormalidades
most affected, from 6,3° focal and 9,8°
regional at the end of five years.
Conclusion: the type of treatment has
not interfered in the kyphosis
progression. Patients with less than
15 years old and kyphosis greater
than 30° had worse prognosis
regarding the deformity progression.
KEYWORDS: Tuberculosis, spinal/
radiography; Spinal diseases;
Abnormalities
fue respectivamente 48.8 o y 47.86o.
Hubo aumento de la deformidad en la
región torácica siendo el segmento
mas comprometido, de 6.3o focal y 9.8o
regional al final de cinco años.
Conclusión: el tipo de tratamiento no
influyó en la progresión de la cifosis.
Paciente con menos de 15 años y
cifosis mayor que 30o tuvieron un peor
pronóstico relacionado con la
progresión de la deformidad.
DESCRIPTORES: Tuberculosis de la
columna vertebral/radiografía;
Enfermedades de la columna
vertebral; Anomalías
INTRODUÇÃO
A tuberculose da coluna é a tuberculose óssea mais freqüente,
correspondendo a 50%. Pode estar associada à doença pulmonar
ou não. Se não diagnosticada e tratada precocemente pode levar
a seqüelas importantes como paraplegia e deformidades, que
determinam perda funcional1. Quanto ao tratamento, a literatura
ainda é controversa. Compere e Jerome, Chandler e Page, e
Cleveland descreveram sua experiência da artrodese da coluna
via posterior. Bennett, Fallen e Kaplana apresentaram seus
resultados com tratamento conservador. Todos com bons
resultados, porém nenhum estudo comparativo. Kidner e Muro,
Mayer e Adams compararam o tratamento conservador com a
artrodese posterior em crianças, concluindo que nenhum
tratamento foi superior ao outro na fase aguda da doença. No
entanto, no estágio tardio da doença, onde três ou mais vértebras
estão colapsadas, a artrodese mostrou-se melhor, determinando
uma menor progressão da cifose2.
No tratamento cirúrgico nos deparamos com nova
controvérsia: descompressão e artrodese anterior, posterior ou
combinada. A fusão posterior foi introduzida em 1961 por Hibbs
e Albee. A descompressão e fusão anterior foi introduzida por
Muller, em 1906 e popularizada por Hodgson3, em 1960. A vantagem
da cirurgia posterior é a menor morbidade, enquanto a da cirurgia
anterior é a possibilidade de descomprimir diretamente o canal
vertebral, desbridar a lesão e corrigir a deformidade. Shunmugam
Govender4 e Ozdemir5 demonstraram que enxertos homólogos
de banco de osso associado com instrumentação anterior são
superiores aos enxertos autólogos de costelas, com menor índice
de migração do enxerto às custas de uma consolidação mais
tardia. Alguns autores sugeriram que para espondilodiscíte por
tuberculose de um nível a cirurgia mais efetiva seria por via
anterior e quando dois ou mais níveis eram acometidos dever-
se-ia combinar via anterior e posterior. Dessa maneira, esses
autores tiveram menor progressão da cifose6,7.
O tratamento conservador atualmente é realizado com três
drogas quimioterápicas: Rifampicina, Isoniazida e Pirazinamida
e o tempo de uso dessas drogas é discutível na literatura.
Moon8 conclui em seu trabalho de 2002 que deve ser no mínimo
de 12 meses. Parthasarathy9 conduziu um trabalho pelo Centro
de Pesquisa de Tuberculose de Chennai (Madras), observando
que os pacientes tratados com antibioticoterapia isolada por
seis meses, nove meses ou cirurgia tiveram a mesma evolução
funcional, favorável (respectivamente, 94%, 99% e 90%) e sem
diferença estatisticamente significante.
A incidência de envolvimento neurológico nos pacientes
com tuberculose da coluna é de 10 a 46%3,10-11. No tratamento
conservador existe uma progressão da deformidade de 15o.
Desses pacientes, 3 a 5 % apresentam uma deformidade
maior que 60o. A progressão da deformidade tem duas fases:
fase 1: ativa da doença; fase 2: após a cura da doença. Essa
piora é influenciada pela gravidade da deformidade inicial,
nível de lesão e idade do paciente. Cifose acima de 30o,
acometimento toracolombar e idade menor que 15 anos têm
maior chance de progressão. Para cada corpo vertebral
destruído existe uma cifotização de 30 a 35o. A cirurgia está
indicada para prevenir essa complicação12.
O objetivo de nosso trabalho é avaliar radiograficamente
as deformidades de pacientes com tuberculose da coluna
tratados no Grupo de Coluna do IOT HC-FMUSP.
MÉTODOS
Foram avaliados retrospectivamente 63 casos do Instituto de
Ortopedia e Traumatologia do HC-FMUSP com diagnóstico
de tuberculose da coluna vertebral com comprovação clínica
ou anátomo-patológica no período 1989 a 2003. Foram excluídos
os pacientes que tiveram menos de um ano de acom-
panhamento, prontuário incompleto e avaliação radiográfica
inadequada. Portanto, nosso estudo incluiu 24 pacientes.
A análise radiográfica das deformidades foi feita de acordo
com o método de Cobb. Mediu-se a cifose focal, sendo utilizadas
as placas terminais preservadas imediatamente cranial e caudal
ao nível acometido, e cifose regional, sendo utilizadas as placas
terminais inferior de C2 e C7 para deformidades cervicais, superior
de T2 e inferior de T10 para deformidades torácias, superior de
T11 e inferior de L2 para deformidades toracolombares e superior
29_col_7_1.pmd 15/3/2008, 11:0424
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COLUNA/COLUMNA. 2008;7(1):23-26
Deformidade residual na tuberculose da coluna vertebral
de L2 e inferior de L5 para deformidades lombares. Deformidades
no plano coronal foram registradas e medidas com o mesmo
método. Em todos os pacientes foram analisados idade, sexo,
raça, nível vertebral acometido, quadro clínico, deformidade da
coluna ao diagnóstico, tipo e duração do tratamento, deformidade
ao final do seguimento, com o mínimo de um ano. A análise
estatística dos dados obtidos foi feita de acordo com os Testes
de Fisher e Mann-Whitney.
RESULTADOS
A distribuição por sexo foi de 13 homens e 11 mulheres. A faixa
etária mais acometida pela doença foi até os 10 anos, sendo
que 50% dos pacientes tinham menos de 30 anos. A média de
idade foi de 29 anos, variando de 1 a 68 anos. Todos os pacientes
tinham dor axial, somente 7% tinham ciatalgia, 36,8% referiram
emagrecimento e 10,5% febre. A deformidade era a queixa de
34,2% e o déficit neurológico em 39,5%. O nível mais acometido
foi a coluna torácica, 12 pacientes (50%). A coluna toracolombar
em cinco pacientes (21%), a coluna lombar em seis pacientes
(25%) e a cervical em um paciente (4%). A vértebra mais afetada
foi a de T9 (29%). No nível lombar, L2 e L4 foram as vértebras
mais afetadas (13%). No nível cervical acometeu C1,C2,C3.
Quanto à extensão da doença, tivemos 46% (11 pacientes) com
um nível acometido, 46% (11 pacientes) com dois níveis
acometidos e 8% (2 pacientes) com três níveis acometidos.
Quanto ao tratamento, 17 pacientes (71%) receberam o
tratamento conservador e sete pacientes (29%) foram operados.
Os tipos de cirurgias são citadas nos Quadro 1 e Figura 1.
Os esquemas de antibióticos variaram muito, desde
esquemas simples com droga única até esquemas
quádruplos. Diversos antibióticos foram usados: rifampicina,
isoniazida, pirazinamida, etambutol, estreptomicina, entre
outros. O esquema tríplice atualmente usado (rifampicina,
isoniazida e pirazinamida) foi utilizado em 13 pacientes (55%).
O tempo de uso do antibiótico foi de seis meses em 18% dos
casos, nove meses em 13% e 12 meses em 68%.
No início do quadro clínico, encontramos 13 pacientes (55%)
com escoliose com uma média de 8,4o (variação de 4o-26o), sem
predomínio de lado. Essa deformidade não se alterou até o final do
seguimento (>1 ano). Foram observadas as médias dos valores
angulares iniciais da cifose focal e regional da região torácica, de
48,8o (20o – 90o) e 47,86o (24o – 90o), respectivamente. Houve um
aumento da deformidade na região torácica de 6,3o focal e 9,8o
regional (55,13o e 57,7o, respectivamente), ao final do seguimento.
Foram observadas as médias dos valores angulares iniciais da
cifose focal e regional da região lombar, de 28,5o (5o – 40o) e 5,5o (-31o
– 38o), respectivamente. Houve um aumento da cifose lombar de
9,25o focal e 19,25o regional (37,5o e 24,75o, respectivamente), ao
final do seguimento. Pode-se observar que houve inversão da
lordose fisiológica lombar. Foram observadas as médias dos
valores angulares iniciais da cifose focal e regional da região
toracolombar de 22,3o (7o – 30o) e 19o (7o – 30o), respectivamente.
Houve um aumento da cifose toracolombar de 13,7o focal e 18,7o
regional (36o e 37,7o, respectivamente), ao final do seguimento.
Para analisar a influência do segmento acometido para a
progressão da deformidade foram utilizados somente a angulação
Artrodese por via posterior 3
Descompressão e artrodese via posterior 2
Descompressão e artrodese via anterior 1
Descompressão e artrodese via combinada 1
QUADRO 1 - Tratamento cirúrgico realizado
Figura 1
Paciente de 25 anos e quadro clínico de dor, deformidade e
paraparesia de membros inferiores. Diagnóstico de tuberculose
óssea T7,T8 e T9 confirmado por meio de biópsia. Radiografias
pré-operatórias em AP (A) e perfil (B); e ressonância magnética
(C). O paciente apresentou recuperação completa da
paraparesia após abordagem anterior e posterior (D)
A B
C
D
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COLUNA/COLUMNA. 2008;7(1):23-26
26
REFERÊNCIAS
1. Pott P. The chirurgical works of Percivall
Pott, F.R.S., surgeon to St. Bartholomew’s
Hospital, a new edition, with his last
corrections. 1808. Clin Orthop Relat Res.
2002; (398): 4-10.
2. Bailey HL, Gabriel SM, Hodgson AR,
Shin JS. Tuberculosis of the spine in
children. 1972 [classical article]. Clin
Orthop Relat Res. 2002; (394): 4-18.
3. Hodgson AR, Stock FE. The Classic:
Anterior spinal fusion: a preliminary
communication on the radical treatment
of Pott’s disease and Pott’s paraplegia.
1956. Clin Orthop Relat Res. 2006; 444:
10-5. Republished from: Clin Orthop
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4. Govender S. The outcome of allografts
and anterior instrumentation in spinal
tuberculosis. Clin Orthop Relat Res.
2002; (398): 60-6.
5. Ozdemir HM, Us AK, Ogün T. The role
of anterior spinal instrumentation and
allograft fibula for the treatment of pott
disease. Spine. 2003; 28(5): 474-9.
6. Chen WJ, Wu CC, Jung CH, Chen LH,
Niu CC, Lai PL. Combined anterior and
posterior surgeries in the treatment of
spinal tuberculous spondylitis. Clin
Orthop Relat Res. 2002; (398): 50-9.
7. Klöckner C, Valencia R. Sagittal
alignment after anterior debridement and
fusion with or without additional
posterior instrumentation in the
treatment of pyogenic and tuberculous
spondylodiscitis. Spine. 2003; 28(10):
1036-42.
8. Moon MS, Moon YW, Moon JL, Kim
SS, Sun DH. Conservative treatment of
tuberculosis of the lumbar and
lumbosacral spine. Clin Orthop Relat
Res. 2002; (398): 40- 9.
9. Parthasarathy R, Sriram K, Santha T,
Prabhakar R, Somasundaram PR,
Sivasubramanian S. Short-course
chemotherapy for tuberculosis of the
spine. A comparison between ambulant
treatment and radical surgery—ten-year
report. J Bone Joint Surg Br. 1999;
81(3): 464-71.
10. Griffiths DLL. The treatment of spinal
tuberculosis. In: Mckibbin B, editor.
Recent advances in orthopaedics.
Edinburgh: Churchill Livingstone;
1979. p. 1-17.
11. Jain AK. Treatment of tuberculosis of
the spine with neurologic
complications. Clin Orthop Relat Res.
2002; (398): 75- 84.
Narazaki DK, Correia LS, Araújo MP, Cristante AF, Iutaka AS, Marcon RM, Oliveira RP, Barros Filho TEP
focal uma vez que cada segmento apresenta sua própria curva
fisiológica (torácica - cifose, toracolombar – neutra e lombar –
lordose). Observamos que o de pior prognóstico de progressão
é o nível toracolombar (13,7o), sendo a diferença estatisticamente
significante (p<0,05). O nível lombar (9,25o) mostrou uma
progressão maior que a torácica (6,3o), porém essa diferença não
se mostrou estatisticamente significante (p>0,05).
Quando comparamos a progressão da cifose torácica entre
pacientes com menos de 15 anos de idade (aumento de 18,1o focal
e 20,4o regional) e mais de 15 anos de idade (diminuição de 3o focal
e aumento de 2,3o regional), observamos que pacientes mais jovens
apresentam uma maior progressão da cifose que pacientes mais
velhos. Esses dados foram estatisticamente significantes (p<0,05).
Quando comparamos a progressão de cifose torácica entre
pacientes com deformidades maiores que 30o (aumento de 8,7o
focal e de 13,3o regional) e menores que 30o (aumento de 5,3o focal
e 7,5o regional), notamos que pacientes com deformidades
moderadas e graves apresentam maior progressão da cifose do
que em pacientes com deformidades leves. A diferença da
progressão focal não foi estatisticamente significante (p>0,05),
sendo significante na diferença regional (p<0,05).
O tipo de tratamento, conservador ou cirúrgico, não
mostrou ser estatisticamente significante para a progressão
da deformidade torácica (p>0,05). Os pacientes submetidos à
cirurgia tiveram um aumento da cifose em 5,3o focal e 9,6o
regional, enquanto os submetidos ao tratamento conservador
tiveram um aumento de 8,6o focal e 12,1o regional.
DISCUSSÃO
Mais de 30 milhões de habitantes no mundo sofrem com a
tuberculose residual (reativação) e mais de dois milhões sofrem
com a doença ativa, na forma espinhal13. Hoje a doença pode
ser tratada com sucesso com antibioticoterapia e nossa aten-
ção recai sobre a deformidade residual. A cifose grave determi-
na um problema psicossocial na criança e cardiorrespiratório
secundário. A prevenção da deformidade deve ser hoje uma
das prioridades do tratamento da tuberculose espinhal.
Observamos que a idade mais acometida é antes dos dez
anos; o nível mais acometido foi o torácico, especificamente
T9; a sintomatologia predominante é a dor em todos pacientes,
o déficit neurológico esteve presente em 39,5% dos casos.
Esses dados são concordantes com a literatura2-3,8-9,11-14.
Quanto à deformidade residual, observamos os pacientes
menores de 15 anos, com cifose maior que 30o e acometimento
do segmento toracolombar apresentam pior prognóstico,
sendo nesses casos indicada uma abordagem mais agressiva
com tratamento cirúrgico, por via anterior e posterior, com
objetivo de evitar essa piora. Rajasekaran12,14 em dois
trabalhos relata os mesmos dados.
O tipo de tratamento, conservador ou cirúrgico não
influenciou na progressão da deformidade, em concordância
com os dados encontrados por Parthasarathy9.
CONCLUSÃO
Portanto, nossas recomendações seguem as de Parthasarathy9:
- O tratamento inicial deve ser o conservador com
antibioticoterapia; a antibioticoterapia deve ser o esquema
tríplice: Rifampicina, Isoniazida e Pirazinamida por um perío-
do de nove a 12 meses;
- A cirurgia é indicada nos seguintes casos: a) Pacientes meno-
res de 15 anos com deformidade maior que 30o; b) Progressão da
deformidade apesar do tratamento conservador; c) Sem melhora
neurológica apesar do tratamento com antibióticos; d) Sinais de
instabilidade pela radiografia.
Correspondência
Douglas Kenji Narazaki
Rua Carneiro da Cunha, 675, ap. 115
São Paulo (SP), Brasil
CEP 04144-001
Tel.: + 55 11 8297-8139
E-mail: dogkn@ig.com.br
12. Rajasekaran S. The problem of
deformity in spinal tuberculosis. Clin
Orthop Relat Res. 2002; (398): 85-92.
13. Satyasri S. Global epidemiology of
tuberculosis. In: Sathyasri S, editor.
Text book of pulmonary and extra-
pulmonary tuberculosis. Madras:
Interprint; 1993. p. 13-8.
14. Rajasekaran S. The natural history of
post-tubercular kyphosis in children.
Radiological signs which predict late
increase in deformity. J Bone Joint
Surg Br. 2001; 83(7): 954-62.
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... • the rapid development of gross kyphotic deformation in infants with multisegmental processes [5,6]; ...
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OBJECTIVE: to present our experience on the surgical treatment of spinal tuberculosis and to compare our data to the recent literature. METHODS: a retrospective evaluation of patients who underwent surgical procedure to treat the disease was done. We analyzed the type of surgery, neurological status and angle of kyphosis before the surgery and after twelve months. The neurological status was determined by the Frankel scale modified by ASIA. The kyphotic deformity was measured using the Cobb method. We identified 23 patients with confirmed diagnosis of tuberculosis of the spine. Thirteen individuals in this group were operated. Three patients were excluded and ten participated in the study. RESULTS: most of the patients underwent decompression, anterior and/or posterior fusion by combined or posterior approach. Six patients presented neurological deficit at the time of diagnosis. Two of these six were children and presented with Pott's disease on admission. Three patients presented complete recovery of the motor function of their legs. One patient had neurological status aggravated after the surgery due to bacterial resistance at the administration of four different drugs and to tuberculous meningitis. Regarding to the kyphosis, the mean focal kyphotic angle in the beginning of the follow up was 26,7º (0º to 90º) and 21,2º (0º to 50º) at the end of the study. The mean regional kyphotic angle was 24,10º (-27º to +60º) in the beginning and 21º(-33º to +65º) at the end of the follow-up. There was a decrease of the mean focal and regional kyphosis of 5,7º and 3,1º, respectively. We did not observe important kyphotic angle increase in any operated patient at the end of the study. CONCLUSION: The surgical treatment was efficient to prevent kyphosis progression. The neurological deficit associated with spinal tuberculosis was critical in children.
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We performed a randomised, controlled clinical trial to compare ambulant short-course chemotherapy with anterior spinal fusion plus short-course chemotherapy for spinal tuberculosis without paraplegia. Patients with active disease of vertebral bodies were randomly allocated to one of three regimens: a) radical anterior resection with bone grafting plus six months of daily isoniazid plus rifampicin (Rad6); b) ambulant chemotherapy for six months with daily isoniazid plus rifampicin (Amb6); or c) similar to b) but with chemotherapy for nine months (Amb9). Ten years from the onset of treatment, 90% of 78 Rad6, 94% of 78 Amb6 and 99% of 79 Amb9 patients had a favourable status. Ambulant chemotherapy for a period of six months with daily isoniazid plus rifampicin (Amb6) was an effective treatment for spinal tuberculosis except in patients aged less than 15 years with an initial angle of kyphosis of more than 30° whose kyphosis increased substantially.
Article
The progression of post-tubercular kyphosis in 61 children who received ambulatory chemotherapy was studied prospectively. The angles of deformity and kyphosis were measured for each patient at diagnosis, 3, 6, 9, 12 and 18 months later and every year thereafter for 15 years. During the course of the disease signs of instability appeared on the radiographs of some of the children. These were dislocation of the facets, posterior retropulsion of the diseased fragments, lateral translation of the vertebrae in the anteroposterior view and toppling of the superior vertebra. Each sign was allocated one point to create a spinal instability score. The influence on the progression of the deformity of the level of the lesion, the vertebral body loss, the number of segments involved, the angle of deformity before treatment and the spinal instability score was analysed. The mean angle of deformity at the start of treatment was 35°. This increased to 41° at 15 years. Progression occurred during the active phase of the disease and again after cure when variations in progression were observed. Type-I progression showed an increase in deformity until growth had ceased. This could occur either continuously (type Ia) or after a lag period of three to five years (type Ib). Type-II progression showed decrease in deformity with growth. This could occur immediately after the active phase (type IIa) or after a lag period of three to five years (type IIb). Type-III progression showed minimal change during either the active or healed phases and was seen only in those with limited disease. Multiple regression analysis showed that a spinal instability score of more than 2 was a reliable predictor of patients with an increase of more than 30° in deformity and a final deformity of over 60°. Since signs of radiological instability appear early in the disease, they can be reliably used to identify children whose spine is at risk for late progressive collapse. Surgery is advised in these cases.
Article
Neurologic complications are the most dreaded complication of spinal tuberculosis. The patients who have paraplegia develop in the active stage of tuberculosis of the spine require active treatment for spinal tuberculosis and have a better prognosis than the patients who have paraplegia develop many years after the initial disease has healed. Neurologic dysfunctions in association with active tuberculosis of the spine can be prevented by early diagnosis and prompt treatment. Prompt treatment can reverse paralysis and minimize the potential disability resulting from Pott's paraplegia. When needed, a combination of conservative therapy and surgical decompression yields successful results in most patients with tuberculosis of the spine who have neurologic complications. The vertebral body primarily is affected in tuberculosis; therefore, decompression has to be anterior. Laminectomy is advocated in patients with posterior complex disease and spinal tumor syndrome. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis develop (< 60 degrees) on completion of treatment should have surgery in the active stage of disease to improve kyphus.
Article
Spinal tuberculosis is the most common form of osteoarticular tuberculosis. Fractures, slippage, and increasing deformity have been reported with the use of autologous rib grafts after anterior spinal decompression. Forty-one patients with neurologic deficits caused by spinal tuberculosis had radical anterior decompression, and the anterior column was reconstructed with fresh-frozen femoral allografts and stabilized with a single-rod screw construct. Antituberculous therapy was administered for 12 months and complete neurologic recovery occurred in 32 patients. The incorporation of allografts commenced between 12 and 18 months. Fusion and remodeling was observed in 33 patients and partial remodeling with fusion was observed in eight patients at a mean followup of 6.4 years. Forty-two percent correction of the kyphosis was achieved and there were no cases of fracture or late sepsis. Fresh-frozen allografts and anterior instrumentation are superior to rib grafts in supporting the anterior spinal column, and although fusion occurred late, the grafts remained stable.
Article
Methods for the treatment of tuberculous spondylitis still are controversial. The authors treated 32 consecutive patients with a two-stage surgical technique combined with antituberculous chemotherapy for 1 year. After anterior debridement, fusion with autogenous anterior iliac tricortical strut bone graft was done, and in a second stage, posterior instrumentation and fusion with autogenous posterior iliac corticocancellous bone graft was done 11 days (range, 4-22 days) later. Postoperatively, patients were encouraged to ambulate with brace protection as early as possible. Twenty-nine patients were followed up for a minimum of 2 years (median, 4.7 years; range, 2-10 years) of whom 28 patients achieved solid fusion (97%). All patients had improvement of back pain including the only patient with pseudarthrosis. Neurologic deficits completely recovered in 84% (16 of 19) of patients after 3 months. Kyphotic deformity improved in all 29 patients (34.6 degrees versus 17.3 degrees ) with the average correction angle of 17.3 degrees. Clinically, 27 patients had achieved a satisfactory outcome (93%). There were no evident surgical complications. The authors, therefore, recommend a two-stage surgical technique combined with antituberculous chemotherapy to treat patients with severe vertebral body destruction attributable to tuberculosis because of its high success rate and a low complication rate.
Article
Fifty-six adults (average age, 38 years) with active tuberculosis of the lumbar and lumbosacral spine were treated conservatively with triple chemotherapy for 12 to 18 months. The minimum followup was 3 years. Three methods of assessments of the chronologic changes of sagittal spinal deformity were used on lateral radiographs of the lumbar spine obtained with the patient standing: deformity, kyphos angles, and total lumbar lordosis. The lumbosacral joint angle was measured for tuberculosis of the lumbosacral joint. The disease healed in all patients with a minimum increase of kyphosis, although in 23 patients there was minimal new involvement of the adjacent vertebral bodies within 6 months of treatment. The pattern of the involved vertebral body collapse in tuberculosis of the lumbar and lumbosacral joints was vertical (telescoping), along a longitudinal axis that minimized the progression of kyphosis. The outcome was judged on the basis of residual kyphosis (British Medical Research Council criteria) and found to be favorable in 96.4% (54 patients). Triple chemotherapy for lumbar and lumbosacral tuberculosis is effective in curing the disease and in minimizing the residual kyphosis through early diagnosis and immediate initiation of chemotherapy. The pattern of vertebral body collapse is the telescoping type, which is the determining factor in minimizing residual spinal deformity.
Article
The authors retrospectively reviewed 28 patients with multilevel Pott disease who underwent anterior radical débridement, decompression, and fusion with anterior spinal instrumentation and fibular allograft replacement. To assess the efficacy of allograft fibular fusion and anterior spinal stabilization as an alternative treatment of spinal tuberculosis. The results of anterior surgery in preventing late or early spinal deformity from Pott disease have been closely related to the status of the segmental stability and graft materials, especially in cases of multisegmental involvement. The use of allograft and anterior spinal instrumentation in tuberculous spondylitis remains controversial because of the risk of persistence and recurrence of infection in the presence of devitalized bone graft, which may also be prone to poor incorporation. Between 1993 and 1998, a total of 28 patients with Pott disease (two or more segments involved) underwent anterior débridement, allograft fusion, and stabilization. The patients were given antituberculosis treatment in the postoperative period according to a standardized protocol. The authors retrospectively analyzed their experience in tuberculous spondylitis, with particular attention to method, allograft incorporation, and anterior spinal instrumentation. Incorporation of the allograft was evaluated by either static or dynamic (flexion/extension) radiographs. None of the patients used external support in the postoperative period. A minimum of 3 years' follow-up was achieved in 26 patients. The overall fusion rate was 96%. There were no graft problems. Two patients died in the early postoperative period as a result of multiorgan failure. One patient suffered from an instrumentation failure. No other complications were observed. The segmental correction was maintained successfully in all of the patients. The mean correction loss was 6 degrees. The use of anterior spinal stabilization accompanied with a structural allograft fibula is effective after proper radical débridement for interbody fusion, deformity correction, and maintenance in cases of multisegment-involved Pott disease.