spinal tuberculosis - recent trends of surgical management

Spinal Tuberculosis - Recent Trends of Surgical Management in Modern Era

1 2 2 2Sameer Ruparel , Ankit Patel , Vishal Kundnani , Saijyot Raut

AbstractPrinciples of treatment for surgical management of spinal tuberculosis has been ever changing over the years. With advances in medical management and surgical techniques, the aim is to achieve optimum functional outcomes with minimum patient morbidity. Development of effective anti-tuberculous drugs and extensive trials over the years have now finally laid down basic principles and indications of this ‘medical disease’. The principles of surgical treatment include optimum debridement and decompression, adequate bone on bone contact for fusion, providing immediate stability for early mobilization with an approach which causes least morbidity coupled with effective ATT. To achieve these goals either anterior/ posterior / combined approaches can be utilized with each having their advantages and disadvantages. Similarly, the treatment principles for healed TB spines are entirely different due to altered pathology and biomechanics. However, to reduce the morbidity of available surgical techniques, recent success of Minimally Invasive Spine Surgery has prompted spine surgeons to utilize them for the treatment of spinal tuberculosis. Modern technologies like endoscopic approaches, percutaneous biopsies and pedicle screw fixation, expandable muscle splitting retractors and intervertebral cages, intra operative neuromonitoring and navigation have recently revolutionized the surgical management of spinal tuberculosis. This manuscript focusses on the development of recent surgical principles, techniques and trends for the treatment of Koch’s spine. Keywords: Spinal Tuberculosis, Koch's spine, recent advances, surgery, surgical management.

Before venturing into modern management principles, it is beneficial to have the basic knowledge of how these developed over time. The two most important landmarks in history that had a profound impact on treating spinal tuberculosis is the development of ATT and results of MRC trials. During the pre-chemotherapy era, treatment was watchful observation and emphasis was laid on sanitation and nutrition. The aim was to achieve ankyloses in least disabling position by plaster cast immobilization for 2 to 3 years [1-6]. Unsatisfactory results of this orthodox treatment [6] prompted surgeons to surgically excise the diseased bones and joints by targeting the pathological area directly [7,8]. However, this lead to persistent sinus discharge, ulcers and death in many patients. This prompted Hibbs and Albee [9,10] to develop ‘distant operations’ with posterior spinal fusions with the aim to provide permanent internal stability and reduce the period of immobilization. Since the pathology was anterior, the results were still not satisfactory [11]. The development of effective ATT between 1950-1960 prompted surgeons to directly target the area of pathology. They believed that thorough

IntroductionTubercle bacilli have been known to live in symbiosis with mankind since centuries. Hippocrates (100-300 BC) has been credited for the first description of tuberculosis of spine. Though tubercle bacilli primarily cause pulmonary affection, extra- pulmonary manifestations are fairly common with spine being the most common site [1]. Treatment of spinal tuberculosis requires special attention amongst bone and joint tuberculosis, because it is not only the biology and mechanics that gets affected but also the neurology. The principles of treatment have changed rapidly with the improvement in socio-economic status, development of BCG vaccine and effective Anti- Tuberculous drugs. However, with changing principles, there also exists numerous controversies. Though studies with regards to the effective combination and duration of Anti Tubercular Treatment (ATT), indications, principles, approach and instrumentation for surgery have been conducted in literature, the answers have been ever changing with time. This picture is even changing today with the advent of Minimally Invasive Spine Surgery (MISS), domains of

Tubular/Endoscopic decompression and Percutaneous Pedicle Screw (PPS) fixation. Since tuberculosis is an epidemic in many parts of the world [2,3], it is necessary for an astute spine surgeon to remain abreast with latest principles a n d t r e n d s i n m a n a g e m e n t o f o n e o f t h e m o s t incomprehensible disease known to mankind. This manuscript focusses on recent trends in the surgical treatment of spinal tuberculosis in modern era.

Historical Perspective

E-mail: [email protected]

Address for correspondence:

Dr. Vishal Kundnani,

¹Consultant Spine Surgeon, Jaslok and Global Hospitals, Mumbai.

²Department of Orthopaedics, Lilavati and Bombay Hospitals, Mumbai.

Room No 3 , OPD block, Lilavati Hospital & Research Centre, Reclamation, Bandra

West, Mumbai, Maharashtra 400050.

Symposium Journal of Trauma & Orthopaedic Surgery | 2021 January-March |16(1):24-30

Submitted:18 January 2021; Reviewed: 16 February 2021; Accepted: 25 February 2021; Published: 10 March 2021

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License , https://creativecommons.org/licenses/by-nc-sa/4.0/which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms

DOI:10.13107/jto.2021.v16i1.356

© 2021 Journal of Trauma & Orthopaedic Surgery Published by Indian Orthopaedic Research Group |624

debridement was necessary as ATT would not penetrate the intra-osseous lesions which was proved otherwise by numerous studies [12,13]. The remarkable results with ATT alone [14] led to the development of Middle Path Regimen whereby the indications of surgery become fairly limited to prevent neurology and deformity, thus conferring the tag of ‘medical disease’ for spinal tuberculosis. This also changed principles of radical anterior debridement as proposed in the ‘Hong Kong’ procedure by Hodgson and Stock [15]. Presently, decompression has become less aggressive and confined to remove only tissues causing neurological compression. Similarly, the MRC trials divided patients into three different prospective groups. They concluded that drug treatment group, debridement group and debridement with anterior spinal fusion group has similar outcomes at 15 years [16] except that the fusion group had quicker pain relief and decreased tendency for deformity progression. This laid down the principle of fusion and bone to bone contact for effective results. The landmark results of Oga et al [17] showed that tubercle bacilli do not adhere to metal and form biofilms, thus allaying the anxiety to use instrumentation for immediate stability amongst spine surgeons.

Surgical PrinciplesThe above historical perspective has laid down the indications and principles of modern day surgical treatment for spinal tuberculosis. Today, the indications of surgery are pretty well defined [Table 4]. These include severe and rapidly progressive neurological deficit, significant destruction

causing

mechanical instability and deformity, large abscess causing pressure symptoms and lack of response to ATT. Similarly, the principles of surgery include- optimum debridement and decompression, adequate bone on bone contact for fusion, providing immediate stability for early mobilization with an approach which causes least morbidity coupled with effective ATT [Table 1]. Decompression and debridement is restricted to removal of sequestrated disc, loose pieces of bone with drainage of pus to allow spinal cord decompression. Radical debridement until bleeding edges are obtained is not recommended as it results in larger anterior column defect requiring reconstruction. In children, injury to growth plates must be avoided by limited debridement [18]. Adequate bone on bone contact is established by anterior column reconstruction. This is possible by anterior or posterior approaches. This is achieved with help of strut grafts (autograft/allograft) or titanium mesh cages. When the anterior defect is small, this contact can also be obtained by compression from behind with posterior approach [19]. Immediate stabi l i t y i s prov ided w ith adequate instrumentation. Graft related complications and loss of correction of kyphosis [20, 21] has been described after isolated arthrodesis. Upadhyay reported dislodgment of graft after anterior fusion in 10 out of 104 patients and increase in kyphosis by 20 degrees in one year [22]. Stabilization also provide immediate pain relief, promotes healing and neurological recovery, enhances fusion rates and allows early mobilization. These principles can be achieved with either anterior alone, posterior alone or combined approaches. Since

www.jtojournal.comRuparel S et al

Journal of Trauma & Orthopaedic Surgery | January-March 2021 | Volume 16 | Issue 1 | 4-30

Figure 1a: MRI showing T2 sequence with D8 body destruction and pre-vertebral abscess causing canal compromise and cord compression

Figure 1b: Pre operative (a) Antero posterior (b) Lateral radiograph showing wedging of D8 vertebrae

Figure 1c: Post operative (a) Antero posterior (b) Lateral radiograph showing D6,D7 and D9,D10 pedicle screw fixation

Figure 2a: 65 year old female c/o low back pain with B/L lower limb claudication. MRI T2 sagittal sequence shows L2-L3 discitis and canal stenosis at L3-4 level

Figure 2b: Dynamic lateral radiograph of lumbar spine showing L2-L3 disc space narrowing

Figure 2c: (a) Lateral (b) antero-posterior, Post-op Xray showing L2-L5 fixation done with L3-L4 interbody

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The surgical approach

The anterior approach: [Table 2]Anterior approach for treating spinal tuberculosis is considered as the ‘gold standard’. This is based on the fact that the disease mainly affects anterior column. Thus, this approach provides direct access to disease pathology and adequate room for decompression and anterior column reconstruction [24,25]. The vertebral bodies also have a large surface area to promote fusion. The Smith Robinson approach has stood the test of time to access the sub axial cervical spine. Similarly lesion involving vertebral levels T5 to

T12 can be approached through left sided thoracotomy. Thorough debridement is possible with a subtotal/total corpectomy to achieve neural decompression and the void is f i l led with strut grafts/ cage f i l led with bone graft supplemented with screw-rod construct. Pathology affecting thoraco-lumbar levels involve taking down the diaphragm and retroperitoneal approach is suitable for lumbar levels. This approach is difficult for upper thoracic and lumbo-sacral lesions where injury to visceral and vascular structures is a possibility. Numerous studies have shown good efficacy with anterior-only approach for spinal tuberculosis [26,27,28]. Dai et al conducted a prospective study of 39 cases with spinal Tuberculosis and found that the therapeutic effect of single anterior approach was excellent in single-stage anterior debridement, bone grafting and instrumentation with a very low rate of non-healing [24]. However, weak screw purchase in cancellous, osteoporotic and diseased bone might prompt the surgeon to opt for additional posterior instrumentation. Similarly, lungs may be scarred in tuberculosis which may make transthoracic approach more morbid particularly in elderly patients. At present, an ideal case for anterior approach alone in cervical and mid thoracic spine is a patient with single motion segment involvement and kyphosis less than 30-40 degrees. The combined approach: There is no doubt that the combined approach combines the advantages of both approaches to achieved best clinical and radiological outcomes. However, it also entails the risks, complications and

TB is a medical disease, without effective ATT any surgery performed keeping above principles in mind can fail. It is one of the important pillars for successful clinico-radiological outcomes. A recent study [23], conducted by authors found as high as 43.6% of Xpert- MTB proven spinal TB cases to be Multi-Drug Resistant (MDR- resistant to both Rifampicin and Isoniazid). Widespread prevalence of MDR TB has further changed the principles of suspicion based empirical ATT to biopsy proven effective ATT based on drug sensitivity patterns.

Surgical management is aimed at debridement of tubercular abscess, decompression of spinal cord, reconstructing the stability of spine along with preventing/ correcting deformity. Three main approaches have been defined to achieve these goals. These include the anterior approach, the posterior approach and the combined anterior-posterior approach with each having its advantages and disadvantages.


Journal of Trauma & Orthopaedic Surgery | January-March 2021 | Volume 16 | Issue 1 | Page 24-30

Figure 3a: Pre-operative Sagittal and Axial MRI T2 sequence images with L1-L2 complete disc involvement and destruction of vertebral body forming abscess. Figure 3b: Trans-foraminal puss drainage and decompression

through the sheath

Figure 3c: Post operative Antero- Posterior and Lateral radiograph showing pedicle screw fixation done in D11,12 and L3,4

Figure 3ca: Post-operative (a) & (b) radiograph images showing anterior C4-C5 corpectomy stabilized by expandable cage and anterior cervical plating with posteriorly lateral mass screw in C3,C4,C5,C6

Figure 4b: Pre-operative lateral radiograph of cervical spine showing destruction of C4 & C5 vertebrae

Figure 4a: 60 year old male c/o right side upper limb weakness and radiculopathy. MRI T2 Sagittal sequence show s C4- C5 destr uct ion of ver tebral body prever tebral and epidural col lect ion causing compression of cord

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The posterior approach: [Table 3]Currently, the most popular approach to thoracic and lumbar spine is the postero-lateral approach. This allows for anterior debridement and reconstruction through transfacetal / transpedicular / costo-transversectomy / Lateral Extra-cavitatory Approach (LECA) corridors (Figure 1). Curettes are used to remove the necrotic material anteriorly and spinal cord is decompressed along with drainage of the paraspinal abscess. The defect is reconstructed from one side using a Titanium mesh cage infused with an autograft (Figure 2). Posterior instrumented fusion is achieved with pedicle screws which provides for rigid three column fixation necessary for stabilization and deformity correction. It is an extra-pleural approach hence preferred in patients with tuberculosis with poor pulmonary function. The approach is familiar amongst spine surgeons and the construct can be easily extended to include levels above and below. Though the disadvantage include that the decompression and reconstruction is indirect as compared to anterior approach, results demonstrating the superiority of posterior approach in correcting and maintain deformity is documented by many [30,31]. Liu et al [32] in a meta-analysis concluded that posterior approach has the same clinical efficacy but with less

operation time, blood loss, hospital stay and complication when compared with combined or anterior only surgeries. All in all, surgery done by either approaches are successful only if all surgical principles are strictly adhered to.Surgery in Healed TB spines: Utilization of posterior approach for surgery in healed TB spines need special mention. These usually present with sharp angular deformities or late onset neurological deficits. In such cases, it is difficult to approach the spine through anterior transthoracic approach [33]. Combined approaches employ anterior corpectomy, posterior shortening, and instrumentation and anterior and posterior grafting [34,35]. Though these multi stage techniques were initially employed to treat them, recently, various techniques like transpedicular decancellation procedures, pedicle subtraction osteotomies, vertebral column resections and closing opening wedge osteotomies [36-39] have shown excellent comparable outcomes. Depending upon the severity of angular deformity, either of the techniques are undertaken. Achieving deformity correction by restoring anterior column height might stretch the sensitive spinal cord, hence above techniques involve taking out wedges (with base of wedge posterior) along with compression maneuverers to correct deformities. Closing opening wedge osteotomies is particularly useful in tuberculosis which may involve collapse of up to three vertebral bodies. A pure closing technique might produce severe kinking of the cord [40]. Hence, in such surgeries the anterior column is reconstructed with strut grafts/ vertebral spacers filled with autografts. Rajasekaran et al, in a series of 17 patients, reported that the average kyphosis improved from 69.2 º preoperatively to 32.4º postoperatively by closing opening wedge osteotomy [41]. Authors have employed a novel technique of apical spinal osteotomies through posterior approach in rigid severe kyphoscoliosis and found excellent results validating its use in children less than 14 years age [42].

morbidity of either approaches [29]. This has prompted more and more surgeons to achieve similar results with a single approach preferably. This has been possible recently with posterior-only approach.

Role of Minimally Invasive Spine Surgery (MISS) in Spine TBThough the current approaches have managed to achieve good clinico-radiological results over the years, spine surgeons strive for better outcomes day by day. A recent meta- analysis by Wang et al (43) comparing anterior versus posterior instrumentation for Spinal TB found blood loss in the range of 385-1100 ml. They also found the average duration of hospital stay ranging from a week to month and a half for either approaches. These appear to be huge in a patients with tuberculosis who are usually morbid and more prevalent in poor socio-economic areas. MISS has proven its might with regards to better patient outcomes, less post-operative stay, less blood loss, less post-operative pain, smaller incisions and early return to work in degenerative pathologies (44,45)[Table 5]. Any procedure that reduces the morbidity of conventional techniques can be defined as MISS technique. MISS aims to achieve surgical aims through smallest possible ‘foot print’ utilising inter-muscular planes. Applications of MISS have ben myriad in treating tumours, deformities, trauma in addition to



Anterior retropharyngeal approach Subaxial Cervical spine

Anterior manubrium splitting approach Cervico-Thoracic junction

Anterior transthoracic approach, VATS Mid Thoracic spine T5-T12

Anterior trans diaphragmatic approach Thoraco-Lumbar junction

Anterior retro-peritoneal approach, OLIF Lumbar spine L1-4

Anterior laparotomy approach Lumbo-Sacral junction

Neurological deficit: Acute onset neurological deterioration, paraparesis

or paraplegia

Deformity: Kyphosis > 40 degrees or two out of 4 ‘spine at risk’ signs in

children

Instability: causing severe mechanical back pain

Large Abscess: causing compressive symptoms like dyspnoea,

dysphagia, ect

Lack of response to 6-8 weeks of chemotherapy or any of the above

increasing despite effective ATT

Table 3: Surgical Approaches- Posterior

Posterior Transfacetal approach

Posterior Transpedicular approach

Posterior Costo-Transversectomy approach for anterolateral

decompression

Extended Posterior versatile approach for Vertebral Column

Reconstruction/ Anterior column reconstruction, LECA

Table 4: Indications for surgical management

Table 2: Surgical Approaches- Anterior

Table 1: Effective surgical principles

Optimum decompression and debridement

Immediate stability for early mobilization

Bone on bone contact for fusion

Approach with least morbidity

Effective ATT based on biopsy and drug sensitivity patterns

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Recent trend is for an all posterior global reconstruction whereas Anterior Cervical Decompression & Fixation (ACDF) remains the gold standard in subaxial/ Cervico-thoracic region TB (Figure 4). Hu et al [52] in a series of 18 patients have demonstrated the role of image processing and planning software like SURGIMAP (Nemaris Inc) in determining preoperatively the level and type of osteotomy so as to achieve the best surgical correction. Percutaneous pedicle screw placement have been used extensively in MISS stabilization procedures. These however have disadvantages like increased radiation exposure, guide wire related complications and superior facet joint violations [53] [Table 6]. Intraoperative 3D Navigation is also a very useful tool for guided screw placement and intraoperative osteotomy planning and has been extensively put to use for complex post-tubercular deformities. Intraoperative Neuro-Monitoring (IONM) is a useful adjunct for such scenarios where the spinal cord is stretched over the internal gibbus and the surgical team can get a reasonable correction without endangering the spinal cord and resultant postoperative neurological worsening as INOM give real-time feedback regarding the functioning across the operated segment via the multimodal monitoring.

Conclusion

degenerative pathologies. Though nascent in treating spinal TB and infections, initial reports are promising with limited applications. These can be utilized to procure specimens for culture, drainage of epidural abscess, percutaneous debridement of early discitis, anterior/transforaminal debridement and reconstruction followed by percutaneous screw fixation. Applications of MISS are a boon in immunocompromised and elderly morbid patients. Ashizwa et al [46] performed percutaneous transpedicular biopsies and found 92% accuracy without significant complications. Paraspinal and epidural abscesses tend to resolve with chemotherapy. However, if pressure symptoms appear or there is failure of resolution, percutaneous drainage & debridement aided by transforaminal or posterior full-endoscopic techniques help in immediate symptom resolution as well as getting a representative sample for laboratory studies and change in MDT [47] (Figure 3). Expandable retractor systems (Quadrant retractor system- Medtronic Inc, Syn Frame, XLIF – Nuvasive Inc) have been also utilised in the surgical management of TB spine with notable success. Direct lateral Interbody fusion (DLIF) & Oblique lateral interbody fusion (OLIF) offer thorough anterior debridement and fusion for up to 2 levels of involvement followed by percutaneous MIS Screw fixation [48]. These approaches have been rendered much more useful with the advent of expandable cages with variable footplates which help in placement through the

narrow corridors yet achieve excellent kyphosis correction and restoring the loss of height due to the disease process. Minimally invasive surgery techniques using video assisted thoracoscopic (VATS) decompression of the anterior tuberculous lesions have also been reported. Such techniques minimize surgical morbidity however indications are primarily for debridement, as these techniques only allow for minimal correction of sagittal parameters [49,50,51]. The advantages of these MIS Anterior techniques are that the lead to significantly less morbidity, minimal epidural fibrosis and excellent anterior release which aids in good deformity correction with the posterior fixation technique.

Spinal tuberculosis though has been known to co-exist with humans since ages, the principles of management and techniques to treat them are ever changing. Irrespective of methodology of treatment, basic principles should always be adhered to. Great strides achieved in medical management along with recent advances in MISS serve as a perfect combination of medical and surgical management for patients with Spinal TB to achieve more than better outcomes in recent times.

Table 5: Advantages of Minimally Invasive Spine Surgery (MISS)

Less post-operative pain and need for analgesia

Decreased blood loss

Small incisions, Better cosmesis

Less muscle damage

Low infection rates

Early return to work

Day care surgeries – Cost efficient

Table 6: Limitations of MISS

Increased radiation exposure

Steep learning curve

Guide-wire related complications

Resource intensive

Superior facet joint violations

Skill based reproducibility of results

Higher implant cost

Indications limited in complex cases

Declaration of patient consent : The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for patient images and other clinical information to be reported in the journal. The patient's parents understand that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.Conflict of interest:Nil Source of support:None

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How to Cite this ArticleRuparel S, Patel A, Kundnani V, Raut S, Kundnani V. Spinal tuberculosis recent trends of surgical management in modern era. Journal of Trauma and Orthopaedic Surgery January-March 2021;16(1): 24-30.

Conflict of Interest: NILSource of Support: NIL

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spinal tuberculosis - recent trends of surgical management

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