Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 20  |  Issue : 3  |  Page : 164--168

Postoperative clinicoradiological outcome of pott's spine


Pranav Charde, Nitin Samal, Mahendra Gudhe, Sohael Khan 
 Department of Orthopaedics, DMIMS, Wardha, Maharashtra, India

Correspondence Address:
Dr. Pranav Charde
48, New Subhedar Layout, Nagpur - 440 024, Maharashtra
India

Abstract

Introduction: Tuberculosis (TB) is one of the main diseases impacting humanity. Fifty percent of all the cases of skeletal TB belong to spinal TB (STB), and it is also the most common form of TB. In India, patients usually present late after the onset of neurological symptoms, for which surgical management is essential for recovery. In our study, we have evaluated the outcome of forty patients of STB who underwent posterior decompression and instrumentation. Methods: Forty patients with STB who underwent posterior decompression and instrumentation were reviewed. All cases were followed up for 18 months. The groups were compared by parameters such as improvement in pain, improvement in kyphosis, and neurological recovery. Visual Analog Scale (VAS) score and american spinal cord injury assosciation (ASIA) score are used for the assessment. Results: VAS score was significantly decreased postoperatively (mean: 1.28) as compared to preoperative values (mean: 7.25). Erythrocyte sedimentation rate (ESR) was significantly decreased postoperatively (mean: 30.95) as compared to preoperative values (76.15). Cobb's angle was significantly decreased immediate postoperatively (mean: 7.8) as compared to preoperative values (mean: 24.8). There was no deterioration of neurological symptoms in any of the patients. Conclusion: Surgical intervention in Pott's spine with posterior decompression and stabilization, whenever indicated, gives good improvement in pain, decreases kyphotic deformity, and in most cases, also improves neurology.



How to cite this article:
Charde P, Samal N, Gudhe M, Khan S. Postoperative clinicoradiological outcome of pott's spine.Ann Afr Med 2021;20:164-168


How to cite this URL:
Charde P, Samal N, Gudhe M, Khan S. Postoperative clinicoradiological outcome of pott's spine. Ann Afr Med [serial online] 2021 [cited 2021 Dec 6 ];20:164-168
Available from: https://www.annalsafrmed.org/text.asp?2021/20/3/164/326190


Full Text



 Introduction



Tuberculosis (TB) is one of the main diseases impacting humanity.[1] Mycobacterium tuberculosis, and sometimes Mycobacterium bovis, and Mycobacterium africanum cause the disease. Many parts of the body can be affected by TB, lungs being the primary target of the disease. The involvement of the skeletal system was found in 1%–2% of all the patients suffering from TB.[2] Fifty percent of all the cases of skeletal TB belong to spinal TB (STB), and it is also the most common form of TB. STB is a very slowly progressive disease. Early diagnosis of the disease is very difficult, and generally, diagnosis is made at the advanced stages. If diagnosed early, patients can be treated conservatively with medications. Even though clinicoradiological findings are clear in STB, making a definitive and early diagnosis is difficult, due to the slow progression of the disease. Due to the late diagnosis of the disease, most of the patients receive treatments such as nonsteroidal anti-inflammatory drugs, physiotherapy, and a brace, prior to the correct diagnosis.[3],[4],[5] Antituberculous drugs form the mainstay of treatment and surgery reserved for those with neurological symptoms and progressive deformity. In India, patients usually present late after the onset of neurological symptoms, for which surgical management is essential for recovery. In our study, we have evaluated the outcome of forty patients of STB who underwent posterior decompression and instrumentation in regard to clinical improvement, neurological recovery, and correction of kyphotic deformity.

 Materials and Methods



This is a prospective interventional study carried out at Acharya Vinoba Bhave Rural Hospital in the Department of Orthopedics between June 2017 and September 2019. In this study, forty patients of Pott's spine cases new or relapse with magnetic resonance imaging (MRI) showing significant compression over cord or dura mater with or without neurological deficit with progressive kyphotic deformity were included and were managed with the posterior decompression and spinal fusion. Patients who are not willing for surgical treatment of Pott's spine, not willing to give written consent, and not willing for follow-up were excluded. Pott's spine was diagnosed with history, clinical examination, X-rays, MRI, and computed tomography-guided biopsy [Figure 1] and [Figure 2]. All patients were categorized under ASIA grading and Visual Analog Scale (VAS) score. All the patients were started on antitubercular treatment prior to the surgery. After the anesthetic fitness and proper consent, patients were taken for surgery. All cases were given general anesthesia and managed by debridement and stabilization with pedicle screw and rods via a posterior approach only [Figure 3]. A posterior midline approach was used in all cases, with the incision centering over the involved vertebral level. Pedicle screws were placed under fluoroscopic guidance in vertebral bodies above and below the lesion. If the upper segment of the vertebral body was undestroyed, the affected vertebra was incorporated in the instrumentation. Temporary stabilization of the spine was done by connecting the pedicle screws on one side so as to prevent collapse during debridement and permit the transforaminal approach from the other side. Laminectomy of the affected level is done, and debridement of the infected tissues, pus, sequestrum, and the disc is done through the transforaminal approach with the help of curettes. Autograft harvested from the laminectomy bone is inserted. Screws are connected with connecting rods, and the affected vertebral level is compressed. The drainage tube is placed, and the wound is sutured. Intraoperative sample of granulation tissue was collected and sent for histopathological examination. All the patients were given braces to be worn for a period of 1 year. All patients were given antituberculous therapy for a period of 18 months. Liver function tests and erythrocyte sedimentation rate (ESR) were monitored at regular interval. Complete examination was done immediate postoperative (within 1 month), first follow-up at 6 months and second follow-up at 18 months. On follow-up ESR values, VAS scoring and ASIA charting were done to assess the clinical, hematological, and functional outcome of patients. Likewise, X-rays of the involved vertebral level were done to calculate Cobb's angle to assess the deformity correction [Figure 4]. Qualitative data are provided as frequencies and percentages and analyzed using Chi-square test. Quantitative data were presented and measured by t-test as mean and standard deviation. P < 0.05 was taken as a level of significance.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Results



All cases were followed up at immediate postoperative (within 1 month), at 6 months, and at 18 months. Most of the study population belong to the age group of more than 50 years (35%), followed by 16–30 years (25%) and 41–50 years (22.5%), with a mean age of 44.3 ± 16.34 years. Lumbar spine (42.5%) was the most commonly involved site, followed by thoracic spine (30%) and thoracolumbar level (15%). Neurological deficit was observed in 60% of the study population on admission. Preoperatively, most of the study population had ASIA E (40%) neurological level, followed by ASIA C (27.5%) and ASIA A (15%). On 18-month follow-up, most of the study population had ASIA E (62.5%) neurological level, followed by ASIA D (17.5%) and ASIA C (10%) [Figure 5]. Neurological deficit was observed most commonly in thoracic spine involvement (37.5%). VAS score was significantly decreased postoperatively (mean: 1.28) as compared to preoperative values (mean: 7.25) [Table 1]. ESR was significantly decreased postoperatively (mean: 30.95) as compared to preoperative values (76.15) [Table 2]. Cobb's angle was significantly decreased immediate postoperatively (mean: 7.8) as compared to preoperative values (mean: 24.8) [Table 3].{Figure 5}{Table 1}{Table 2}{Table 3}

 Discussion



TB is a chronic disease associated with constitutional symptoms and is among the world's leading cause of death.[6],[7] To restore and preserve the structure of the spine, alleviate pain, and eradicate the infection, medical management should always be the treatment of choice. Concomitant medical therapy is necessary even when surgery is indicated.[8] The main aims of management is to treat the infection, prevent and manage neurological deficit. And to finally achieve normal spine curvature by correcting deformities and achieve near normal activities of daily living as early as possible.[9] Surgical management of STB includes posterior approach, extrapleural anterolateral procedure, combined anterior and posterior procedure, and anterior approach.[10]

While anti-TB treatment is now the cornerstone of STB management, it may not be adequate in all circumstances, especially for patients with progressing deformity, instability, and advancing neurologic deficit. Numerous studies conducted previously have described the surgery as the treatment modality for such cases, though very few studies describe pigtail aspiration of the paraspinal abscess as an option for selected patients.[11],[12]

In the present study, most of the study population belong to the age group of more than 50 years (35%), followed by 16–30 years (25%) and 41–50 years (22.5%), with a mean age of 44.3 ± 16.34 years. Such findings are consistent with the research carried out by Ankur Gupta et al., in which the mean age was 44.0 ± 12.3 years.[13]

In the present study, there was male predominance (65%) in the study population as compared to females (35%). This result is in line with the Gupta et al. study, which consisted of 23 male patients and 18 female patients.[13] This may be due to the reason that men are more prone to get exposed to infected people due to their outdoor work and activities and greater social circle as compared to females.

In the present study, lumbar spine (42.5%) was the most commonly involved site, followed by thoracic spine (30%) and thoracolumbar level (15%). Likewise, a research conducted by Prasad Bodapati et al. reported that most of the patients (54.1%) had the disease of the lumbar spine followed by that of the dorsal spine. TB of the cervical spine was relatively rare and was seen only in one patient.[14] This was comparable with the Korean study, in which 44.8% of the patients had the disease of the lumbar spine, 31.3% had that of the dorsal spine, and none with cervical spine disease.[15] Universally, lumbar spine and thoracic spine are commonly affected, which is also found in this series as well. However, they noted that lumbar involvement was slightly more common in the elderly, while thoracic involvement was more in the younger age group.[16]

In the present study, neurological deficit was observed in 60% of the study population. Such results are in line with the study conducted by Cao et al., and the study found that the specific complications which occurred are abscess (78.7%) and neurological defects (50.2%), which were higher than those of Erdem and et al.[17],[18] Jain AK believes that neurodeficits are the most grievous and unfavorable prognostic factor in STB.[19] Erdem H also believes that the presence of neurodeficits is a predictor of poor outcome.[18]

In the present study, preoperatively, most of the study population had ASIA E (40%) neurological level, followed by ASIA C (27.5%) and ASIA A (15%). Similarly, in the study done by Shah et al., in which they reported majority of patients were having Frankel Grade E (40%). Sixty percent of the patients had neurological compromise, with 24% having Frankel Grade D and 14% having Grade C.[20] On the second follow-up at 18 months, most of the study population had ASIA E (62.5%) neurological level, followed by ASIA D (17.5%) and ASIA C (10%). Thus, there is significant improvement in the neurological status of the patient.

In the present study, neurological deficit was observed most commonly in thoracic spine involvement (37.5%), followed by lumbar spine involvement (29.2%) and thoracolumbar (12.5%) and cervical (12.5%). Similarly, in the study done by Ankur et al., most of the patients with complete paraplegia had dorsal vertebral lesions (55%).[13] In the present study, neurological deficit was observed most commonly in more than 50 years (41.7%), followed by 16–30 years (25%) and 41–50 years (20.8%). None of the patients was neurologically degraded in the current study.

In the present study, VAS score was significantly decreased postoperatively on final follow-up (mean: 1.28) as compared to preoperative values (mean: 7.25). Similarly, in research done by Cao et al., the average preoperative VAS score and ESR was 6.90 ± 2.00 and 44.65 ± 16.30 mm/h, respectively. Postoperatively, the majority of patients had improvement of symptoms, as well as results of imaging studies. They also saw an improvement of blood parameters and neurological function to varying degrees. The postoperative VAS score had a significant improvement from preoperative 6.90 ± 2.00–1.99 ± 0.81 after 6-month interval.[17]

In the present study, ESR was significantly decreased postoperatively on final follow-up (mean: 30.9 mm/h) as compared to preoperative values (mean: 76.15 mm/h). Similarly, in the study performed by Yasaratne et al., where the average preoperative ESR was reportedly 82 mm/h.[21]

In the present study, Cobb's angle was significantly decreased postoperatively, FFU and SFU as compared to preoperative values with preoperative mean being 24.8° and mean at final follow-up being 7.8°. This result is in line with the analysis by Gupta et al., in which the mean preoperative kyphotic angle was 23.8° ± 4.2° which improved to a mean of 8.1° ± 2.7°.[13]

Limitations of the study is less sample size. Also the follow up period is less so radiological fusion cannot be evaluated. Postoperative MRI is not done so disease eradication cannot be predicted.

 Conclusion



Surgical intervention in Pott's spine done with posterior decompression and stabilization results in improvement in clinical outcome (significant decrease in VAS score), significant improvement in functional outcome (significant improvement in ASIA score), and significant decrease in deformity (significant decrease in Cobb's angle).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Donoghue HD, Spigelman M, Greenblatt CL, Lev-Maor G, Bar-Gal GK, Matheson C, et al. Tuberculosis: From prehistory to Robert Koch, as revealed by ancient DNA. Lancet Infect Dis 2004;4:584-92.
2Tuli SM. Textbook- Tuberculosis of the Skeletal System (Bones, Joints, Spine and Bursal Sheaths). 3rd ed. New Delhi: Jaypee Brothers; 2004.
3McLain RF, Isada C. Spinal tuberculosis deserves a place on the radar screen. Cleve Clin J Med 2004;71:537-9, 543-9.
4Mehta JS, Bhojraj SY. Tuberculosis of the thoracic spine. J Bone Joint Surg Br 2001;83-B: 859-63.
5Moon 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.
6Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine (Phila Pa 1976) 1997;22:1791-7.
7Moon MS. Managing tuberculosis of spine. Med Progr (Hong Kong) 2004;31:593-602.
8Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X. Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 2013;133:765-72.
9Bridwell KH, Lenke LG, McEnery KW, Baldus C, Blanke K. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976) 1995;20:1410-8.
10Vanti C, Prosperi D, Boschi M. The Prolo Scale: History, evolution and psychometric properties. J Orthop Traumatol 2013;14:235-45.
11Parthasarathy 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;81:464-71.
12Vidyasagar C, Murthy HK. Management of tuberculosis of the spine with neurological complications. Ann R Coll Surg Engl 1994;76:80-4.
13Gupta A, Jain P, Thakur R, Sharma S. Posterior only debridement and instrumentation in thoracolumbar spinal tuberculosis. Int J Orthop Sci 2017;3:38-42.
14Bodapati PC, Vemula RC, Mohammad AA, Mohan A. Outcome and management of spinal tuberculosis according to severity at a tertiary referral center. Asian J Neurosurg 2017;12:441-6.
15Park DW, Sohn JW, Kim EH, Cho DI, Lee JH, Kim KT, et al. Outcome and management of spinal tuberculosis according to the severity of disease: A retrospective study of 137 adult patients at Korean teaching hospitals. Spine (Phila Pa 1976) 2007;32:E130-5.
16Kaplan CJ. Pott's disease in South African Bantu children; an analysis of results and comparison with Lancashire figures. Br J Tuberc Dis Chest 1952;46:209-13.
17Cao G, Rao J, Cai Y, Wang C, Liao W, Chen T, Qin J, Yuan H, Wang P. Analysis of treatment and prognosis of 863 patients with spinal tuberculosis in Guizhou Province. BioMed research international. 2018 Sep 23;2018.
18Batirel A, Erdem H, Sengoz G, Pehlivanoglu F, Ramosaco E, Gülsün S, et al. The course of spinal tuberculosis (Pott disease): Results of the multinational, multicentre Backbone-2 study. Clin Microbiol Infect 2015;21:1008.e9-18.
19Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br 2010;92(7):905–13.
20Shah M, Suthar K, Zala R. To study the outcomes of posterior decompression and fixation of tuberculosis of dorsolumbar spine. Int J Orthop Sci 2017;3:691-5.
21Yasaratne BM, Wijesinghe SN, Madegedara RM. Spinal tuberculosis: A study of the disease pattern, diagnosis and outcome of medical management in Sri Lanka. Indian J Tuberc 2013;60:208-16.