Neurological recovery in patients of old healed tubercular rigid kyphosis with myelopathy treated with transpedicular decancellation osteotomy

Surgery for deformities in pediatric spinal tuberculosis: single centre review of 51 cases

PURPOSE

To retrospectively report on the clinical presentation, radiological features, indication, and outcome of surgical management of children with posttubercular spinal deformities with long term outcome.

METHODS

This retrospective study was conducted in a single center operated by a single surgeon from 2002 to 2022, and data from an electronic medical record was reviewed. The indications for surgery included failure of medical treatment, to prevent deformity (depending on location, extent of bone loss, stabilization patterns (A, B, or C), and the presence of "Spine at Risk" signs) or correct deformity and in the presence of major neurodeficit.

RESULTS

51 children (< 15 years) of mean age 12.5, and mean follow-up of 7 years (2-15) were included. Pain, deformity/instability, and limb weakness were seen in 34 (66.6%) patients (mean mJOA score was 13.44, which improved to 14.7 and 16.8 at immediate postoperative and latest follow-up), with 17 (33.3%) patients presenting with deformity alone. Dorsal affection was commonest (60.8%), followed by lumbosacral (19.6%) and cervical (19.6%), with multilevel/skip lesions seen in four patients. The mean coronal/sagittal Cobb at presentation was 24.2°/40.96°, which improved to 8.2°/25.6° in the immediate and 8.8°/24.8° at the latest follow-up. Gene Xpert positivity was found in 95%, AFB culture positivity in 84%, and histopathology was positive in 91%. All patients had posterior surgery with an additional anterior reconstruction in 6. The complication rate was 5.8% (N = 3); 2 had implant loosening requiring revision surgery, 1 with prolonged discharging sinus with MDR TB, healed with chemotherapy.

CONCLUSION

Pediatric post-tuberculous spinal deformities require identification of those who are likely to worsen, and close follow-up is mandatory. Failure of medical management, major destruction of vertebral bodies, type C stabilization pattern, and worsening deformity/neurodeficit require surgery with a good outcome.

[Current status of surgical treatment for angular kyphosis in spinal tuberculosis]

Objective

To review current status of surgical treatment for angular kyphosis in spinal tuberculosis and provide reference for clinical treatment.

Methods

The literature on the surgical treatment for angular kyphosis of spinal tuberculosis in recent years was extensively reviewed and summarized from the aspects of surgical indications, surgical contraindications, surgical approach, selection of osteotomy, and perioperative management.

Results

Angular kyphosis of spine is a common complication in patients with spinal tuberculosis. If kyphosis progresses gradually, it is easy to cause neurological damage, deterioration, and delayed paralysis, which requires surgical intervention. At present, surgical approaches for angular kyphosis of the spine include anterior approach, posterior approach, and combined anterior and posterior approaches. Anterior approach can be performed for patients with severe spinal cord compression and small kyphotic Cobb angle. Posterior approach can be used for patients with large kyphotic Cobb angle but not serious neurological impairment. A combined anterior and posterior approaches is an option for spinal canal decompression and orthosis. Osteotomy for kyphotic deformity include Smith-Peterson osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection(VCR), vertebral column decancellation (VCD), posterior vertebral column resection (PVCR), deformed complex vertebral osteotomy (DCVO), and Y-shaped osteotomy. SPO and PSO are osteotomy methods with relatively low surgical difficulty and low surgical risks, and can provide 15°-30° angular kyphosis correction effect. VCR or PVCR is a representative method of osteotomy and correction. The kyphosis correction can reach 50° and is suitable for patients with severe angular kyphosis. VCD, DCVO, and Y-shaped osteotomy are emerging surgical techniques in recent years. Compared with VCR, the surgical risks are lower and the treatment effects also improve to varying degrees. Postoperative recovery is also a very important part of the perioperative period and should be taken seriously.

Conclusion

There is no consensus on the choice of surgical treatment for angular kyphosis in spinal tuberculosis. Osteotomy surgery are invasive, which is a problem that colleagues have always been concerned about. It is best to choose a surgical method with less trauma while ensuring the effectiveness.

Global realignment after posterior vertebral column resection in severe thoracolumbar post-tubercular kyphosis: correlation with patient-reported outcomes

PURPOSE

To investigate spinal realignment in patients with severe post-tubercular kyphosis (PTK) who underwent posterior vertebral column resection (PVCR) and its correlation with patient-reported outcomes (PROs).

METHODS

Eighty-two patients were included in this study. Spinopelvic parameters (focal scoliosis (FS), coronal balance (CB), sagittal vertical axis (SVA), focal kyphosis (FK), C2-7 lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and pelvic incidence minus lumbar lordosis (PI-LL)) and PROs (Visual Analog Scale (VAS) and Oswestry Disability Index (ODI)) were analyzed. The correlation between spinopelvic parameters and PROs was evaluated.

RESULTS

FK, FS, CL, TK, LL, and PI-LL significantly changed after surgery. FK decreased from pre-operative 108.5 ± 16.4° to 31.8 ± 4.5° at three months after surgery and increased to 38.7 ± 6.6° at final follow-up (P < 0.001). FS decreased from pre-operative 20.9 ± 2.2° to 5.1 ± 2.2° at final follow-up (P < 0.001). CL decreased from pre-operative 7.2 ± 7.3° to 3.3 ± 8.3° at final follow-up (P = 0.002). TK improved from pre-operative - 5.6 ± 7.1° to 12.9 ± 8.2° at final follow-up (P < 0.001). LL decreased from pre-operative 75.5 ± 12.6° to 45.5 ± 7.9° at final follow-up (P < 0.001). PI-LL improved from pre-operative - 24.8 ± 13.4° to 4.8 ± 9.9° at final follow-up (P < 0.001). The improvement of PROs was found to be significantly correlated with the variations of FK, CL, TK, LL, and PI-LL. The multiple regression analysis revealed that FK was an independent predictor for the improvement of VAS and ODI.

CONCLUSIONS

PVCR is effective in treating severe PTK, which can significantly improve patients' clinical and radiographic outcomes. Spine surgeons should pay more attention to reducing the residual kyphosis.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up

PURPOSE

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy.

METHODS

The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded.

RESULTS

The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient.

CONCLUSION

Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Utilization of ring-shaped bone allograft for surgical treatment of adolescent post-tubercular kyphosis: A retrospective study

This study aimed to investigate the mid-term outcome of ring-shaped bone allografts in the surgical treatment of adolescent post-tubercular kyphosis secondary to spinal tuberculosis.The records of adolescent patients diagnosed with spinal tuberculosis who received treatment in our department between 2009 and 2013 were retrospectively reviewed. The anterior approach was used in cases of cervical kyphosis and the posterior approach was used in cases of thoracic and lumbar kyphosis. During the surgery, the ring-shaped bone was used as a structural bone graft associated with the cancellous bone filing in the center portion of the ring shape. Cobb's angle, signs of spinal infusion on computed tomography, and complications were followed up.A total of 25 patients were included in our study. Among them, 3 involved the cervical region, 5 involved the thoracic region, 8 involved the thoracolumbar region, and 9 involved the lumbar region. The preoperative kyphosis deformity was a mean 65° Cobb's angle (40°-97°) compared to the postoperative 14° Cobb's angle (10°-21°) for an average correction of 51°. All wounds healed well without graft rejection. All patients achieved bone fusion 3 months postoperative for a 100% fusion rate.Our results show that the ring-shaped allograft bone is an effective option for the treatment of adolescent kyphosis. The ring-shaped allograft bone demonstrated satisfactory mechanical strength and vertebral fusion without mid-term metallic toxicity.

Review article: Surgical approaches for correction of post-tubercular kyphosis

This study reviewed the literature regarding the pros and cons of various surgical approaches (anterior, anterolateral, combined, and posterior) for correction of post-tubercular kyphosis. The anterior and anterolateral approaches are effective in improving neurological deficit but not in correcting kyphosis. The combined anterior and posterior approach and the posterior approach combined with 3-column osteotomy achieve good neurological improvement and kyphosis correction. The latter is superior when expertise and facilities are available.