versión On-line ISSN 2309-8309
SA orthop. j. vol.8 no.4 Pretoria ene. 2009
C ReidI; RN DunnII
IIMBChB(UCT), MMed(Orth), FCS(Orth)SA; Consultant Spine and Orthopaedic Surgeon, Head of Spine Services, Groote Schuur Hospital and Red Cross War Memorial Children's Hospital, Division of Orthopaedic Surgery, University of Cape Town
BACKGROUND: Antituberculous chemotherapy remains the cornerstone of treatment of tuberculosis (TB) of the spine and the paediatric and adolescent populations respond particularly well to medical management. These patients are however more prone to kyphotic deformity of the spine both during the active phase, and after the disease has been cured. The British Medical Research Council Working Party on tuberculosis of the spine has found only slight advantages to surgical management over medical management and advocated ambulant chemotherapy alone where adequate facilities are lacking.1 However patients with neurological compromise were excluded from the initial trials. Patients managed surgically had either anterior debridement and strut grafting (Hong Kong procedure) or anterior debridement alone. No posterior fusion was performed and no instrumentation was used.
METHODS: We reviewed all patients under the age of 18 years who had undergone surgery for TB spine at Groote Schuur and the Red Cross War Memorial Children's Hospital from 2001-2008. Forty patients were identified on interrogation of the senior author's (RND) prospectively maintained database. The anatomical distribution was: Sixty-six per cent thoracic, 15% lumbar, 14% cervical or cervicothoracic and 5% thoracolumbar. Indications for surgery included: deformity (50%), neurological compromise (44%), instability (13%), pain (10%), revision (10%), diagnosis (4%) and failure of medical management (4%) Surgical procedures included: primary fusion (35), graft revision (5), drainage of psoas abscess (4), costotransversectomy (3) and biopsy (2). The majority of the fusions were anterior and posterior (25) the others were posterior only (9) or anterior only (1).
RESULTS: Where acute correction of deformity was attempted, an average kyphosis of 53° was improved to an average of 38°. At last follow-up correction was better maintained in cases where instrumentation was used, compared to un-instrumented fusions. No neurological deterioration occurred after surgery but two patients failed to improve despite decompression. The rest became ambulant. Complications included graft failure that required revision in five cases and recollection of psoas abscesses in a patient with multi-drug-resistant (MDR) TB.
CONCLUSIONS: Surgery for spinal TB in the paediatric and adolescent groups can be safe in terms of a low complication rate, and effective with good correction of deformity that is well maintained with instrumentation.
“Full text available only in PDF format”
1. Medical Research Council. A 10-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. J Bone Joint Surg (Br) 1982;64-B:393-8. [ Links ]
2. WHO 2009 report on TB.
3. Naim-ur-Rahman. Atypical forms of spinal tuberculosis. J Bone Joint Surg (Br) 1980;62-B(2):162-5. [ Links ]
4. Harries AD. WHO HIV/TB clinical manual 1996. [ Links ]
5. Fountain SS, Hsu LCS, Yau ACMC, Hogdson AR. Progressive kyphosis following solid anterior spine fusion in children with tuberculosis of the spine. J Bone Joint Surg (Am) 1975;57-A:1104-7. [ Links ]
6. Konstam PG, Blesovsky A. The ambulant treatment of spinal tuberculosis. Br J Surg 1962;50:26-8. [ Links ]
7. Medical Research Council. A five-year assessment of controlled trials of in-patient and out-patient treatment and of Plaster-of-Paris jackets for tuberculosis of the spine. J Bone Joint Surg (Br) 1976;58-B:399-411. [ Links ]
8. Rajasekaran S. The problem of deformity in spinal tuberculosis. Clin Orthop 2002;398:85-92. [ Links ]
9. Yau ACMC, Hsu LCS, O'Brien JP, Hodgson AR. Tuberculosis kyphosis-correction with spinal osteotomy, halo-pelvic distraction and anterior and posterior fusion. J Bone Joint Surg (Am) 1974;56-A:1419-34. [ Links ]
10. Rajasekaran S. The natural history of post-tubercular kyphosis in children. J Bone Joint Surg (Br) 2001; 83:954-62. [ Links ]
11. Rajasekaran S, Shanmugasundaram M.S. Prediction of the angle of gibbus deformity in tuberculosis of the spine. J Bone Joint Surg (Am) 1987;69-A:503-9. [ Links ]
12. Jutte P, Wuite S, The B, Van Altena R, Veldhuizen A. Prediction of deformity in spinal tuberculosis. Clin Orthop 2006;455:196-201. [ Links ]
13. Hoffman EB, Crosier JH, Cremin BJ. Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging. J Bone Joint Surg (Br) 1993;75-B:534-8. [ Links ]
14. Tuli S. Treatment of neurological complications in tuberculosis of the spine. J Bone Joint Surg (Am) 1969;51-A:680-92. [ Links ]
15. Pattinson PRM. Pott's paraplegia: An account of the treatment of 89 consecutive patients. Paraplegia 1986;24:77-91. [ Links ]
16. Moon M, Ha K, Sun D, Moon J, Moon Y, Chung J. Pott's paraplegia 67 cases. Clin Orthop 1996;323:122-8. [ Links ]
17. Louw JA. Spinal tuberculosis with neurological deficit. J Bone Joint Surg (Br) 1990;72-B:686-93. [ Links ]
18. Travlos J, Du Toit G. Spinal tuberculosis: Beware the posterior elements. J Bone Joint Surg (Br) 1990;72-B:722-3. [ Links ]
Prof RN Dunn
Department of Orthopaedic Surgery
Groote Schuur Hospital
Tel: (021) 404-5387; Fax: 086 6715 294
This article is the sole work of the authors. No benefits of any form are to be received from a commercial party related directly or indirectly to the subject of this article.