Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years’ follow-up in the MRC study long enough?

Introduction

Tuberculosis of the spine is a still a common disease entity, not only in developing countries but is also returning in developed countries especially in the immune-compromised patients. Conservative treatment with chemotherapy is still the main stay of treatment. This article focuses on the clinical and radiological outcomes, and problems with conservative treatment.

Method

The available literature of anti-tuberculosis chemotherapy in managing spinal tuberculosis was reviewed. Data sources included relevant literature of the English language identified through Medline search from 1946 to 2011. Personal experience and unpublished reviews from the authors’ institution were also included.

Results

Although majority of patients respond well to anti-tuberculosis chemotherapy, about 15 % of them develop paradoxical response. The Medical Research Council (MRC) studies have shown that for patients without significant neurological deficits, operative and conservative treatment could produce the same clinical outcome at 15 years follow-up. Patients treated operatively with debridement and spinal fusion with strut graft had faster bony fusion and less kyphotic deformity. In contrast, those treated with drugs alone or with simple debridement without fusion may result in disease reactivation, severe kyphosis or late instability, which in turn may lead to late-onset Pott’s paraplegia, back pain, sagittal imbalance and compromised pulmonary function that are difficult or risky to treat.

Conclusion

Recognition of the clinical and radiologic features of these late sequels is important for the management. Prevention of deformity in the early disease has been added to the modern standard of treatment of TB spine.

     

Etiology-Based Classification of Adjacent Segment Disease Following Lumbar Spine Fusion

Background

Adjacent segment disease (ASDz) is a potential complication following lumbar spinal fusion. A common nomenclature based on etiology and ASDz type does not exist and is needed to assist with clinical prognostication, decision making, and management.

Questions/Purposes

The objective of this study was to develop an etiology-based classification system for ASDz following lumbar fusion.

Methods

We conducted a retrospective chart review of 65 consecutive patients who had undergone both a lumbar fusion performed by a single surgeon and a subsequent procedure for ASDz. We established an etiology-based classification system for lumbar ASDz with the following six categories: “degenerative” (degenerative disc disease or spondylosis), “neurologic” (disc herniation, stenosis), “instability” (spondylolisthesis, rotatory subluxation), “deformity” (scoliosis, kyphosis), “complex” (fracture, infection), or “combined.” Based on this scheme, we determined the rate of ASDz in each etiologic category.

Results

Of the 65 patients, 27 (41.5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as “neurologic.” Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as “degenerative.” Ten patients (15.4%) had spondylolisthesis or instability and were classified as “instability,” and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as “deformity.” Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as “combined.”

Conclusion

This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.

     

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis

Introduction

Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature.

Materials and methods

We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups.

Conclusion

We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

     

Advances in Spinal Fusion Strategies in Adult Deformity Surgery

Background

As the frequency of adult deformity surgery (ADS) continues to increase, our understanding of techniques that enhance fusion must continue to evolve because pseudarthrosis can be a serious and costly event.

Purposes/Questions

We sought to conduct a review of the literature investigating techniques that can enhance outcomes of ADS.

Methods

Two databases were searched for keywords such as “advances in spinal fusion,” “new technology in adult spinal deformity,” “interbody devices for adult spinal deformity,” “adult spinal deformity rods,” and “screw design in adult spinal deformity” to examine recent literature and trends in ADS.

Results

We identified 45 articles for our review. Topics studied include the use of multiple rods, interbody fusion, distal fixation techniques, and bone morphogenetic protein or iliac crest bone graft.

Conclusions

Many recent innovations in treatments to enhance fusion in ADS have been studied, some more controversial than others. Further research into the efficacy of these techniques may increase fusion rates in ADS.

     

一期后路病灶清除植骨融合内固定治疗胸腰椎结核

目的：探讨一期后路病灶清除植骨融合内固定治疗胸腰椎结核的临床疗效。方法回顾性分析2010年1月～2012年6月本院采用一期后路病灶清除植骨融合内固定治疗的28例胸腰椎结核患者的临床资料,对比研究患者手术前后患椎后凸Cobb角、红细胞沉降率（ erythrocyte sedimentation rate, ESR）、C 反应蛋白（ C-reaction protein, CRP）、植骨融合及美国脊髓损伤协会（ American Spinal Injury Association, ASIA）分级变化情况。结果28例获得随访,平均随访1．2年,术后Cobb角无明显丢失,后凸畸形平均纠正4．12°,平均矫正率24．5％。末次随访ESR、CRP恢复正常,植骨大部分骨性融合,融合时间平均为7．8个月,原有症状大部分消失,神经功能均有不同程度恢复。结论一期后路病灶清除植骨融合内固定治疗胸腰椎结核可有效完成病灶清除、减压、矫正后凸畸形、恢复生理曲度和重建脊柱稳定性,效果满意。     

Natural history of Pott’s kyphosis

The natural history of Pott’s kyphosis is different from that of other spinal deformities. After healing of the spinal infection, the post-tubercular kyphosis in adults is static but in children variable progression of the kyphosis is seen. The changes occurring in the spine of children, after the healing of the tubercular lesion, are more significant than the changes that occur during the active stage of infection. During growth, there is a decrease in deformity in 44 % of the children, an increase in deformity in 39 % of the children and no change in deformity in 17 % of the children. The critical factor leading to the progress of the deformity is dislocation of the facets. This can be identified on radiographs by the “Spine-at-risk” signs. Dislocation of facets at more than two levels can lead to the “Buckling collapse” of the spine, which is characteristically seen only in severe tubercular kyphosis in children. Age below 10 years, vertebral body loss of more than 1–1.5 pre-treatment deformity angle of greater than 30° and involvement of cervicothoracic or thoracolumbar junction are the other risk factors for deformity progression. In children, the kyphosis can progress even after healing of the spinal infection and hence children with spinal tuberculosis must be followed-up till skeletal maturity.

     

Impact of spinal imbalance and back muscle strength on locomotive syndrome in community-living elderly people

BackgroundThe Japanese Orthopaedic Association has proposed the term locomotive syndrome (“locomo”) to designate a condition of individuals in high-risk groups with musculoskeletal disease who are highly likely to require nursing care. The specific characteristics of “locomo” must still be determined. The spinal column is a major and important component affected by “locomo,” but no literature has examined the relationship between spinal factors and “locomo.” The current study investigates the influence of spinal factors on “locomo” in the elderly.MethodsA total of 135 subjects >70 years old were enrolled in the study (Yakumo study). Those answering yes to least one of the seven categories in the self-assessment checklist for “locomo” were defined as having “locomo.” We evaluated lateral lumbar radiographs, sagittal parameters, sagittal balance using the spinal inclination angle (SIA) as an index, spinal mobility as determined with SpinalMouse®, back muscle strength (BMS), and body mass index (BMI).ResultsAge, BMS, and SIA showed significant correlations with “locomo” and five of the seven self-assessment categories. Multivariate logistic regression analysis indicated that a decrease in BMS (OR 0.971, p < 0.001) and an increase in SIA (OR 1.144, p < 0.05) were significantly associated with “locomo.” BMS had significant negative correlations with age (r = ?0.363), SIA (r = ?0.294), and lumbar kyphosis (r = ?0.254), and positive correlations with sacral slope angle (r = 0.194). SIA had significant negative correlations with BMS (r = ?0.294), lumbar spinal range of motion (ROM) (r = ?0.186) and total spinal ROM (r = ?0.180), and positive correlations with age (r = 0.403) and lumbar kyphosis (r = 0.593).ConclusionsA decrease in BMS and an increase in SIA may be the most important risk factors for “locomo.” Lumbar kyphosis is an important factor related to BMS and SIA. Back muscle strengthening and lumbar spinal ROM exercises could be useful for improving the status of an individual suffering from “locomo.”     

Cervical ossification of the posterior longitudinal ligament: factors affecting the effect of posterior decompression

Objective: Decompression procedures for cervical myelopathy of ossification of the posterior longitudinal ligament (OPLL) are anterior decompression with fusion, laminoplasty, and posterior decompression with fusion. Preoperative and postoperative stress analyses were performed for compression from hill-shaped cervical OPLL using 3-dimensional finite element method (FEM) spinal cord models.

Methods: Three FEM models of vertebral arch, OPLL, and spinal cord were used to develop preoperative compression models of the spinal cord to which 10%, 20%, and 30% compression was applied; a posterior compression with fusion model of the posteriorly shifted vertebral arch; an advanced kyphosis model following posterior decompression with the spinal cord stretched in the kyphotic direction; and a combined model of advanced kyphosis following posterior decompression and intervertebral mobility. The combined model had discontinuity in the middle of OPLL, assuming the presence of residual intervertebral mobility at the level of maximum cord compression, and the spinal cord was mobile according to flexion of vertebral bodies by 5°, 10°, and 15°.

Results: In the preoperative compression model, intraspinal stress increased as compression increased. In the posterior decompression with fusion model, intraspinal stress decreased, but partially persisted under 30% compression. In the advanced kyphosis model, intraspinal stress increased again. As anterior compression was higher, the stress increased more. In the advanced kyphosis +?intervertebral mobility model, intraspinal stress increased more than in the only advanced kyphosis model following decompression. Intraspinal stress increased more as intervertebral mobility increased.

Conclusion: In high residual compression or instability after posterior decompression, anterior decompression with fusion or posterior decompression with instrumented fusion should be considered.     

病灶清除一期植骨内固定治疗脊柱结核

目的探讨脊柱结核病灶清除手术后内固定方式的选择。方法对35例脊柱结核患者采用3种不同术式：16例前路病灶清除、植骨,一期前路钢板或钉棒内固定;14例前路病灶清除、植骨,一期后路经弓根钉棒内固定;5例前路病灶清除、植骨,一期前路钢板、后路钉棒联合内固定。结果35例均获随访,时间18-24个月。X线显示病灶静止,植骨融合,内固定无松动断裂,后凸畸型改善,其中合并脊髓损害15例,按Frankel分级,C级3例、D级12例术后全部恢复到E级。结论病灶清除一期植骨内固定有利于重建脊柱稳定性,纠正和预防脊柱后凸畸形,可避免或减少结核复发。     

Debridement,interbody graft using titanium mesh cages,posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only

PurposeTo analyse the efficacy and feasibility of surgical management for elderly patients with multilevel non-contiguous spinal tuberculosis(MNSTB)by using one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion.MethodsFrom September 2009 to October 2013, 15 elderly patients with MNSTB were treated with one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion. There were 10 males and 5 females with a mean age of 63.2 years (range: 60–68 years) at the time of surgery. The mean follow-up time was 40 months(range 26–68 months). Patients were evaluated before and after surgery in terms of erythrocyte sedimentation rate(ESR), neurological status, pain and kyphotic angle.ResultsThe spinal tuberculosis was completely cured, and the grafted bones were fused in all 15 patients. There were no recurrent tuberculous infections. The ESR reached a normal level within 3 months in all patients. The ASIA neurological classification improved in all cases, and pain relief was reported by all patients. The average preoperative kyphosis was 20.1° (range 8–38°) and decreased to 7.6° (range 1–18°) postoperatively. There was no significant loss of the correction at the latest follow-up.ConclusionsOur results showed that one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion was an effective treatment for elderly patients with MNSTB. It is characterized by minimum surgical trauma, good neurological recovery, and good correction of kyphosis.     

Ⅰ期前后方融合后路内固定治疗胸腰椎结核

目的：探讨胸腰椎结核Ⅰ期前后方融合、后路内固定治疗的临床疗效。方法：自2003年3月至2006年12月,应用Ⅰ期前后方融合后路内固定治疗胸腰椎结核23例,男15例,女8例;年龄17～61岁,平均37.6岁。结核病灶位于胸段4例,胸腰段8例,腰段11例。结果：术后随访9～40个月（平均28.7个月）,患者术后2～3周症状基本缓解并下床活动,术后6个月X线片显示植骨融合。16例不完全性截瘫患者Frankel分级平均恢复1.62级。并发症主要有暂时性窦道形成2例,内固定断裂1例,因抗结核化疗周期不足复发1例。结论：Ⅰ期前后方融合后路内固定治疗胸腰椎结核能有效地清除病灶、重建脊柱稳定性、促进植骨融合和截瘫恢复。     

Sitting imbalance cause and consequence of post-traumatic Charcot spine in paraplegic patients

Purpose

To analyze the role of spine alignment in post-traumatic paraplegic patient as a potential cause of late Charcot spine disease (CSD).

Method

A retrospective review of three cases in which the disease appeared more than 15 years after a spinal cord injury treated by posterior fusion. A review of the literature concerning spine balance in sitting position, especially referred to paraplegic patients, is done to validate this hypothesis.

Results

Lumbar kyphosis in paraplegic patients during the sitting position may increase the mechanical load on disks and ligament below the previously fused area. This phenomenon, in combination with lack of protective mechanism because of poor muscular support and lack of sensitivity can speed up and amplify the normal degenerative changes in the disk and ligaments.

Conclusions

More investigations are required to fully understand all the mechanisms underlying CSD pathogenesis to prevent it. Until then, a systematic long-term clinical and radiological follow-up in all post-trauma paraplegic patients is suggested. Combined anterior and posterior fusion, when feasible, can restore the sagittal balance providing a better quality of life in these patients.

     

Scheuermann’s Kyphosis Following Cervical Spinal Cord Injury

Abstract

Background: Scheuermann’s kyphosis is an uncommon autosomal dominant disease that manifests as a progressive thoracic skeletal deformity. It can lead to severe restrictive lung disease or predispose to spinal cord injury (SCI). Neurologic sequelae are rarely reported in the literature.

Method: Case Presentation

Summary: A 47-year-old man sustained a cervical SCI requiring surgical anterior fusion and reoperation for fracture of the affected vertebra. One year after SCI, he presented with further kyphotic progression and cervical spine instability. Clinical presentation and family history led to a diagnosis of Scheuermann’s kyphosis. To prevent further progression, he underwent extensive multilevel anterior and posterior surgical stabilization.

Conclusion: This case illustrates the importance of early diagnosis and treatment of progressive spinal deformities. With proper surgical correction, this patient made substantial gains in mobility, self-care, and respiratory status.

J Spinal Cord Med. 2003;26:92-94     

后路病灶清除椎弓根内固定治疗胸腰椎结核后凸畸形

目的 探讨经后路病灶清除椎问植骨椎弓根螺钉内固定治疗胸腰椎结核后凸畸形的疗效。方法 采用经后路病灶清除椎问植骨椎弓根螺钉内固定治疗23例胸腰椎结核后凸畸形患者。结果 术后随访1,5～3年,23例患者胸腰椎结核全部治愈,无复发病例,X线片显示椎问植骨全部融合,后凸矫正度无明显丢失。结论 该术式可在一次手术中同一切口内达到椎管内减压、脊柱矫形、融合和脊柱恢复稳定的目的,能获得满意效果。     

Ⅰ期手术经后路病灶清除内固定治疗儿童胸椎结核

目的:探讨Ⅰ期手术经后路结核病灶清除植骨融合内固定治疗儿童胸椎结核的效果.方法:2005年6月至2010年12月采用病灶清除植骨融合内固定治疗儿童胸椎结核9例,其中男7例,女2例;年龄3～12岁,平均7岁;病史3个月～1年,平均6个月.患儿均有不同程度胸背痛、肋间神经痛以及脊柱后凸畸形,同时伴有低热、盗汗、消瘦等全身症状.术前X线片、CT、MRI检查提示病变部位多发生于T4-T9节段.胸段后凸角35°～72°,平均48.2°.术前脊髓功能ASIA分级:B级2例,C级5例,D级2例.术后定期复查X线片了解后凸角变化和椎间植骨融合情况,采用ASIA分级评定术后脊髓功能恢复情况.结果:术中无大血管或脊髓损伤,术后随访16～38个月,平均24个月.所有患儿结核症状消失,无结核复发、切口感染、窦道形成或内固定失败等并发症,复查血沉正常.术后4～8个月复查X线片提示椎间植骨均获骨性愈合,内固定位置正常.最后随访后凸角12°～30°,平均19.5°,脊髓功能ASIA分级:C级2例,D级2例,E级5例.脊髓功能均有不同程度改善.结论:Ⅰ期经后路清除胸椎结核病灶彻底,椎管减压可靠,矫形效果显著,行自体或同种异体骨植骨钉棒系统内固定可有效重建胸段脊柱的稳定性.     

脊柱后凸全脊柱截骨内固定31例临床观察

目的　研究USS椎弓根内固定系统应用于脊柱后凸畸形截骨矫治内固定的疗效。方法　应用USS椎弓根内固定系统固定 ,对后凸角度矫正率 ,截骨融合率 ,内固定结构稳定性 ,对 31例接受截骨矫治内固定治疗的患者进行随访分析。结果　 31例得到术后平均 1 2个月随访 ,术前脊柱后凸角平均 73° ,术后后凸角平均为 1 2°,截骨融合率 96 77% ,后凸角度矫正率为 83 56 %。无一例发生断钉、断棒及联接结构松脱。结论　USS椎弓根内固定系统具有内固定坚固、稳定 ,可早期离床活动 ,无须外固定的优点 ,使脊柱基本呈流线型 ,恢复生理曲度     

Long-term follow-up assessment of vascularized rib pedicle graft for tuberculosis kyphosis

This article reports a long-term follow-up assessment (10-15 years) of eight children treated with a vascularized rib pedicle graft after an anterior spinal decompression for paralysis resulting from tuberculosis. Neurologic recovery, fusion, and hypertrophy of the rib grafts were noted in all patients. The vascularized rib pedicle grafts were superior to autologous rib grafts in supporting and promoting early fusion of the anterior column in children with kyphosis resulting from tuberculosis.     

后路固定前路病灶清除植骨融合手术治疗脊柱结核

目的观察后路固定前路病灶清除植骨融合手术治疗脊柱结核的临床效果。方法回顾分析2001年3月至2006年7月采用后路固定前路病灶清除植骨融合手术治疗脊柱结核59例,术后随访1~5年,平均2.5年。观察结核治愈率,后凸畸形矫正及截瘫恢复情况。结果所有病人术后均骨性融合、神经症状及后凸畸形均得到明显改善,手术前后后凸角分别为(29±5)°和(11±3)°,P值<0.01。结论后路固定前路病灶清除植骨融合手术适用于脊柱结核的治疗,此方法能一次性完成畸形矫形,病灶清除,植骨融合固定,临床疗效肯定。     

Ⅰ期后路病灶清除植骨融合内固定治疗胸椎结核

目的:探讨Ⅰ期单纯后路病灶清除、椎弓根螺钉固定、植骨融合治疗胸椎结核的疗效及适应证。方法:2005年1月至2011年5月对12例胸椎结核患者行术前、术后常规抗痨治疗,Ⅰ期行单纯后路病灶清除植骨椎弓根螺钉内固定,其中男7例,女5例;平均年龄45岁,平均病程15个月。观察手术时间、出血量,术后植骨融合、局部后凸畸形矫正、神经功能恢复情况。结果:所有患者病灶清除彻底,植骨融合良好。手术时间120～210min,平均170min;术中出血量200～1000ml,平均510ml。后凸Cobb角术前平均(28.7±9.2)°,术后平均(8.2±3.5)°,差异具有统计学意义(P<0.05)。术后末次随访无内固定并发症,无后凸矫正丢失,无结核复发。神经功能Frankel分级均恢复为E级。结论:单纯Ⅰ期后路病灶清除并植骨融合、椎弓根螺钉固定治疗胸椎结核具有病灶清除彻底、手术时间短、出血量少、后凸畸形矫正明显、融合率高等优点。