Volume 16 | Issue 1 | January-March 2021 | Page 10-16 | Awyay Rege, Amarjeet Jagadale, Sameer Ruparel, Ram Chaddha
Authers: Awyay Rege , Amarjeet Jagadale , Sameer Ruparel , Ram Chaddha 
 Clinical Spine Fellows at Lilavati, Jaslok and Global Hospitals, Mumbai.
 Consultant Spine Surgeon at Jaslok and Global Hospitals, Mumbai.
 Consultant Spine Surgeon at Lilavati, Jaslok and Global Hospitals, Mumbai.
Address of Correspondence
Dr. Ram Chaddha,
Room No 3, OPD Block, Lilavati Hospital and Research Centre, Reclamation, Bandra West, Mumbai, Maharashtra- 400050.
Though tuberculosis of spine is known to affect humans since ages, knowledge about its pathogenesis is fairly recent. With the advent of Anti Tuberculous therapy, treatment principles have changed tremendously in recent times. With clarity of indications for surgery, the preferred technique and approach still varies amongst spine surgeons across the world. Though anterior approach was initially preferred, recently posterior approach is favoured by many. Combined approach encompasses the advantages of either, however, is also more morbid. With the quest for better patient outcomes, surgeons have managed to treat most cases with either anterior or posterior approaches. Anterior approach has the advantage of direct decompression, better debridement with acceptable blood loss and operative time. It is more cost effective and holds its ground even with recent advances in Minimally Invasive Spine Surgeries. All in all, authors feel each patient and its pathology is different and both approaches have their own indications and advantages and thus follow an effective algorithm for patient management. This manuscript focusses on the importance of transthoracic approach for treating spinal tuberculosis in present era.
Keywords: Transthoracic approach, Anterior approach, Spinal Tuberculosis, Koch’s spine.
1. Tuli SM. 3rd ed. New Delhi: Jaypee Brothers; 2004. Textbook- Tuberculosis of the skeletal system (Bones, Joints, Spine and Bursal sheaths).
2. Sharif HS , Clark DC, Aabed MY, Haddad MC, Al Deeb SM, Yaqub B, Al Moutaery KR. Granulomatous spine infections: MR imaging. 1990;117(1):101-7.
3. Farer LS, Lowell AM, Meador MP. Extrapulmonary tuberculosis in the United States. Am J Epidemiol. 1979;109:205–17.
4. 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;75:233–9.
5. Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol. 1984;12:178–186.
6. Omari B, Robertson JM, Nelson RJ, Chiu LC. Pott’s disease: A resurgent challenge to the thoracic surgeon. Chest. 1989;95:145–50
7. Research Council Working Party on Tuberculosis of the Spine A 15-year assessment of controlled trials of the management of tuberculosis of the spine in Korea and Hong Kong. Thirteenth Report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg Br 1998;80(3):456–62.
8. Jutte PC, Van Loenhout-Rooyackers JH. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Database Syst Rev 2006;(1):CD004532.
9. Tuli SM. Results of treatment of spinal tuberculosis by ‘middle path’ regime. J Bone Joint Surg Br 1975;57(1):13–23.
10. Mak KC, Cheung KM: Surgical treatment of acute TB spondylitis: indications and outcomes. Eur Spine J 22 (Suppl 4):603-611, 2013.
11. Zhang HQ, Lin MZ, Li JS, Tang MX, Guo CF, Wu JH, Liu JY. One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg. 2013;133(3):333–41.
12. Machino M, Yukawa Y, Ito K, Nakashima H, Kato F. A new thoracic reconstruction technique “transforaminal thoracic interbody fusion”: a preliminary report of clinical outcomes. Spine. 2010;35(19):E1000–5.
13. Zaveri GR, Mehta SS. Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar interbody fusion (TLIF) and posterior instrumentation. J Spinal Disord Tech. 2009;22(4):257–62.
14. Benli T, Kaya A, Acaroglu E. Anterior instrumentation in tuberculous spondylitis: Is it effective and safe? Clin Orthop Relat Res. 2007;460:108–16.
15. Jain AK, Dhammi IK, Prashad B, Sinha S, Mishra P. Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. J Bone Joint Surg Br. 2008;90:1477–81.
16. Hodgson AR, Stock FE, Fang HS, Ong GB. Anterior spinal fusion: The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg. 1960;48:172–8.
17. Hee HT, Majd ME, Holt RT, Pienkowski D. Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech. 2002;15:149–56.
18. Krodel A, Kruger A, Lohscheidt K, Pfahler M, Refior HJ. Anterior debridement.fusion, and extrafocal stabilization in the treatment of osteomyelitis of spine. J spinal Disord. 1999;8:304–9.
19. Fukuta S, Miyamoto K, Masuda T, Hosoe H, Kodama H, Nishimoto H, et al. Two stage (Posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine (Phila Pa 1976) 2003;28:E302–8.
20. Laheri VJ, Badhe NP, Dewnany GT. Single stage decompression, anterior interbody fusion and posterior instrumentation for tuberculous kyphosis of the dorso-lumbar spine. Spinal Cord. 2001;39:429–36.
21. Moon MS. Combined posterior instrumentation and anterior interbody fusion for active tuberculous kyphosis of the thoraco-lumbar spine. Curr Orthopaedics. 1991;5:177–9.
22. Moon MS, Woo YK, Lee KS, Ha KY, Kim SS, Sun DH. Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines. Spine (Phila Pa 1976) 1995;20:1910–6.
23. Jain AK, Dhammi IK. Tuberculosis of the Spine: A Review. Clin Orthop Relat Res. 2007;460:39–49.
24. Güven O, Kumano K, Yalçin S, Karaham M, Tsuji S. A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of spinal tuberculosis. Spine (Phila Pa 1976) 1994;19:1039–43.
25. Louw JA. Spinal tuberculosis with neurological deficit: Treatment with anterior vascularised rib grafts, posterior osteotomies and fusion. J Bone Joint Surg Br. 1990;72:686–93.
26. Lee TC, Lu K, Yang LC, Huang HY, Liang CL. Transpedicular instrumentation as an adjunct in the treatment of thoracolumbar and lumbar spine tuberculosis with early state bone destruction. J Neurosurg. 1999;91(2 Suppl):163–9.
27. Jain AK, Aggarwal A, Dhammi IK, Aggarwal PK, Singh S. Extrapleural anterolateral decompression in tuberculosis of the dorsal spine. J Bone Joint Surg Br. 2004;86:1027–31.
28. Bhavuk Garg, Pankaj Kandwal, Upendra Bidre Nagaraja, Ankur Goswami, and Arvind Jayaswal Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: A retrospective analysis Indian J Orthop. 2012; 46(4): 390.
29. Shen J, Zheng Q, Wang Y, Ying X. One-stage combined anterior-posterior surgery for thoracic and lumbar spinal tuberculosis. J Spinal Cord Med 2019 May 3;1-8.
30. Huang QS, Zheng C, Hu Y, Yin X, Xu H, Zhang G, Wang Q: One-stage surgical management for children with spinal tuberculosis by anterior decompression and posterior instrumentation. Int Orthop 2009;33:1385-1390.
31. Zhang HQ, Lin MZ, Li JS, Tang MX, Guo CF, Wu JH, Liu JY: One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg 2013;133:333-341.
32. Wang X, Pang X, Wu P, Luo C, Shen X. One-stage anterior debridement, bone grafting and posterior instrumentation vs. single posterior debridement, bone grafting, and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis.
Eur Spine J 2014;23:830–837.
33. Pu X, Zhou Q, He Q, Dai F, Xu J, Zhang Z, Branko. A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis. Int Orthop 2012;36:307–313.
34. Hodgson AR, Stock FE, Fang HS, Ong GB. Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg. 1960;48:172–8.
35. Sundararaj GD. Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. J Bone Joint Surg Br 2009 May;91(5):702.
36. Lu G, Wang B, Li J, Liu W, Cheng I. Anterior debridement and reconstruction via thoracoscopy-assisted mini-open approach for the treatment of thoracic spinal tuberculosis: minimum 5-year follow-up. Eur Spine J 2012;21:463–469.
37. Jin D, Qu D, Chen J, Zhang H. One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J 2004;13:114–121.
38. Dai LY, Jiang LS, Wang W, Cui YM. Single-stage anterior autogenous bone grafting and instrumentation in the surgical management of spinal tuberculosis. Spine (Phila Pa 1976) 2005;30:2342–2349.
39. Zhao J, Lian XF, Hou TS, Ma H, Chen ZM. Anterior debridement and bone grafting of spinal tuberculosis with one stage instrumentation anteriorly or posteriorly. Int Orthop 2007;31:859–863.
40. Cui X, Li LT, Ma YZ. Anterior and posterior instrumentation with different debridement and grafting procedures for multi-level contiguous thoracic spinal tuberculosis. Orthop Surg. 2016;8(4):454–61.
41. Dunn RN, Ben HM. Spinal tuberculosis. Bone Joint J. 2018;100-B(4):425–31.
42. Li W, Liu Z, Xiao X, Zhang Z, Wang X. Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults. BMC Musculoskeletal Disorders. 2019;20:570.
43. Assaghir YM, Refae HH, Alam-Eddin M. Anterior versus posterior debridement fusion for single-level dorsal tuberculosis: the role of graft-type and level of fixation on determining the outcome. Eur Spine J 2016 Dec;25(12):3884-3893.
44. Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol Surg Res. 2012;98: 900–909.
45. De Iure F, Cappuccio M, Paderni S, Bosco G, Amendola L. Minimally invasive percutaneous fixation of thoracic and lumbar spine fractures. Min Invasive Surg. 2012;2012:141032.
46. McLain RF. Spinal cord decompression: an endoscopically assisted approach for metastatic tumors. Spinal Cord. 2001;39:482–487.
47. Palmisani M, Gasbarrini A, Brodano GB, De Iure F, Cappuccio M, Boriani L, Amendola L, Boriani S. Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures. Eur Spine J. 2009;18(suppl 1):S71–S74.
48. St Clair SF, McLain RF. Posterolateral spinal cord decompression in patients with metastasis: an endoscope assisted approach. Surg Technol Int. 2006;15:257–263.
49. Garg N, Vohra R. Minimally Invasive Surgical Approaches in the Management of Tuberculosis of the Thoracic and Lumbar Spine Clin Orthop Relat Res. DOI 10.1007/s11999-014-3472-6.
50. Jayaswal A, Upendra B, Ahmed A, Chowdhury B, Kumar A. Video assisted thoracoscopic anterior surgery for tuberculous spondylitis. Clin Orthop Relat Res. 2007;460:100–107.
51. Kapoor SK, Kapoor S, Agarwal M, Aggarwal P, Jain BK Jr. Thoracoscopic decompression in Pott’s spine and its long term follow up. Int Orthop. 2012;36:331–337.
52. Kandwal P, Garg B, Upendra BN, Chowdhury B, Jayaswal A. Outcome of minimally invasive surgery in the management of tuberculous spondylitis. Indian J Orthop. 2012;46:159–164.
53. Ringel F, Stoffel M, Stuer C, Meyer B. Minimally invasive transmuscular pedicle screw fixation of the thoracic and lumbar spine. Neurosurgery. 2006;59(4 suppl):361–367.
54. J S Mehta , S Y Bhojraj. Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies J Bone Joint Surg Br. 2001 Aug;83(6):859-63.
|How to Cite this article: Rege A, Jagadale A, Ruparel S, Chaddha R. Transthoracic Approach for Spinal Tuberculosis: Where it has the Advantage in the Present Era?. Journal of Trauma and Orthopaedic Surgery January-March 2021;16(1): 10-16.|