Paraplegia in Pott’s Spine: Evidence-based Management Strategy

Volume 16 | Issue 1 | January-March 2021 | Page 31-38 | Shailesh Hadgaonkar, Divakar Modipalli, Siddarth Aiyer, Pramod Bhilare, Ajay kothari, Parag Sancheti


Authers: Shailesh Hadgaonkar [1], Divakar Modipalli [1], Siddarth Aiyer [1], Pramod Bhilare [1], Ajay kothari [1], Parag Sancheti [1]

[1] Department of spine and Neurosciences, Sancheti Institute for Orthopaedics and Rehabilitation Shivajinagar, Pune, Maharashtra, India 41103.

Address of Correspondence
Dr. Shailesh Hadgaonkar,
Department of spine and Neurosciences, Sancheti Institute for Orthopaedics and Rehabilitation Shivajinagar, Pune, Maharashtra, India 41103
E-mail: drshadgaonkar@gmail.com.


Abstract

Study Design: Review article
Objective: To present a review of literature on the epidemiology, pathophysiology, diagnosis and outline evidence-based management strategy for paraplegia in Pott’s spine
Methods: A systematic literature search was performed using PubMed systematic Reviews. Studies published over the last 20 years were analysed and conclusions were drawn. The search was conducted using key words “Tuberculosis of Spine”, “Paraplegia” and “Management”.
Results: Early diagnosis and timely initiation of treatment is the key to successful treatment of Spinal Tuberculosis (STB) with neurological deficit. Surgery along with appropriate chemotherapy is the mainstay of treatment when STB is complicated by neurological deficits. In cases of late onset neurological deficit, the decision regarding the surgical approach is based on the severity and location of the deformity, and the nature of pathology causing the neurological deficits. Surgery is warranted in case of the early-onset spinal TB complicated by neurological deficits, disease compromising the spinal stability, spinal deformity and in patients presenting with progressive neurological deficits. Surgery for late onset neurological deficits and deformity are associated with complications like worsening of the neurological deficits, persistence of the deformity and suboptimal outcome.
Conclusions: Tuberculosis is a medical disease and chemotherapy is the cornerstone of treatment. Surgery in early disease for neurological deficits/spine instability is associated with good neurological recovery. Surgery in late onset disease is necessary to correct
deformity and arrest progression of neurological deficits, However is associated with inferior outcomes
Keywords: Spinal tuberculosis, Pott’s paraplegia, Neurological deficits, chemotherapy, Late onset paraplegia, kyphosis, Surgical approach.


References

1. Tuli SM. 3rd ed. New Delhi: Jaypee Brothers; 2004. Textbook- Tuberculosis of the skeletal system (Bones, Joints, Spine and Bursal sheaths).
2. Barnes PF, Barrows SA. Tuberculosis in the 1990s. Ann Intern Med. 1993;119:400-10.
3. Patel S, Collins DA, Bourke BE. Don’t forget tuberculosis. Am Rheum Dis. 1995;54:174-5.
4. Duraiswami PK, Tuli SM. 5000 years of orthopaedics in India. Clin Orthop Relat Res. 1971;75:269-80.
5. Scott JE, Taor WS. The changing pattern of bone and joint tuberculosis. J Bone Joint Surg Am. 1969;51:1331-42.
6. Bick KM. Classics of Orthopaedics. Philadelphia, PA: JB Lippincott Co.; 1976.
7. Dobson J. Tuberculosis of spine. J Bone Joint Surg Br. 1951;33:517-31.
8. Seddon HJ. Pott’s paraplegia, prognosis and treatement. Br J Surg. 1935;22:769-99.
9. Albee FH. The bone graft operation for tuberculosis of spine. JAMA. 1930;94:1467-71.
10. Hibbs RA, Risser JC. Treatment of vertebral tuberculosis by the spine fusion operations. J Bone Joint Surg. 1928;10:805-14.
11. Mercer W. Then and now: the history of skeletal tuberculosis. J R Coll Surg Edinb. 1964;10:243-54.
12. Andre T. Studies on the distribution of tritium-labelled dihydrostrptomyem and tetracycline in the body. Acta Radiol. 1956;46:1-89.
13. Barclay WR, Ebert RH, Le Roy GV, et al. Distribution and excretion of radioactive isoniazid in tuberculosis patients. JAMA. 1953;151:1384-8.
14. Stevenson FH, Manning CW. Tuberculosis of the spine treated conservatively with chemotherapy, series of 72 patients collected 1949-1954 and followed to 1961. Tubercle. 1962;43:406-11.
15. Hodgson AR, Stock FE. Anterior spinal fusion for the treatment of tuberculosis of the spine. J Bone Joint Surg Am. 1960;42:1147-56.
16. Konstam PG, Konstam ST. Spinal tuberculosis in southern Nigeria with special reference to ambulant treatment of thoracolumbar disease. J Bone Joint Surg Br. 1958;40:26-32.
17. Oga M Arizono T, Takasita M, et al. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis: clinical and biologic study. Spine. 1993;18:1890-4.
18. Rajasekaran S. The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br. 2001;83(7):954-962.
19. Zaveri G. The role of posterior surgery in spinal tuberculosis. Argo Spine News J. 2011;23(3);112-119.
20. H L Bailey, M Gabriel, A R Hodgson, J S Shin. Tuberculosis of the spine in children. Operative findings and results in one hundred consecutive patients treated by removal of the lesion and anterior grafting J Bone Joint Surg Am. 1972;54(8):1633-57.
21. Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg Am. 1989;71:1314-23.
22. Upadhyay SS, Sell P, Saji MJ, et al. 17-year prospective study of surgical management of spinal tuberculosis in children. Hong Kong operation with debridement surgery for short and long-term outcome of deformity. Spine (Phila Pa 1976). 1993;18:1704-11.
23. Upadhyay M, Patel J, Kundnani V, Ruparel S, Patel A. Drug sensitivity patterns in Xpert-positive spinal tuberculosis: an observational study of 252 patients. Eur Spine J. 2020;29(7):1476-1482.
24. 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.
25. 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.
26. 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.
27. Dunn RN, Ben HM. Spinal tuberculosis. Bone Joint J. 2018;100-B(4):425–31.
28. 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.
29. 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.
30. Talu U, Gogus A, Ozturk C, Hamzaoglu A, Domanic U. The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases. J Spinal Disord Tech. 2006;19(8):554-9.
31. Garg B, Kandwal P, Nagaraja UB, Goswami A, Jayaswal A. Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: a retrospective analysis. Indian J Orthop. 2012;46(2):165-70.
32. Liu J, Wan L, Long X, Huang S, Dai M, Liu Z. Efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal tuberculosis: a meta-analysis. World Neurosurg. 2015;83(6):1157-1165.
33. Lonstein JE. Cord compression. In: Bradford DS, Lonstein JE, Ogilvie JW et al. (Eds). Moe’s textbook of scoliosis and other spinal deformities, 2nd edition. Philadelphia:WB Saunders;1987.pp540-7.
34. Dalvie SS, Laheri VJ. Closed-wedge spinal osteotomy for the correction of post-tubercular kyphosis in children. J Bone Joint Surg Br. 2000;82:283-284.
35. Kanna RM, Shetty AP, Rajasekaran S. Surgical management of Pott’s spine induced kyphosis in older children or adults. Curr Orthop Pract. 2017;28:15-22.
36. Bezer M, Mucukdurmaz F, Guven O. Transpedicular decancellation osteotomy in the treatment of post-tubercular kyphosis. J Spinal Disord Tech. 2007;20:209-15.
37. Kalra KP, Dhar SB, Shetty G, et al. Pedicle subtraction osteotomy for rigid post-tubercular kyphosis. J Bone Joint Surg Br. 2006;88:925-7.
38. Deng Y, Lv G, An HS. En bloc spondylectomy for the treatment of spinal tuberculosis with fixed and sharply angulated kyphotic deformity. Spine (Phila Pa 1976). 2009;34:2140-6.
39. Kawahara N, Tomita K, Baba H, et al. Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine (Phila Pa 1976). 2001;26:391-402.
40. Gertzbein SD, Harris MB. Wedge osteotomy for the correction of post-traumatic kyphosis. A new technique and a report of three cases. Spine (Phila Pa 1976). 1992;17:374-9.
41. Kanna RM, Shetty AP, Rajasekaran S. Surgical management of Pott’s spine induced kyphosis in older children or adults. Curr Orthop Pract. 2017;28:15-22.
42. Patel A, Ruparel S, Dusad T, Mehta G, Kundnani V. Posterior-approach single-level apical spinal osteotomy in pediatric patients for severe rigid kyphoscoliosis: long-term clinical and radiological outcomes. J Neurosurg Pediatr. 2018;21(6):606-614.
43. Wang K, Wang N, Wang Y, et al. Anterior versus posterior instrumentation for treatment of thoracolumbar tuberculosis : A meta-analysis. Orthopade. 2019 Mar;48(3):207-212.
44. Schwender JD, Holly LT, Rouben DP, Foley FT. Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF): Technical Feasibility and Initial Results. J Spinal Disord Tech. 2005;18 Suppl:S1-6.
45. Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and Radiological Outcomes of Open Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion. Eur Spine J. 2012;21(11):2265-70.
46. Ashizawa R, Ohtsuka K, Kamimura M, et al. Percutaneous transpedicular biopsy of thoracic and lumbar vertebrae–method and diagnostic validity. Surg Neurol. 1999;52:545-51.
47. Jayaswal A, Upendra B, Ahmed A, et al. Video-assisted tharacoscopic anterior surgery for tuberculous spondylitis. Clin Orthop Relat Res. 2007;460:100-107.
48. Tong YJ, Liu JH, Fan SW, et al. One-stage Debridement via Oblique Lateral Interbody Fusion Corridor Combined with Posterior Pedicle Screw Fixation in Treating Spontaneous Lumbar Infectious Spondylodiscitis: A Case Series. Orthop Surg. 2019 Dec;11(6):1109-1119.
49. Jayaswal A, Upendra B, Ahmed A, et al. Video-assisted thoracoscopic anterior surgery for tuberculous spondylitis. Clin Orthop Relat Res. 2007 Jul;460:100-7.
50. Kapoor SK, Agarwal PN, Jain BK Jr, et al. Video-assisted tharacoscopic decompression of tubercular spondylitis: clinical evaluation. Spine (Phila Pa 1976). 2005;30:E605-E610.
51. Kandwal P, Garg B, Bn U, et al. Outcome of minimally invasive surgery in the management of tuberculous spondylitis. Indian J Orthop. 2012;46(2):159-64.
52. Hu W, Zhang X, Yu J, et al. Vertebral column decancellation in Pott’s deformity: use of Surgimap Spine for preoperative surgical planning, retrospective review of 18 patients BMC Musculoskelet Disord. 2018;19(1):13.
53. Patel JY, Kundnani VG, Merchant ZI, Jain S, Kire N.Superior Facet Joint Violations in Single Level Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion: A Comparative Study.Asian Spine J. 2020 Feb;14(1):25-32.


How to Cite this article: Hadgaonkar S, Modipalli D, Aiyer S, Bhilare P, kothari A, Sancheti P. Paraplegia in pott’s spine: evidence-based management strategy. Journal of Trauma and Orthopaedic Surgery January-March 2021;16(1): 31-38.

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