Surgery in Spinal Tuberculosis

Surgery in spinal tuberculosis is considered in the patients where the disease is not responding to the drug treatment, rest and other conservative measures.

The aims of treatment of tuberculosis of the spine are:

• Control and cure of the existing ac­tive systemic and local infection and prevent its further spread.
• Achieving the stability of the spine with sound bony or strong fibrous union be­tween the involved vertebrae. Heal­ing of the lesion is implied in bony fu­sion
• Prevention and treatment of compli­cation like the neural deficit and defor­mity

Antitubercular chemotherapy is the mainstay of the treatment. Surgery is indicated in some situations in spinal tuberculosis –

• For neural complications such as paraplegia and tetraplegia.
• For kyphosis correction in active dis­ease when predicted/expected kyphosis is more than 60 degrees

How Does Surgery Help in Spinal Tuberculosis?

Surgery helps in local healing by

• Reducing the local disease load by removing the fluid abscess, granulation tissue, caseous material, sequestered bone, and disc. These are dead and de­stroyed products, and no regenera­tion of them is possible. They may not be absorbed in the natural healing, and the process may be imperfect and incomplete.
• Removes the mechanical effects of compression
• Fortifies local healing by bone grafts so that sound bony fusion between
  the involved vertebrae is achieved.
• Improves neural recovery and prevents the progression of deformity.

Types of Surgeries in Spinal Tuberculosis

Radical surgery

The bone is excised until healthy bleed­ing cancellous bone, suitable for reception of graft is achieved. In tuberculous lesion of the spine which is extensive and if all necrotic, separated, infiltrated and infracted bone is removed, it leaves behind a large gap, to be bridged by bone graft. The spine may become unstable and require fixation

Debridement Surgery

Here only pus caseous tissue and loose sequestrae are removed. The unaffected or viable bone is removed only to provide ad­equate access to the focus and to decom­press the spinal canal. Since surgical de­compression is only restricted to necrotic and separated bone, it leaves behind a relatively stable spine.

Anterolateral Decompression of the Spine

Anterolateral decompression of the spine is used in thoracic lesions and is also called extrapleural anterolateral approach is a simpler and safe technique.

Operative steps

• The patient is positioned in the lateral position
• A left-sided approach is preferred since Vena Cava is on the right side and handling of the aorta is easier than Vena Cava.
• However, the right-sided approach can be used
  • When pa­tient has already been operated from the left side and a repeat surgical decompression is per­formed
  • When the right side of the vertebral body is predominantly destroyed.
• Incision Planning
  • Minimum 3 ribs should be removed
  • The maximum number is 4 ribs
• The standard semicircular incision can be used centered over the diseased vertebra
  • If concomitant posterior instrumen­tation is planned than T incision can be used.
• Count the ribs and confirm correlation on x-ray
•  The ribs are removed subperiosteally painstakingly.
  • About 7-10 cms of ribs are removed from rib head.
• After removal of ribs, intercostal nerves are identified to define intervertebral foramina and the pedicles. The tissue in front of the vertebral body is lifted.
• The liquid pus drains out at this stage.
• The loose bone pieces, sequestrae, granulation tissues are removed and the cord is exposed
• This completes the decompression
• A rib is shaped and inserted between the two vertebrae
• The wound is closed over a drain

Benefits of the Anterolateral Approach

it is a simple safe op­eration which can be performed in any op­eration theatre and can be done on all pa­tients with consistent outcome in term of cord decompression, neural recovery, and kyphus correction.

It does not require open surgery and being extrapleural, has minimum lung problems in the postoperative period.

The postoperative morbidity is less.

References

• Jain AK, Kumar S, Tuli SM: Tuberculosis of spine (C1-D4). Spinal cord 37:362-369,1999.
• Jain AK: Treatment of tuberculosis of the spine with neurological complication. Clinical orthopaedics and related research 398:75 – 84, 2002
• Moon MS, Ha KY, Sun DH, et al: Pott’s paraplegia. Clin Orthop 323:122-128,1996.
• Rajasekaran S, Soundarapandian S: Progression of Kyphosis in tuberculosis of the spine treated by anterior arthodesis. J Bone Joint Surg 71 A:1314-1323,1989.
• Tuli SM: Tuberculosis of the skeletal system. New Delhi, Jaypee Brothers Medical Publishers LTD. 217:301.1997.
• Upadhyay SS, Seff P, Saji MJ, Seff B,Hsu LC: Surgical management of spinal tuberculosis in adults. Clin Orthop302:173-182,1994.
• Vidyasagar C, Murthy HKRS, Management of tuberculosis of the spine with neurological complications. Ann R Coll Surg Engl 76; 80-4, 1994.