Childhood spinal tubercular osteomyelitis- case paper - dr r l shahu
Isolated Caries spine in children – DR R L ShahuAbstractBackgroundPulmonary tuberculosis in infants and children in India is quite common and skeletaltuberculosis accounts for 10-20% of all extra pulmonary cases. Tuberculosis of spine orcaries spine is a serious disease and if not treated adequately, carries high morbidity andmortality. This study was undertaken to highlight the occurrence of bone destruction,spinal deformity and neural complications in children if not diagnosed early and treatedproperly.Materials and MethodsA prospective study of 18 children with the diagnosis of caries spine was done during theperiod of July 2005 to July 2010. All the children were within 10 years of age. Out of 18,11 were male and 7 were female with the mean age of 5.2 years. Pulmonary involvementof tuberculosis were not found in all the children. Out of 18, 12 children wereneurological deficit and 5 were having gibbus deformity. Out of 18 children, 10 weretreated conservatively and 8 by operations. Diagnosis was based on clinical features,history of contact with tuberculous patient, abnormalities on chest and spine X-rays andmagnetic resonance imaging studies of spine.Results Total number of patients studied was 18. Among them 18 (100%) cases of low backpain, constitutional symptoms 14 (71%), Para spinal abscesses 7 (39%), neurologicaldeficit 12 (66.7%) and spinal deformity 5 (27.8%). 55.5% patients were treated withconservatively and 45.5% were treated operatively. All patients were treated according toDOTS strategy, and 7 (39%) underwent surgical drainage of abscesses. The entire patientwith paraplegia recovered by 5 to 16 months except one who was lost to follow up. Nonparaplegia patients were mobilized at 5 months. This procedure helped in early cure withbony fusion, quick recovery from spinal cord dysfunction when associated with pressureon the spinal cord and prevented progressive vertebral destruction responsible forkyphotic deformity.Conclusions In caries spine conservative treatment will continue to be successful in majority of casesbut when indicated, especially in patients with neurological deficit, good decompressionand fusion should be done promptly and neurological deficit due to tuberculosis of spine
is reversible in majority of cases especially if decompression is done promptly. Goodfusion and stabilization can prevent pain and late deformityKey words: Caries spine, Gibbus, Para spinal abscess, Paraplegia.IntroductionSPINAL tubercular infection is the most common and dangerous form of skeletaltuberculosis. It constitutes 1/3 to 1/2 of all bone and joint tuberculosis. It is a result ofhematogenous dissemination from primary focus in the lungs, lymph nodes, etc1.Thoracic and lumbar spine are commonly affected area. 10-40% of patients with thoracicspine tuberculosis may get neurological deficit. Urgent Measures are needed to haltprogression of destruction and deformity and especially to prevent and overcomeparaplegia. Proper selection of drug therapy and operative modalities, however, is neededto optimize functional outcome for each individual case of Pott’s disease 2.
Materials and MethodsBetween July 2005 to July 2010, a total of 8 patients underwent surgical treatment withspinal decompression. Out of 8 patients, bone grafting done in 5 patients having gibbusdeformity. Out of 18, 10 patients were kept on conservative treatment with antituberculardrugs. The mean follow up was 14 months (range 12 to 19 months). Inclusion criteria:1.Children were within 2-10 years of age, 2. Isolated caries spine with and withoutneurological deficit. 3. Early onset of paraplegia is included. Exclusion criteria: 1.Extraspinal tuberculosis is excluded. 2. Let onset of paraplegia is excluded. Tuberculosisdiagnosis was confirmed by a combination of clinical and Para clinical findings.Laboratory examinations included: CBC, ESR, PPD, smear and culture of gastric lavageand abscess discharge for AFB, chest X-ray and CT-scan, abdominal CT-scan, spinal X-rays, and spinal MRI All patients benefited from antituberculous chemotherapy. Theregimen adopted was 2SRHZ/10RH in all cases: Streptomycin (1 mg/kg/day), Rifampicin(10 mg/kg/day), Isoniazid (5 mg/kg/day) and Pyrazinamide (30 mg/kg/day) wereadministrated during 2 months and then Rifampicin and Isoniazid were continued duringthe following 10 months. A hepatic assessment of the control was systematically carriedout every 3 months until the end of the treatment protocol. Average preoperativetreatment in all paraplegics was 3 weeks and that in non paraplegics 18 weeks.Streptomycin was discontinued in all the children after 20 weeks.INDICATIONS FOR SURGERY1. Caries spine without neurological deficit• Large abscess.• Large destruction not responding to ATT - Pain ++.• Spine at risk in children.2. Caries spine with neurological deficit• All indications recommended in middle path regime• Significant neurological deficit with demonstrableOperative procedure: Para spinal transthoracic approach reached from the left side wasused for upper thoracic spine. This approach was used in 3 patients.Oblique transthoracicapproach from left side was used for lower thoracic spine. This approach was used in 3
patients. For all thoraco-lumber lesions, trans-thoracic retroperitoneal approach was used.Table 5This approach was used in 2 patients. The third rib was excised to reach the first to fourthvertebral bodies. To approach fifth thoracic to eleventh thoracic vertebral bodies the ribthat felt to the level of the lesions in mid axillary line. In all children either with or without paraplegia the vertebral lesion was thoroughly excised till the spinal cord wasexposed after the abscess was well evacuated. The intervertebral gap following excisionof the lesion was bridged with autogenous bone grafts. Figure 3 After correcting thekyphotic deformity to the possible degree, Rib grafts were used in 5 patients. Thecommon pathology responsible for paraplegia in all the children was pus and granulationtissue.Observations: Out of the 18 children with caries spine in this study the youngest was 2years and the oldest was 10 years old. Maximum numbers of patient were between 2 to 3years of age. Table 1.The male were 11 and female were 7. All the children came fromlow socio economic groups and poor hygienic sourroundings.The exact duration ofdisease could not be ascertained properly. It varied from 2 months to one year. Out of the18 children 4 had lesions in upper thoracic spine, 9 in lower thoracic and 5 inthoracolumber spine. Table 2,3 None of them presented with more than one lesion.Minimum 2 and maximum 3 vertebral bodies were affected. Figure 1, 2 Out of 18children, 12 had neurological deficit at the time of admission. Out of 12, 8 had completeupper motor neuron type of paraplegia with bladder and bowel involvement, and 4 hadPara paresis without bladder and bowel involvement. The onset of paraplegia was suddenin 4 and gradual in 8 patients. Skiagrams of 7 children with thoracic lesions showed Paravertebral abscess. In 5 children with thoracic lesions showed gibbus deformity. Table 3Ethical and legal procedureThe protocol was approved by an ethics committee and thus meets the standards of theDeclaration of Helsinki in its revised version of 1975 and amendments made to it in1983, 1989 and 1996 (JAMA 1997; 277:925–6).
Results: All the 12 children with partial and complete paraplegia, recovered fully,4 ofthem in 6 months, 6 at 10 months and 2 at 12 months. Eighteenth children were followed-up from 10 to 20 months at monthly intervals after they were discharged as inpatients. Allthose children without paraplegia were ambulated 5 months after surgery and those withparaplegia were ambulated soon after the recovery from neurological deficit, rangingfrom 5 to 16 months. In all the 5 children the bone grafts had taken up in 3 to 4 monthstime. There was no slipping of the graft in any of the children. Figure 3,4 Posterior spinalfusion was not done in any of the patients to augment the stability of the spine. There wasno mortality or recrudescence of the disease in any of the 18 children at follow-up.
Discussion:Potts paraplegia resulting in severe spinal deformity is a disastrous complication, whichis difficult to treat by chemotherapy alone and/or by surgical decompression. 3,4 It isgenerally accepted that Potts paraplegia in early spinal tuberculosis can be curedeffectively through chemotherapy alone.5,6 In our series 4 patients out of 12 patients ofpott’s paraplegia were successfully treated with chemotherapy alone. Hsu et al.recommended surgical decompression of the compressed cord at the level of activetuberculous focus and kyphosis since this resulted in good neurological results.7Paraplegia together with residual spinal deformity is one of the most disastrouscomplications of Potts disease.3,4,6,8,9,10,11 Up to now, there have been numerous paperswhich dealt with Potts paraplegia12,13,14,15,16 however, there are only a few papers, whichaddressed Potts paraplegics complicated by severe spinal deformity.11,12,15 In our series 5patients out of 18 had gibbus deformity. An accurate assessment of the disease activity isnecessary in order to achieve a successful outcome before any initiation of treatment. Asingle radiographic assessment of activity is notoriously difficult because a patient doesnot always show clinical evidence of activity. Generally, it has been believed thatchemotherapy alone is an inappropriate method for managing paraplegia in patients withadvanced tuberculosis and deformity,1,7,16 since paraplegia usually resolves rapidly afteradequate decompression. Many surgeons believe that it is inappropriate to require apatient to lie paralyzed for extended periods waiting for a cure through conservative care,and prefer management by anterior decompression and fusion with bone graft.1,7,10,16Therefore, the afore-mentioned treatment protocol has been well accepted, and was usedfor paraplegic patients with mild and moderate degrees of spinal deformity. In our series8 patients had paraplegia with bladder and bowel involvement with Para spinal abscessand 4 patients had Para paresis without involvement of bladder and bowel.Decompression was done in 8 patients with paraplegia and rests were treated
conservatively. All the patients recovered fully due to early diagnosis and treatedpromptly. However, those principles could not effectively solve the neurologicalproblems in Potts paraplegic patients with severe spinal deformity. Chemotherapy wasinstituted first, but when patients were unresponsive, and had worsening neurology,decompression surgery was indicated. In these patients, radical decompressive surgerycarried a high neurological risk with only a small chance of recovery. In previous studies,the senior author of this study had listed the factors influencing the neurological recoveryrate in Potts paraplegics.5,6 The recovery rate is influenced by many factors such as: thepatients general condition, the patients age, the condition of the spinal cord, the level,duration and severity of paraplegia, the time of onset before the initiation of treatment,the type of treatment, and the patients drug sensitivity. Paralysis persisting longer than 6months is unlikely to improve. Late paralysis with inactive disease and significantkyphosis is much less responsive to treatment as found in this current series. Paralysiscaused by vascular embarrassment has a worse prognosis. Patients with an atrophic spinalcord assessed by a preoperative MRI usually do poorly after decompression. In treatingadult patients with chronic Potts paraplegics with severe spinal deformity,decompression surgery should be avoided to prevent damage to the circulation and thecompressed spinal cord. However, for child paraplegics, more promising results may beobtained through decompression surgery. That is, neurological recovery was better inchildren who had decompression surgery than in adults who received chemotherapyalone or in combination with decompression surgery. It is noteworthy to remind treatingphysicians and surgeons that paraplegics with a severely deformed spine showed adifferent neurological response to chemotherapy treatment or combined chemotherapyand surgical treatments than those paraplegics with mild to moderate degrees of spinaldeformity. When surgical decompression is chosen as a last choice of treatment, eachpatient should be cautioned about the high neurological risk and the slim chance ofneurological recovery by surgery even under the cover of chemotherapy.6,17 Adultparaplegic with severe spinal deformities had poorer spinal cord conditions than thosewith milder deformities.5,18 Thus, it is essential to assess the condition of the spinal cordthrough plain X-rays, myelograms, C-T myelograms and MRI before any treatmentcommences. It is strongly recommended that a spinal cord circulation study be conductedwherever possible. In two cases of this current series, the authors attempted to combinedecompression surgery with posterior corrective and instrumented stabilization surgerybecause of segmental instability after decompression surgery. In one case, the deformitywas corrected successfully and neurological recovery ensued, while in the other cases,there was no neurological recovery despite effective decompression and a relatively goodcorrection of the deformity. For corrective surgery the risk of neurological damage byoperative distraction was related both to the severity of the original deformity and to thedegree of correction. For posterior instrumented corrective surgery, the length of thevertebral canal and vertebral column should be considered. A short cord may be placed atmore risk in idiopathic scoliosis by posterior instrumented correction because of the shortvertebral canal in comparison to the vertebral column. Thus, anterior surgery excising thebody and discs may lengthen the vertebral canal relatively, and is less dangerous to the
spinal cord.19 A preoperative measurement of the vertebral canal and column lengthmight help to quantify the risk of neurological damage. In this study, it was found that thepatients with active tuberculosis, who showed a neurological response after the start ofchemotherapy, achieve more favorable result when surgery was combined, In our seriesall the children with partial paralysis made complete recovery in 4 months time. Of the 8children with complete paraplegia, 6 recovered in 10 months and 2 in 12 months."Conflict of interest: None."References : 1. Kumar R. Spinal tuberculosis: with reference to the children of northern India. Childs Nerv Syst 2005 Jan; 21(1): 19-26. 2. Khoo LT, Mirada K, Fizzler RG. A surgical revisitation of Pott distemper of the spine. Spine J 2003 Mar-Apr; 3(2): 130-145. 3 Govender S, Charles RW, Naildo KS & Gogre IE. Result of surgical decompression in chronic tuberculous paraplegia. S Afr Med 1988; 74: 58– 59. 4 Moon MS & Lee MK. The Change of the kyphosis of the tuberculosis of spine in Children following ambulant treatment. J Korea Orthop Assoc 1971; 6(3): 189–202.
5 Moon MS et al. Potts paraplegia 67 cases. Clin Orthop 1996; 323: 122–128.6 Moon MS. Tuberculosis of the spine–controversies and a new challenge. Spine 1997; 22(15): 1791–1797. |7 Hsu LCS & Leong JCY. Tuberculosis of the lower cervical spine (C2 to C7): A report on 40 cases. J Bone Joint Surg 1984; 66B: 1–5.8 Frankel HL et al. The value of postural reduction in the initial management of closed injuries of spine with paraplegia and tetraplegia. Paraplegia 1969; 7: 179–192. |9 Guirgui AR. Potts paraplegia. J Bone Joint Surg 1967; 49B: 658–667. Hodgson AR, Shinesnes OK & Leong CY. The pathogenesis of Potts paraplegia. J Bone Joint Surg 1967; 49A: 1147–1153.10 Hodgson AR, Shinesnes OK & Leong CY. The pathogenesis of Potts paraplegia. J Bone Joint Surg 1967; 49A: 1147–1153.11 Moon MS et al. Posterior instrumentation and anterior interbody fusion for tuberculosis kyphosis of dorsal and lumbar spine. Spine 1995; 20: 1910– 1916. |12 ee JI, Kang SY, Moon MS & Suk SI. Treatment of the spinal tuberculosis with severe kyphosis and paraplegia. J Korean Orthop. Assoc 1970; 5: 73–78.13 Kim BJ, Ko HS & Lin Y et al. Surgical treatment of paraplegia in spinal
tuberculosis. J Korean Orthop Assoc 1993; 28: 1595–1602. 14 Kim NH. Study of causal factor of Potts paraplegia. J Korean Orthop Assoc 1974; 9: 209–220. 15 Lee HK, Ahn JW & Choi JS. Treatment of spinal tuberculosis associated with Neurological symptoms. J Korean Orthop Assoc 1980; 15: 236–241. 16 Martin NS. Potts paraplegia. J Bone Joint Surg 1971; 53B: 596–608. 17 Winter RB. Major neurological complications in spinal deformity surgery: One surgeon’s carrier experience (review article). J Orthop Surg 1999; 7(2): 81 - 88. 18 Pattisson PR. Potts paraplegia: An account of the treatment of 89 consecutive patients. Paraplegia 1986; 24: 77–91. 19 Bridwell KH, Lenke LG, Baldus C & Blanke K. Major intraoperative neurological deficits in pediatric and adult spinal deformity patients: Incidence and etiology at one institution. Spine 1998; 23: 324–331.Table 1: Tuberculosis in different age and sex. Serial Age in years Present series SexNumber M F__________________________________________________________ 1 0-1 0 0 0 2 2-3 6 4 2 3 4-5 3 1 2
4 6-7 5 4 1 5 8-10 4 2 2 Total 18 11 7___________________________________________________________Table 2: Site of caries spine in different age Age _____________________________Site of infection 0-1 2-3 4-5 6-7 8-10 Total__________________________________________________________Cervical 0 0 0 0 0 0Upper thoracic 0 0 1 2 1 4Lower thoracic 0 2 2 3 2 9Thoraco lumber 0 4 0 0 1 5___________________________________________________________Table 3: Site of caries spine in different sex Sex _________________Site of infection Male Female_____________________________________
Cervical 0 0Upper thoracic 2 2Lower thoracic 6 3Thoraco lumber 3 2_____________________________________Table 4: Signs and symptoms in caries spine _____________________________ Back pain 18 Constitutional symptoms 14 Pulmonary symptoms 0 Para spinal abscesses 7 Neurologic deficits 12 Spinal deformity 5 __________________________________ Table 5: Management of caries spine No. of patient on No. of patient on
Conservative Operative Treatment Treatment_______________________________________________ 10 3- Para spinal transthoracic approach 3- Oblique transthoracic approach 2- trans-thoracic retroperitoneal approach_________________________________________________Figure 1. Preoperative skiagram of anteroposterior and lateral view showingcaries spine of D12 L1 vertebrae, destruction and collapse of L1 vertebra andintervening discs with gibbus deformity in lateral view.Figure 2. Sagital view of magnetic resonance imaging showing caries spine ofD12 L1 vertebrae, destruction and collapse of L1 vertebra and interveningdiscs with Para vertebral and psoas abscess.
2‘Figure 3. Postoperative skiagram of anteroposterior and lateral view showingD12 L1 collapse is filled with rib graft to correct gibbus deformity. Figure 4. Postoperative skiagram showing corrected gibbus deformity.