Background: Spinal tuberculosis, predominantly affecting the thoraco-lumbar region, often requires surgical intervention when conservative treatments fail. This study evaluates the effectiveness of the posterior approach debridement, decompression, and stabilization with pedicle screw fixation in patients with thoraco-lumbar spinal tuberculosis. Methods: A prospective study was conducted on 17 patients, with surgical outcomes assessed through kyphotic angle correction, ESR, VAS, and ODI scores. Results: Post-operative results demonstrated a mean kyphotic angle correction of 12 degrees. ESR levels significantly decreased from a pre-operative mean of 37 mm/h to 9 mm/h post-operatively. Pain and functional disability also improved markedly, with VAS scores reducing from 6.0 to 0.6, and ODI scores from 34 to 3. Conclusion: The posterior approach for thoraco-lumbar spinal tuberculosis is effective in achieving significant spinal alignment correction, reducing inflammation, and improving pain and functional outcomes. This study supports its use as a viable surgical option in appropriately selected patients. |
Tuberculosis (TB) remains a global health challenge, with musculoskeletal tuberculosis representing a significant fraction of extrapulmonary manifestations. Among these, spinal tuberculosis, also known as Pott's disease, is the most common form, predominantly affecting the thoraco-lumbar region of the spine [1]. The management of spinal TB has evolved over the years, with the aim to eliminate infection, alleviate pain, restore spinal stability, and prevent or correct deformities. While conservative treatment with anti-tubercular therapy remains the cornerstone for most cases, surgical intervention is warranted in instances of spinal instability, neurological deficit, or severe kyphotic deformity [2].
The surgical approaches to spinal TB include anterior, posterior, and combined anteroposterior procedures. The choice of approach is influenced by the location of the lesion, the extent of the disease, and the specific objectives of surgery, such as decompression of the spinal canal and stabilization of the affected segment. Recently, the posterior approach for debridement, decompression, and stabilization with pedicle screw fixation has gained favor for its ability to address both the need for stability and correction of deformities, particularly in the thoraco-lumbar region [3].
The rationale behind the posterior approach includes direct access to the spine for effective debridement, the ability to achieve significant decompression of the spinal canal, and the facilitation of spinal stabilization through pedicle screw fixation. This method has demonstrated promising outcomes in terms of infection control, neurological recovery, and structural integrity of the spine [4]. However, the complexity of spinal TB cases, varying degrees of bone destruction, and the presence of neurological deficits necessitate a careful selection of surgical candidates and personalized surgical planning [5].
This study aims to analyse the application of posterior approach debridement, decompression, and stabilization with pedicle screw fixation in the management of thoraco-lumbar spinal tuberculosis. We discuss the surgical technique, patient selection criteria, outcomes, and challenges encountered in the treatment of this debilitating condition. Through a comprehensive review of recent literature and an analysis of clinical outcomes, this article contributes to the ongoing discussion on optimizing surgical management strategies for spinal TB.
Aims and Objectives
The primary aim of our study was to evaluate the efficacy and outcomes of the posterior approach for debridement, decompression, and stabilization with pedicle screw fixation in patients suffering from thoraco-lumbar spinal tuberculosis. Specifically, the study focused on assessing functional and neurological outcomes post-surgery. The objectives were to ascertain the extent of neurological recovery, measure the improvement in spinal stability and alignment, and evaluate the reduction in pain and disability among the treated patients. These outcomes were intended to provide insight into the viability of the posterior approach as a preferred surgical intervention for thoraco-lumbar spinal tuberculosis, particularly in cases where conservative treatments had failed or were deemed inadequate.
The study was designed as a prospective observational study, conducted over a period of 16 months from November 2020 to May 2022, at a tertiary healthcare center specializing in spinal disorders. The sample comprised 17 patients diagnosed with thoraco-lumbar spinal tuberculosis, confirmed through clinical evaluation, radiographic imaging, and histopathological examination. The inclusion criteria were strictly adhered to, encompassing HIV-negative individuals presenting with constitutional symptoms indicative of spinal tuberculosis, such as thoraco-lumbar spine instability and neurological deficits. Additionally, patients exhibiting radicular pain due to compression by granulation tissue or those not responding to medical therapy were included. Conversely, the study excluded individuals with non-tubercular causes of spinal deformities, Pott’s spine involving regions other than the thoraco-lumbar area, and patients who showed significant improvement with medical therapy alone.
All participants underwent a thorough pre-operative evaluation, including x-rays and MRI to establish the extent of the disease, routine hematological tests, and a detailed radiographic evaluation to assess spinal stability and alignment. Following diagnosis, patients were managed medically with the standard RNTCP (Revised National Tuberculosis Control Program) anti-tubercular regimen, alongside the surgical intervention of posterior approach debridement, decompression, and stabilization with pedicle screw fixation. Post-operative care included histopathological examination and PCR testing of biopsy specimens to confirm the eradication of the tuberculosis infection.
The study meticulously recorded intra-operative blood loss, the extent of bony fusion achieved, and the degree of neurological recovery post-surgery. Follow-up examinations were scheduled at 1, 3, 6, 9, and 12 months post-operatively to monitor recovery and evaluate the clinical efficacy of the surgery. Clinical efficacy was assessed using the Visual Analogue Scale (VAS) for pain, the Oswestry Disability Index (ODI) for functional disability, and the Modified Prolo Scale for overall outcome assessment. Additionally, erythrocyte sedimentation rate (ESR) levels were monitored pre- and post-operatively as an indicator of the inflammatory response and infection resolution.
The study population consisted of 17 patients who underwent surgical intervention for thoraco-lumbar spinal tuberculosis. Demographic analysis revealed a near-equal distribution of gender among the participants, with females constituting 47.1% (n=8) and males 52.9% (n=9). The age range of the patients spanned from 20 to 60 years, with a mean age calculated at 44 years, allowing for a standard deviation of 12 years, indicating a middle-aged cohort predominantly affected by the condition.
Regarding the spinal curvature, the cohort exhibited a mean pre-operative kyphotic angle of 22 degrees, with a standard deviation of 7 degrees. Post-operative assessments showed a notable correction in this angle, with the mean post-operative kyphosis reduced to 10 degrees, and a standard deviation of 2 degrees, indicating a consistent surgical outcome across the sample. The mean improvement in the kyphotic angle was 12 degrees, with a standard deviation of 4 degrees, signifying a significant post-surgical improvement in spinal alignment.
The clinical parameters measured in the study included the Erythrocyte Sedimentation Rate (ESR), Visual Analogue Scale (VAS) for pain, and the Oswestry Disability Index (ODI) for functional disability. The pre-operative mean ESR was 37 mm/h with a standard deviation of 20 mm/h, which significantly reduced to a mean of 9 mm/h with a standard deviation of 5 mm/h post-operatively. This reduction in ESR was maintained at the final follow-up, where the mean ESR remained at 9 mm/h with a slight decrease in variability (standard deviation of 4 mm/h).
The VAS scores, indicative of the patient's pain experience, showed a mean pre-operative value of 6.0 with a standard deviation of 1.5, which improved to a mean of 2.5 with a standard deviation of 0.9 post-operatively. At the final follow-up, the mean VAS score further improved to 0.6 with a standard deviation of 0.5, reflecting a substantial alleviation of pain symptoms after the surgical intervention.
Functional disability, as measured by the ODI, presented a mean pre-operative score of 34 with a standard deviation of 7, which decreased to a mean of 20 with a standard deviation of 8 post-operatively. Upon the final follow-up, the mean ODI score demonstrated a considerable improvement to 3 with a standard deviation of 4, suggesting a marked enhancement in the patients' functional capabilities following surgery.
These results collectively indicate that the posterior approach debridement, decompression, and stabilization with pedicle screw fixation significantly improved the kyphotic deformity and reduced the symptomatic burden of thoraco-lumbar spinal tuberculosis. The consistent improvement across various clinical parameters underscores the potential benefits of this surgical approach in managing a complex and debilitating condition such as spinal tuberculosis.
Table.1 Demographic details
1. Sex |
No of cases (n) |
Percentage(%) |
Female |
8 |
47.1 |
Male |
9 |
52.9 |
2. Age |
||
Range |
20 – 60 years |
|
Mean age |
44+12 years |
Table.2 Stratification of pre operative and post operative data
Mean (In degrees) |
|
Pre operative Kyphosis |
22 +/- 7 |
Post operative Kyphosis |
10 +/- 2 |
Improvement of Kyphosis |
12 +/- 4 |
Table.3 Clinical details of surgery
Schedule |
ESR (mm/h) |
VAS |
ODI |
Pre operative |
37 +/- 20 |
6.0 +/- 1.5 |
34 +/- 7 |
Post operative |
9 +/- 5 |
2.5 +/- 0.9 |
20 +/- 8 |
Final follow up |
9 +/- 4 |
0.6 +/- 0.5 |
3 +/- 4 |
12 |
The outcomes of the current study contribute to the growing body of literature on the surgical management of thoraco-lumbar spinal tuberculosis. The marked improvement in kyphotic angle from a mean of 22 degrees pre-operatively to 10 degrees post-operatively, with a mean correction of 12 degrees, is consistent with findings from other research. For instance, a study by Zhang et al. reported an average correction of kyphosis of approximately 15 degrees using a similar posterior approach, which aligns with our results, albeit with a slightly higher degree of correction [6]. However, it's important to note that direct comparisons are nuanced due to variations in patient populations, surgical techniques, and measurement methods.
The reduction in ESR from a mean of 37 mm/h pre-operatively to 9 mm/h post-operatively in our study is indicative of a successful inflammatory response management. These findings are in concordance with those reported by Garg and colleagues, who documented a significant decrease in ESR levels following surgical intervention for spinal tuberculosis [7]. The enduring reduction observed at the final follow-up underscores the sustained resolution of inflammation, which is a key indicator of successful infection control.
Pain reduction, as evidenced by the decrease in VAS scores from a mean of 6.0 pre-operatively to 0.6 at final follow-up, highlights the potential of the posterior approach in providing symptomatic relief. This significant decrease in pain is comparable to the outcomes observed in the study by Kumar et al., where the VAS scores showed substantial improvement post-surgery [8]. The parallel in these findings suggests that pain reduction is a reliable outcome of the posterior surgical approach.
Furthermore, the improvement in functional outcomes measured by the ODI, which showed a mean decrease from 34 pre-operatively to 3 at final follow-up, is a testament to the procedure's efficacy in enhancing quality of life. This is supported by a study by Wang et al., where patients exhibited similar improvements in functional outcomes post-operatively [9]. The consistency between these studies underscores the posterior approach's role in restoring function.
However, our study presented a lower improvement in kyphotic angle compared to the study by Li et al., where patients experienced an average correction of 18 degrees [10]. This discrepancy could be attributed to differences in surgical techniques, the severity of disease at presentation, or patient demographics.
The current study's findings are largely in alignment with the broader evidence base supporting the posterior approach's effectiveness in managing thoraco-lumbar spinal tuberculosis. The evidence suggests that this surgical method is capable of achieving substantial improvements in spinal alignment, inflammation control, pain reduction, and functional recovery.
The study's findings solidify the role of posterior approach debridement, decompression, and stabilization with pedicle screw fixation as an effective surgical intervention for thoraco-lumbar spinal tuberculosis. The significant correction in kyphotic angle with a mean improvement of 12 degrees, substantial reduction in ESR levels, and remarkable improvements in VAS and ODI scores all point toward a favorable outcome for patients suffering from this condition. The decrease in mean VAS score from 6.0 to 0.6 and the improvement in ODI from 34 to 3 are particularly indicative of the approach's effectiveness in alleviating pain and restoring function. These results not only align with existing literature but also contribute to the advocacy for the posterior approach as a viable surgical option in spinal TB cases necessitating intervention due to instability or neurological impairment.