Outcome of Single Stage Anterior and Posterior Surgery for Tuberculous Paraplegia

ABSTRACT

Background:

Morbidity and mortality from tuberculosis, a significant infectious illness, are expected to rise worldwide. The projected number of new cases rose from 7.5 million in 1990 to 11.9 million in 2005, a 58.6% increase in 2011. The widespread belief that TB is no longer a public health concern is unfounded; on the contrary, the link between HIV/AIDS and antibiotic resistance has further exacerbated the crisis that already existed. Similar to the nations in sub-Saharan Africa, India is now considered a Group IV country, with an annual risk of infection between 1% and 2.5%. 2. Although 60% of TB cases occur in people who are HIV-positive, only 3–5% of cases in HIV-negative individuals are skeletal. The most frequent type of articuloskeletal tuberculosis is spinal tuberculosis.

Aim:

1. The goal of this study is to evaluate the neurological outcome of anterior debridement, fusion, posterior instrumentation, and early rehabilitation in individuals with spinal cord injuries. 2. The goal of this study is to determine the prevalence of pressure ulcers, hypostatic pneumonia, and urinary tract infections urinary tract infections (UTIs) among these individuals. 3. The goal of this study is to determine the frequency of graft-related problems. 4. See how well these individuals are able to keep their corrected deformities from returning.

Materials and Methods:

Patients who had simultaneous anterior (anterior debridement and bone grafting) and posterior (posterior instrumentation and fusion) procedures were followed prospectively.

Result:

Thirty patients’ films were examined. In addition, cord edema was suggested in 13 of the patients based on the presence of strong signal intensities there. Myelomalacia signs were seen in one patient, but he or she went on to make a complete neurological recovery. The average duration of operation was 355 minutes, and this included the time needed to position the patient for the two separate procedures.

Conclusion:

There was an 89.5% rate of neurological recovery with an average corrected loss of 6.98 degrees (0.20 degrees to 35.90 degrees), and the complication rate was acceptable in the group analyzed.

INTRODUCTION

Globally, tuberculosis is expected to cause more deaths and hospitalizations in the future. The estimated number of new cases increased by 58.6%, from 7.5 million in 1990 to 11.9 million in 2005, during a 15-year time period.[1] Although many people may believe tuberculosis (TB) is no longer a public health issue, the link between HIV/AIDS and treatment resistance has only made things worse. There is an estimated 1%–2% 5 yearly chance of infection in India and other sub-Saharan African nations, which places them in Group IV,[2] whereas 60% of TB cases are skeletal in HIV-positive patients, just 3–5% of tuberculosis cases are skeletal in HIV-negative individuals, with the most frequent type being spinal tuberculosis.[3]

Past methods of doing neural decompression for tuberculous paraplegia have shown comparable rates of neurological recovery, despite the emergence of new complications related to the worsening of kyphosis. The recommended course of therapy is an anterior arthrodesis, which entails the surgical removal of the tuberculous focus and its subsequent replacement with a structurally appropriate bone transplant.[4,5] Long-term follow-up studies showed that the potential benefits of this operation were reduced owing to the high frequency of graft-related problems and the requirement for extended immobilization.[6]

To maintain the advantages of an anterior arthrodesis while decreasing graft-related issues and speeding up rehabilitation, several clinics advocate safeguarding the graft using anterior or posterior instrumentation.

Orthopedic surgeons at the Christian Medical College and Hospital, Vellore, have been treating patients with tuberculous spondylitis using techniques including anterior debridement and grafting and posterior instrumentation since 1993. This study examines the long-term effects of radical anterior debridement and fusion and posterior instrumentation for patients who were diagnosed with tuberculosis of the dorsal, dorsolumbar, and lumbar spine and also experienced neurological complications while receiving treatment at the orthopedics and spine surgery unit 1 of Christian Medical College, Vellore.

MATERIALS AND METHODS

Study design

Patients who had both anterior (anterior debridement and bone grafting) and posterior (posterior instrumentation and fusion) surgery were prospectively tracked.

Definitions

Frankel grading

• Type A represents a severed spinal cord;

• Type B, a purely perceptual spinal cord damage; injuries of the type C kind, in which some motor function remains but is of little practical value; injuries of the type D kind, where some motor function is retained; and

• Type E, a head wound without permanent neurological damage.

Angle A 7: The angle formed by connecting the lesion with the superior and inferior surfaces of the first normal vertebrae at the cervical and lumbar levels, respectively. From these rays and the angle, perpendiculars were drawn.

Initial correction: Change in deformity angle from before surgery to right after correction.

Final correction: Progression of deformity after surgery as measured by the difference between pre- and postoperative measurements.

Graft subsidence: Strut graft height reduction after being inserted into the interbody space.

Graft slippage: Moving the strut graft outside the interspace between the bones.

Graft fracture: Damage to the strut graft’s cortex.

Local kyphosis angle 33: The slant formed by the top and lower end plates of the level(s) that have collapsed, or are implicated.

Assessment of loss of vertebral height 16: Based on the vertebral height in the lateral radiograph, each vertebra is further subdivided into ten equal sections. Vertebral body attrition was calculated by averaging the height losses of all afflicted vertebrae. Using an average of the heights of vertebrae above and below the affected levels, we may estimate the expected height of the impacted vertebra.

Initial assessment

Clinical Assessment:

• Symptoms

• Neurology.

Radiological Assessment:

• Preoperative deformity

• Preoperative vertebral loss Investigations—Hb, liver function test, ESR treatment given:

• Type of surgery done first

• Anesthesia

• Duration

• Complications

• Postoperative period.

Follow-up

Clinical:

• Symptomatology

• Examination of neurology

• Radiology:

• Deformity

• Implant issues

• Fusion Functional outcome

• Functional independence

• Capacity to return to previous occupation.

Statistical analysis

In this study, we used the Chi-square or Fisher’s exact test for categorical variables, the Student’s t-test for nominal variables, and the Mann–Whitney U-test for continuous data, or both. The calculations were performed on an IBM-compatible computer using SPSS version.

RESULT

During five years, from 1999 to 2004, this research was conducted. Thirty-seven people with Frankel A, B, or C grade neurological impairments were included in the research out of a total of 76 people with TB of the spine. One patient was not included in the postoperative assessment because of a short follow-up period of just 2 months.

Baseline, Preoperative and Immediate Postoperative Data.

Age: The average age of the participants in this research was 32.49. (range of 4–61 years). Patients’ ages ranged from 15 and up to 55 and up, with 16.2% falling in each category.

Sex Ratio: Somewhat more women than men were present, with a female preponderance of 17 to 20.

Level of the lesion: The thoracic region was the most often affected, accounting for 81.1% of all cases [Table 1].

Table 1.

Site of the disease

	Frequency	Percentage
Thoracic	30	81.1
Thoracolumbar	3	8.1
Lumbar	4	10.8
Total	37	100.0

The origin of the graft which was procured is mentioned in Table 2 where iliac crest was the foremost and better accepted graft in all the surgeries. The outcome variables considered in the univariate analysis were

Table 2.

Origin of graft

Type	Frequency	Percent	Valid percent
Tricortical iliac crest bone graft	25	67.6	69.4
Fibula graft	2	5.4	5.6
Cage with iliac graft	7	18.9	19.4
Local or rib graft	2	5.4	5.6
Total	36	97.3	100.0
Missing	1	2.7
	37	100.0

1. Loss of correction: The statistically significant variables are

   Loss of correction >10°

   1. Preoperative loss of vertebral height >1 (P = 0.021),

   2. Postoperative angle A >20°(P = 0.041)

   3. Post op correction >10° (P = 0.027)

   4. Postoperative local kyphosis angle correction >10° (P = 0.035)

   5. Presence of implant complications (P = 0.027)

   6. Presence of graft complications (P = 0.000) Loss of correction >15°

      1. Local kyphosis angle >35° (P = 0.05)

      2. Preoperative angle A >40° (P = 0.037)

2. Postoperative complications: The statistically significant variables are

   1. Presence of an immunocompromised state (P = 0.003)

   2. Preoperative local kyphosis angle >330° (P = 0.037)

   3. Preoperative angle A >17° (P = 0.021)

   4. Loss of correction of angle A >15° (P = 0.032)

3. Implant complications: The statistically significant variables are

   1. Loss of correction >10° (P = 0.027)

   2. Length of graft >40 mm (P = 0.007)

   3. Presence of graft complications (P = 00.037)

4. Graft complications: The statistically significant variables are

   1. Preoperative local kyphosis angle >45° (P = 0.008)

   2. Preoperative angle A >45° (P = 0.005)

   3. Correction in angle A >15° (P = 0.058)

   4. Correction of local kyphosis angle >25° (P = 0.005)

   5. Loss of correction of angle A >10° (P = 0.000)

   6. Loss of local kyphosis angle >6° (P = 0.002).

DISCUSSION

Age and sex ratio

The age range of this group is from 4 to 61 years old, with the average being 32.49 years old. Just 16.2% of the patients were younger than 15, and the same percentage were 55 and over. A bimodal distribution of prevalence may be found in the frequency distribution.

Number of vertebrae involved

Our series has a mean of 2.43 affected vertebrae and a mean vertebral loss of 0.923, with a range of 0.2–2.4 vertebrae lost. The average number of disks is 1.6. (1–3). Height loss in the spine before surgery was estimated to be 0.7 millimeters by Hodgson et al.[7] and 1.1 millimeters by Rajasekaran et al.[6]

Level of lesion

Eighty-one percent of patients had a substantial lesion in the thoracic area, making it the most often affected location.

Clinical presentation

Pain had been present for an average of 136 days (about four and a half months) and motor impairments for an average of 43 days before presentation. The majority of patients (68.6%) also had constitutional symptoms, and 56.8% also suffered from other serious co-morbidities. Flexor spasms were detected in 8.8% of patients. Compared to the 38% described by Tuli et al., only 6% of patients developed cold abscesses that were easily observable to the naked eye.[8]

Investigations

The average preoperative packed cell volume (PCV), serum albumin concentration (SAC), and serum total protein concentration (7.38 gm%) were all within normal range, suggesting the patient was in excellent overall health.

Magnetic resonance imaging

Thirty patients’ films were reviewed, and 13 of them showed increased signal intensity in the spinal cord, suggesting cord edema. One patient had indications of myelomalacia, but he or she eventually made a full neurological recovery.

Time spent positioning the patient for the next step of the surgery was included into the average 355-minute length of the operation. The studies by Moon et al.[9] and Yilmaz et al.[10] found no instances of implant-related problems.[10]

CONCLUSION

Complication rates were within acceptable ranges, and the average corrective loss throughout the studied population was 6.98° (0.20° to 35.90°).

Finally, we get to the following conclusion:

1. Early ambulation, shorter hospital stay, and quicker recovery times following surgery are all feasible with a procedure that combines anterior debridement and decompression with strut grafting and posterior stabilization and fusion.

2. In addition to reducing mortality during inpatient care, it also helps patients while they are waiting for their neurological condition to improve.

3. Third, it does not get in the way of neurological healing.

4. Reduces the risk of graft slippage, reabsorption, and fractures while also reducing the risk of implant problems.

5. The correction of the deformity is maintained even after a lengthy period of follow-up, which is a major benefit.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.