Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit

Abstract

Background: A combined anterior decompression and stabilization followed by posterior instrumented fusion promotes fusion of the affected segment of spine and prevents further progression of deformity. The objective of this study is to report on outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity who underwent single-stage anterior corpectomy and fusion and posterior decompression with instrumented fusion.

Methods: A total of 49 patients (29 males, 20 females) with varying grades of neurological deficit due to tuberculosis of the spine (thoracic, thoracolumbar, and lumbar) were included in this prospective study. The diagnosis of tubercular infection was established after clinical, hematological, radiological, and histological specimens taken at surgery. All were treated with combined anterior and posterior decompression, debridement, and stabilization with direct autologous bone grafting or wrapped bone graft in mesh or expandable cages. Neurological status and visual analog scale (VAS) pain score were recorded at each visit. X-rays, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function were evaluated at 3, 6, and 12 months after surgery and then once a year thereafter. Results were analyzed in terms of neurological recovery (Frankel grade), bony union time, and correction of kyphotic deformity.

Results: The mean age was 37.8 years (range, 2-65 years). Mean preoperative VAS scores improved from 5.6 to 1.5. The average ESR and CRP returned to normal within 6 months in all patients. The mean time to fusion was 8.4 months for the whole group. The neurological deficit in 42 of 49 patients had excellent or good clinical outcome (P < .0001). A total of 10 of 17 patients improved from Frankel A and B to Frankel E (normal activity). Three patients each in the thoracic and thoracolumbar groups improved to Frankel D. Radiological measurements showed the mean kyphotic correction was 61%, 66%, and 67% in the thoracic, thoracolumbar, and lumbar/lumbosacral spine, respectively.

Conclusions: Combined single-stage anterior decompression and stabilization followed by posterior instrumented fusion is safe and effective in the treatment of tuberculous spondylitis with neurological deficit in the thoracic and lumbar spine. This procedure helps to correct and maintain the deformity, abscess clearance, spinal-cord decompression, and pain relief as well as return to normal motor function. Bony fusion prevents further progression of deformity.

Level of evidence: 2.

Keywords: combined anterior and posterior surgery (A-P); neurological deficit; spinal fusion; spine tuberculosis.

Figure 1

A 58-year-old woman with thoracic (D8-D9) tuberculosis (TB) and paraplegia of 4 months' duration. (a) X-ray antero-posterior view showing D8-D9 collapse. (b) X-ray lateral view showing D8-D9 collapse. (c) MRI (T2 sagittal view) showing the extent of the lesion with compression of the spinal cord. (d) MRI (T2 axial view) showing the extent of the lesion with abscess at D8-D9. (e) 2 weeks' postoperative x-ray antero-posterior view showing corpectomy and cage fusion with rib grafts in situ. (f) 2 weeks postoperative x-ray lateral view showing corpectomy and cage fusion with rib grafts in situ. (g) 3 years' postoperative x-ray antero-posterior view showing healed TB lesion with bony fusion. (h) 3 years' postoperative x-ray lateral view showing healed TB lesion with bony fusion.

Figure 2

A 15-year-old girl presented with L2 vertebral collapse due to tuberculosis with complete paraplegia. (a) X-ray antero-posterior view showing collapse at L2 segment. (b) X-ray antero-posterior view showing collapse of L2 vertebrae with kyphosis. (c) Computed tomography scan sagittal view showing complete destruction of L2 with spinal cord compromise. (d) MRI (T2 sagittal view) showing the extent of the lesion with compression of the spinal cord. (e) 3 years' postoperative x-ray antero-posterior view showing corpectomy and expandable cage with autologous bone graft fusion (between L1 lower end plate and L3 upper end plate). (f) 3 years' postoperative x-ray lateral view showing bone fusion between L1-L3. (g) Clinical photograph at 3-year follow-up with complete recovery.