Nitin Garg1, Renuka Vohra. 1. Department of Neurosurgery, Bhopal Memorial Hospital and Research Centre, Near Karond Square, Bhopal, 462038, India, drnitingarg@hotmail.com.
Abstract
BACKGROUND: Spinal tuberculosis is the most common form of skeletal tuberculosis. Various approaches have been described for surgical management of spinal tuberculosis, but many entail wide exposures with attendant morbidity; whether minimally invasive surgical (MIS) approaches are suitable is unknown. QUESTIONS/PURPOSES: We evaluated (1) neurologic results, (2) radiographic results, and (3) complications in patients with thoracic and lumbar spinal tuberculosis treated with two MIS approaches. METHODS: We retrospectively evaluated 22 patients with thoracic and lumbar tuberculosis managed surgically from October 2008 to February 2011 using MIS methods; one patient was lost to followup, leaving 21 patients with a minimum followup of 15 months (mean, 30 months; range, 15-59 months) for analysis. MIS approaches were used for patients with disease below D6 and minimum pedicle diameters of 4.5 mm to permit percutaneous screw placement. The MIS approach was divided into two groups depending on the extent of destruction of the vertebral body: a posterior-only group (n = 9), where posterior transpedicular decompression sufficed, and the hybrid group (n = 12), requiring anterior débridement and ventral-column reconstruction by conventional or mini-open thoracotomy. All but two patients with more than two contiguous bodies involvement underwent MIS posterior fixation by percutaneous transpedicular screws. Plain radiographs were evaluated for deformity correction and correction maintenance. Neurologic recovery and complications were ascertained by chart review. RESULTS: All patients with neurologic deficits recovered completely with no motor deficits at followup; 13% improved by three grades, 53% by two grades, and 33% by one grade. Mean correction was 2.5° (thoracic) and 8° (lumbar) in the posterior-only group and 4.2° in the hybrid group. Some correction loss occurred with healing (2° and 1.6° in the posterior-only and hybrid groups, respectively), but in none of those who had fixation did this progress to more than preoperative status. Two of 22 patients (9%) had complications. One had a malposition of L5 screw causing painful radiculopathy without motor deficit and required repositioning. The other had an intraoperative dural tear repaired by onlay fascial patch and cerebrospinal fluid diversion. There were no approach-related complications, neurologic deterioration, or implant fatigue at last followup. CONCLUSIONS: We found evidence of neurologic recovery, avoidance of deformity progression, and few complications with these MIS approaches. Comparative trials are called for between open and MIS approaches for patients with spinal tuberculosis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND:Spinal tuberculosis is the most common form of skeletal tuberculosis. Various approaches have been described for surgical management of spinal tuberculosis, but many entail wide exposures with attendant morbidity; whether minimally invasive surgical (MIS) approaches are suitable is unknown. QUESTIONS/PURPOSES: We evaluated (1) neurologic results, (2) radiographic results, and (3) complications in patients with thoracic and lumbar spinal tuberculosis treated with two MIS approaches. METHODS: We retrospectively evaluated 22 patients with thoracic and lumbar tuberculosis managed surgically from October 2008 to February 2011 using MIS methods; one patient was lost to followup, leaving 21 patients with a minimum followup of 15 months (mean, 30 months; range, 15-59 months) for analysis. MIS approaches were used for patients with disease below D6 and minimum pedicle diameters of 4.5 mm to permit percutaneous screw placement. The MIS approach was divided into two groups depending on the extent of destruction of the vertebral body: a posterior-only group (n = 9), where posterior transpedicular decompression sufficed, and the hybrid group (n = 12), requiring anterior débridement and ventral-column reconstruction by conventional or mini-open thoracotomy. All but two patients with more than two contiguous bodies involvement underwent MIS posterior fixation by percutaneous transpedicular screws. Plain radiographs were evaluated for deformity correction and correction maintenance. Neurologic recovery and complications were ascertained by chart review. RESULTS: All patients with neurologic deficits recovered completely with no motor deficits at followup; 13% improved by three grades, 53% by two grades, and 33% by one grade. Mean correction was 2.5° (thoracic) and 8° (lumbar) in the posterior-only group and 4.2° in the hybrid group. Some correction loss occurred with healing (2° and 1.6° in the posterior-only and hybrid groups, respectively), but in none of those who had fixation did this progress to more than preoperative status. Two of 22 patients (9%) had complications. One had a malposition of L5 screw causing painful radiculopathy without motor deficit and required repositioning. The other had an intraoperative dural tear repaired by onlay fascial patch and cerebrospinal fluid diversion. There were no approach-related complications, neurologic deterioration, or implant fatigue at last followup. CONCLUSIONS: We found evidence of neurologic recovery, avoidance of deformity progression, and few complications with these MIS approaches. Comparative trials are called for between open and MIS approaches for patients with spinal tuberculosis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.