Instrumented circumferential fusion for tuberculosis of the dorso-lumbar spine. A single or double stage procedure?

Abstract

Purpose: The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization.

Methods: Between 2003 and 2008, 32 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared to a similar group of 25 patients treated with anterior debridement and fusion, followed 10-14 days later by posterior stabilization and postero-lateral fusion.

Results: The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 34 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 57 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 43 (75.4%) patients returned to their pre-disease activity level or work.

Conclusion: Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Figures

Fig. 1

A 59-year-old farmer presented with persistent back pain, progressive weakness of his lower limbs, inability to walk unsupported and urinary retention. a Lateral X-ray shows reduction of L4-5 disc space, adjacent endplates rarefaction and erosion. b Sagittal MRI shows in addition high signal intensity of L4 and 5 vertebral bodies and the disc in between. c, d Five-year follow-up AP and lateral X-rays after one-stage circumferential fusion show solid fusion and maintenance of sagittal alignment. e Five-year follow-up CT demonstrates complete incorporation the two tricortical iliac grafts (star) and the bone chips inserted in the debrided disc space. f Close-up lateral view shows complete bone remodeling

Fig. 2

A 64-year-old housewife presented with chronic persistent back pain of more than four months, and inability to walk unsupported due to TB spondylodiscitis affecting L1 and L2 vertebrae. She was neurologically free. She has failed conservative treatment including antituberculous treatment and rigid bracing. a, b Coronal and sagittal MRIs show marked destruction and collapse. c, d Post-operative AP and lateral X-rays after one-stage posterior debridement and stabilization with interbody cylindrical cage filled with bone graft spanning the D12-L3 interval and pedicle screw. e, f Two-year follow-up AP and lateral X-rays. g, h, i Follow-up sagittal, coronal and axial CTs, respectively

Fig. 3

A 27-year-old girl presented with back pain, leg numbness and inability to walk unsupported due to TB spondylitis affecting L3 and L4 vertebrae. She was neurologically free. a, b AP and lateral X-rays show marked destruction and collapse and subluxation. c Sagittal MRI. d, e Sagittal and axial CT. f, g AP and lateral plain X-rays taken 6 months following a one-stage posterior debridement, stabilization with an expandable cage and pedicle screws post-operatively show excellent restoration of alignment and advancing fusion. h Magnified lateral X-ray showing the expandable cage filled and surrounded by bone graft spanning the interval between L2 and L5 vertebrae. i Six-month follow-up sagittal CT

Fig. 4

A 43-year-old farmer presented with chronic persistent back pain, progressive weakness of his lower limbs and inability to walk unsupported due to L4-5 TB spondylodiscitis. a Lateral X-ray shows reduction of L4-5 disc height with endplate rarefaction and erosion. b Sagittal MRI shows L4-5 spondylodiscitis with large prevertebral and epidural abscesses. c Post-operative lateral X-ray following a first stage anterior retroperitoneal debridement and tricortical iliac crest graft show significant reduction of the local kyphosis from 15° to (−10°). d, e Two-month follow-up AP and lateral X-rays following second stage posterior stabilization and fusion. f One-year follow-up lateral X-ray. g Five-year follow-up lateral X-ray with bone remodeling 5° loss of correction