Single-Stage Posterior Debridement and Spondylectomy with Column Shortening for Tuberculous Spondylitis of the Lumbar Spine with Kyphotic Deformity: A Case Report
Abubakar K, Shobode MA, Adetan O, Chiroma MM, Yunusa RA, Abdulmalik AM, Waheed TA, Mamman M, Onuminya JE, Abubakar MK
National Orthopaedic Hospitals, Dala, Kano.
Address for correspondence:
Dr MA Shobode,
Department of Clinical Services,
National Orthopaedic Hospital, Dala, Kano, Nigeria
Background: Antikoch’s combination chemotherapy is the gold standard for the treatment of osteoarticular tuberculosis. Surgery is indicated in patients with worsening neurology, mechanical instability and unacceptable kyphotic deformity. The Hong Kong and the Modified Hong Kong’s procedures have been described with satisfactory outcomes including maintenance of column height with cage or bone graft.
Objectives: To describe the safety of a single-stage posterior approach for debridement, spondylectomy, restoration of lumbar lordosis and column shortening in tuberculous spondylitis of the lumbar spine.
Materials and Methods: We present a 26 year old man with low back pain radiating down both legs with associated paraesthesia and paresis of 8 months duration. There was significant weight loss but No cough. Power in the lower limbs was MRC 2 in the Hip and knee extensors and the gastroc-soleus complex (triceps surae). Imaging studies showed the destruction of L4 vertebral body, subluxation of L3 over L4, regional kyphosis of 300 (Gardner’s mono-segmental method) and caseous materials compressing the cord. He was anaemic with moderately elevated ESR. He was admitted and had a biopsy done under image guidance. AFB was isolated and he was commenced on anti-koch’s combination chemotherapy (rifampicin, isoniazid, pyrazinamide and ethambutol) one week before surgery. Intravenous levofloxacin was added. He eventually had surgery done under general anaesthesia (posterior decompression, 2- level Smith Peterson Osteotomy, spondylectomy, interbody fusion of L3L5 and Pedicle Screws- Rod instrumentation of L2 to S1 with postero-lateral gutter fusion) a week after commencement of chemotherapy. Lumbar lordosis was restored to 300 (Cobb’s bisegmental method). McNab classification of surgical results, ODI and the ASIA IS were used as outcome measures.
Results: Duration of surgery was three and a half hours with EBL of 1litre. He had a satisfactory outcome as measured by the McNab classification of surgical results. ODI improved from 46 to 20 a week after surgery. Power also improved from MRC 2 to 4 and he had since commenced ambulation with a walking frame. Anti-koch’s chemotherapy was also continued for 9 months.
Conclusions: In carefully selected patients, a single-stage posterior instrumentation and radical debridement of the vertebral body, with or without vertebral column shortening, is a safe option in the treatment of active tuberculous spondylitis of the lumbar spine.
Key words: Single-stage, posterior approach, tuberculous spondylitis, lumbar spine.