The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia

Abstract

Study design: Retrospective clinical series.

Purpose: To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the "Extended Posterior Circumferential Decompression (EPCD)" technique.

Overview of literature: With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful.

Methods: Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment.

Results: Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively.

Conclusions: The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction.

Keywords: Circumferential spinal canal decompression; Extended posterior approach; Interbody fusion; Kyphosis correction; Neurological recovery.

Fig. 1

Bilateral costo-transversectomy done to gain access to the pre-vertebral space. Approximately 5-8 cm of rib was resected.

Fig. 2

Pedicle screw placement followed by temporary stabilization of one side with a rod. Decompression of the cord was done after laminectomy, and anterior debridement of the affected vertebra after osteotomizing the pedicle.

Fig. 3

Contralateral side was temporarily stabilised, and then the decompression was completed circumferentially from the other side.

Fig. 4

(A, B) Anterior defect was measured and reconstructed with titanium cage filled with morselized autogenous cancellous graft and compressed posteriorly.

Fig. 5

(A-C) A 12-year-old boy, with destruction of D7, 8, 9 vertebra, was treated with first-line anti-tuberculosis drugs elsewhere for four months. He presented to us with progression of the disease, paraplegia Frankel A and kyphosis of 97.7 degrees. He was treated by extended posterior circumferential decompression. The culture was proven multidrug resistant tuberculosis; and the patient was treated with second line anti-tuberculosis drugs treatment for two years. At follow-up, his neurology recovered to Frankel D. Plain radiograph shows healed lesion with interbody fusion, kyphus angle of 47.8 degree kyphosis. The patient is presently pain-free and in near full-functional status. Pre-op, preoperative; Post-op, postoperative.