Rev. bras. ortop. vol.52 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Monosegmental

combined

posterior

instrumentation

for

the

treatment

of

a

severe

lumbar

tuberculous

spondylodiscitis:

case

report

and

literature

review

夽

Petracchi

Matias,

Camino

Willhuber

Gaston

∗

_,

_Tripodi

_Maria,

_Bassani

_Julio,

Gruenberg

Marcelo,

Sola

Carlos

ItalianHospitalofBuenosAires,InstituteofOrthopedics“CarlosE.Ottolenghi”,BuenosAires,Argentina

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n

f

o

Articlehistory:

Received4July2016

Accepted30August2016

Availableonline29December2016

Keywords:

Discitis

Lumbarvertebrae

Tuberculosis,spinal

Thoracicvertebrae

Spinalfusion

Debridement

a

b

s

t

r

a

c

t

Spinaltuberculosis(Pottdisease)canproduceseveredeformitieswhenitisnotproperly

treated. Longinstrumentationsthroughsingleorcombineddoubleapproachesare

usu-allyrequiredtopreventandcorrectthedeformity.Theauthorspresentacaseofsevere

deformity secondarytotuberculousspondylodiscitisinthelumbarspinetreatedwitha

monosegmentalinstrumentationthroughadoubleapproachinapatientwithidiopathic

scoliosis.Deformitycorrectionandinfectionresolutionthroughdebridementand

arthrode-sisisobservedafteroneyearoffollow-up.

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Instrumentac¸ão

monossegmentar

e

posterior

combinada

para

o

tratamento

de

uma

espondilodiscite

tuberculosa

severa:

relato

de

caso

e

revisão

da

literatura

Palavras-chave:

Discite

Vértebraslombares

Tuberculosedacolunavertebral

Vértebrastorácicas

r

e

s

u

m

o

A tuberculoseespinhal(doenc¸adePott)podeproduzirdeformidadesseverassenãofor

tratadaadequadamente.Instrumentac¸õeslongasatravésdeumaabordagemsimplesou

duplageralmentesãonecessáriasparacorrigiradeformidade.Osautoresapresentamum

casodedeformidadeseveraemregiãolombarsecundáriaaespondilodiscitetuberculosa

tratadacominstrumentac¸ãomonossegmentáriaporduplaabordagememumpacientecom

夽

StudyconductedattheItalianHospitalofBuenosAires,InstituteofOrthopedics“CarlosE.Ottolenghi”,BuenosAires,Argentina.

∗ _{Corresponding}_author_.

E-mail:[email protected](C.W.Gaston).

http://dx.doi.org/10.1016/j.rboe.2016.12.010

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rev bras ortop.2017;52(6):735–739

Fusãovertebral

Debridamento

diagnósticoinicialdeescolioseidiopática.Acirurgiacorretivaearesoluc¸ãodainfecc¸ão

atravésdedebridamentoeartrodeseéobservadaapósumanodeacompanhamento.

EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Tuberculosis(TBC)diseaseisanunsolvedproblemin

develop-ingcountries,morethan80%representapulmonarydisease,

tuberculous spondylitis (Pott disease) represent a site for

extra-pulmonarytuberculosis, it occurs in less than 1% of

patientswithtuberculosis.1

Tuberculous spondylitistypicalpresentationcaninvolve

anteriorelements,usuallytwoadjacentvertebralbodiesand

theintervertebraldisc,andformsaparavetebralabscess.It

rarelyinvolvestheposteriorelements(neuralarch

tuberculo-sis)inisolationorcombinationwithlamina,spinoutsprocess,

transverseprocess,articularprocessandpedicles,itcanalso

makeanepiduralabscessand/orpyomyositisoftheposterior

spinalmuscles.

Thetypicalclinicalpresentationisbackpain,butinthose

whenitinvolvesposteriorelementsalsomayleadtothe

sud-denonsetofaneurologicaldeficit.2

The treatment of tuberculosis spondylitis is based on

the structuraldamage secondary tobone and ligamentary

destruction.Ingeneral;debridement andanterioror

poste-riorfusionproceduresarerequired.Approximately5%ofthe

Tuberculosis inthespine developsseveredeformities3 _and

surgicaltreatmentrepresentsachallengeinthisscenario.

Short-instrumentation has been described previously

for one level Tuberculosum spondylodiscitis and mild

deformities,4 _however, _to _our _knowledge, _{monosegmental}

instrumentationforthetreatmentofaseveredeformity

lum-barTBChasnotbeendescribedpreviously.

We present the treatment of lumbar TBC treated by

debridementandone-levelanteriorposteriorarthrodesisof

thelumbarspineinapatientwithmildscoliosis.

Case

report

A23-yearsoldfemalewaspreviouslytreatedinother

insti-tutionbecauseofpsoas tearduringthreemonths,because

ofprogressiveseverelumbarpainsheconsultedtoour

insti-tution.Therewasnoneurologicalcompromise.Weightlost

wasnotdetectedandanyothersymptomwasassociatedto

thelumbarpain.Previousspinalradiographyanalysisshowed

rightthoracicidiopathicscoliosiswitha22degreeslumbar

compensatorycurve(Fig.1).

MRIwasthenperformedshowingL2vertebralbody,L2–L3

discandrightpsoascompromise(Fig.2).Spondylodiscitiswas

then suspected. CT-scanwas performed in order to

evalu-atealabdominalstructuresandtoruled-outanotherclinical

problems related to this severe pain (Fig. 3). Severe L2–L3

compromisewasobservedonCTscanwithincreasedcurve

deformityatthislevel.

Fig.1–(A)Posteriorview,thoracolumbarscoliosiswith22 gradesatthelumbarregion;(B)Lateralradiologicalview approximatelyoneyearbeforediagnosis.

Percutaneous CT scanguided catheterintervention was

performed with 60cm3 _hematogenous _material _drainage

(Fig.3)butthecultureswerenegative.

Surgerywasplannedtostabilizeandcorrectspinal

defor-mity,drainageofnecroticandinflammatorycomponentand

preventneurologicalcompromise.

Surgicaltreatment

Vertebralsegmentarykyphosisandlateralangulationwere17

and25degreesrespectively.

Monosegmentary instrumentation through a double

antero-posterior approachwas planned.Firststage,a

min-imally invasivelateral right sideapproachforintersomatic

and para-vertebraldebridementwasperformedfollowedby

areconstructionwithL2-L3interbodytitaniumcagewithrib

boneautograft.

Posteriorly,withthesameanesthesia,aposteriorapproach

forL2–L3pedicularinstrumentationwas performedandno

normalspinallevelswereinstrumented(Fig.4).

Estimated blood loss during the entire procedure was

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Fig.2–(A)and(B)T1–T2sagittalMRIshowingL2–L3compromise;(C)and(D)AxialMRIshowingrightpsoasmuscle compromise.

monitoring including somatosensory evoked potentials

(SSEPs)andmotorevokedpotentials(MEPs).

Nocomplicationswereobservedduringtheprocedure.

Histologicalanalysis

Microscopicimages(Fig.5)showedgranulomatosusreaction

withmultinucleatedcells.ZiehlNeelsencolorationtechnique

wasnegative,however,polymerasechainreaction(PCR)was

positivefortuberculosis.

Postoperativetreatmentandfollowup

A Thoraco-lumbo-sacralorthosis (TLSO)was indicated and

usedduringthreemonths.

Clinicalandradiologicalcontrolwasperformedeverythree

months,nodeformitiesduringfollowupwereobserved,

post-operativeanteriorandlateralsegmentalangleswere1and2

degreesrespectively.Clinicalparameterswereimprovedand

antituberculosistherapy wassuccessfulafter12monthsof

treatment(Fig.6).

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rev bras ortop.2017;52(6):735–739

Fig.4–Intraoperativeradioscopicstepsfortheanteriorandposteriorarthrodesis,lateralminiinvasiveapproach,vertebral andpsoasdebridementfollowedbyinterbodycageinstrumentationandpostoperativeposteriorinstrumentation.

Postoperative protocol included four anti tuberculosis

agentsfortwomonths(Isoniazide,Ethambutol,Pirazinamide,

Rifampin)followedbytwodrugsforten months(Isonizide,

Rifampin).

Discussion

Thetreatmentofspinaltuberculosisusuallyisnon-surgical,

by the administration of four anti-tuberculosis drugs and

bracing.5_There_are_some_situations_in_which_surgical

treat-mentisrequired:lossofsagittalorcoronalalignmentofthe

spineduetoextensiveosteolysisandspread ofanabscess

intothepara-spinaltissuesandspinalcanal,withprogressive

neurologicdeficit,failedconservativetreatmentoruncertain

diagnosis.2

Posteriorinstrumentationwithorwithoutanteriorfusion

hasdemonstratedgoodclinicalandsurgicalresults.6,7

Anterior fusion alone, is generally indicated for

patients with single level compromise and minor or mild

deformities,8–10 _additional _posterior _{instrumentation} _is

considered in multilevel compromise or severe deformity,

however, short or long instrumentations are performed in

ordertopreventearlyfailureandobtainmorecorrection.11

Theanteriorapproachispossibleonlyiftheposterior

col-umnisintact,anditisdemonstratedthatcandecreasethe

operatingtime,bloodloss,andpostoperativemorbidity.

How-everforapatientwithpanvertebraldisease,orwiththeneed

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Fig.6–(A)and(B)Immediatepostoperativecontrol;(C)and(D)Oneyearpostoperativecontrol;(E)and(F)CT-scanshowing L2–L3interbodyarthrodesis.

forposteriorcolumnshorteningtoreducekyphosis,or

multi-leveldisease,posteriorstabilizationisnecessary.12

Wepresentacaseofseverelumbardeformitysecondary

tospondylitistuberculosistreatedthroughadoubleanterior

posterior approach with monosegmental instrumentation,

arthrodesis was observed after a follow-up of one year.

Thistechnique should beattempt aftera carefullypatient

selection.Morecasesarerequiredtoreinforcethis

recommen-dation.

Toourknowledgecombinedmonosegmental

instrumenta-tionforthetreatmentofaseverespinaldeformitysecondary

toTuberculosumspondylitishavenotbeendescribed.More

casesareneededtosupportthistreatment.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. AroraS,SabatD,MainiL,SuralS,KumarV,GautamVK,etal. Isolatedinvolvementoftheposteriorelementsinspinal tuberculosis:areviewoftwenty-fourcases.JBoneJointSurg Am.2012;94(20):e151.

2. KapoorSK,GargV,DhaonBK,JindalM.Tuberculosisofthe posteriorvertebralelements:ararecauseofcompressionof thecaudaequina.Acasereport.JBoneJointSurgAm. 2005;87(2):391–4.

3. IssackPS,Boachie-AdjeiO.Surgicalcorrectionofkyphotic deformityinspinaltuberculosis.IntOrthop.2012;36(2):353–7.

4.KlöcknerC,ValenciaR.Sagittalalignmentafteranterior debridementandfusionwithorwithoutadditionalposterior instrumentationinthetreatmentofpyogenicand

tuberculousspondylodiscitis.Spine(PhilaPa1976). 2003;28(10):1036–42.

5.MoonMS,KimI,WooYK,ParkYO.Conservativetreatmentof tuberculosisofthethoracicandlumbarspineinadultsand children.IntOrthop.1987;11(4):315–22.

6.MakKC,CheungKM.SurgicaltreatmentofacuteTB spondylitis:indicationsandoutcomes.EurSpineJ.2013;22 Suppl.4:603–11.

7.YangP,HeX,LiH,ZangQ,YangB.Clinicalefficacyof posteriorversusanteriorinstrumentationforthetreatment ofspinaltuberculosisinadults:ameta-analysis.JOrthop SurgRes.2014;9(1):10.

8.DaiLY,JiangLS,WangW,CuiYM.Single-stageanterior autogenousbonegraftingandinstrumentationinthesurgical managementofspinaltuberculosis.Spine(PhilaPa1976). 2005;30(20):2342–9.

9.GueradoE,CervánAM.Surgicaltreatmentof spondylodiscitis.Anupdate.IntOrthop.2012;36(2): 413–20.

10.TosunB,ErdemirC,YongaO,SelekO.Surgicaltreatmentof thoracolumbartuberculosis:aretrospectiveanalysisof autogenousgraftingversusexpandablecages.EurSpineJ. 2014;23(11):2299–306.

11.HuJ,LiD,KangY,PangX,WuT,DuanC,etal.Activethoracic andlumbarspinaltuberculosisinchildrenwithkyphotic deformitytreatedbyone-stageposteriorinstrumentation combinedanteriordebridement:preliminarystudy.EurJ OrthopSurgTraumatol.2014;24Suppl.1:S221–9.