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SP INAL TUBERCULO SIS W ITH NEUROLOG ICAL D EF IC ITTREATM ENT W ITH ANTER IOR VASCULAR ISED R IB GRA FTS ,

PO STER IOR OSTEOTOM IES AND FU S ION

J. A . LOUW

From Ka la fon g H o sp ita l a nd th e U n ive rsity o fP re to ria , R epub lic o fSo u th A fr ica

Nin e t een patien ts w ith thoracic or tho raco lum bar sp in al tube rcu lo sis and neuro log ical d efic its w eretrea ted by an terio r debridem ent, d ecom press ion and vascu larised rib gra fting , fo llow ed , eith er d u ring thes ame procedure o r 14 day s la ter, b y m ultilev e l poste rio r o steo tom ies , in st rumen tat ion and fu sion . S urg eryw as p erfo rm ed unde r cove r of four-d rug an ti tub ercu losis ch em oth erapy , g iv en for 12 m on ths .

T he ave rag e p reope rativ e kypho tic angu lation of 56#{176}as redu ced to 27#{176}o stope ra tive ly and 30#{176}t th ela test fo llow -up (3#{176}os s of correction). R ad io log ica l fu sio n b etw een th e vascu larised rib g ra ft and th ever tebrae w as seen afte r an ave rage o f 3 .3 m onth s. E igh teen pa tien ts (95% ) had no rm a l neuro log ica l fu nc tio na t 14 m on ths , and th e o th e r cou ld w a lk w ith th e a id o f cru tches .

J. A . L ouw , PhD , M M ed (O rth ), M BChB , A ssoc iate P rofessor o fOrth opaed ic Su rg eryC lin ic al B uild ing , K alafong H ospita l, P rivate Bag X396 , Preto ria 0001 ,R epublic o fSouth A fr ica . 1990 B ritish E dito ria l S oc ie ty of B one and Jo in t Surg ery0301-620X /90/4 1 12 $2.0 0J Bo ne Jo in t Surg [B r ] 1990 ; 7 2-B :6 86 -9 3.

F ig . 1A rib gra ft w ith its vascu la r ped ic le, read y fo r inser tion be tw een thevertebrae. So ft t issu e has been cleared for 1 c m from each end of th egraft .

68 6 THE JOURNAL OF BONE AND JO INT SURGERY

S p i n a l tu be rcu lo sis h as d e fo rm ed , pa ra lysed and k illedm a n y o f th e hum an race fo r the past 7000 yea rs. A n ti-tub ercu lou s chem oth erapy rev o lu tion ised its tre a tm en tin th e 1950s, bu t cou ld no t im prov e nor sa tisfacto rilya rres t th e a sso cia ted kypho tic sp ina l d efo rm ity (M ed ica lR esea rch C ounc il 19 76) . M any repo rted su rg ica l te ch -n iques seem to b e equa lly in e ffec tive in p reven tin g aninc rea se in kyphos is .

T he rad ica l su rg ica l tre atm en t p io neered in H ongK ong (an terio r d ebrid em en t, decom press io n and au to-g en ous bon e g ra ftin g un de r an tib io tic co ve r)w as reportedto g ive a 1# {176}o rrectio n o f k yphosis in th e ir se rie s , b u ta llow ed 21#{176 }e ter io ra tion in a Sou th A frican se rie s o fpatients w ith sp ina l tube rcu losis and cen tra l ne rvou ss y s te m inv o lvem en t (M ed ica l R esea rch C ounc il l9 78b ,1 982 ). E v en in H ong K ong , Jenk in s et a l (197 5) repo rteda 46 .4% inc rea se in kypho sis from adm ission to 10 -y ea rfo llo w -u p in c h ild re n m a n a g e d by an te r io r d ecom pres siona nd fu sio n.

Bony fu sion o f th e tu be rc u lo us fo cus in th e sp ine haslo ng b een rega rd ed as th e su re st ev id en ce o f healin g ,t h o u g h positiv e p roo f h as n ev er been p re sen ted . S oundheal ing is k now n to be s lo w : o u t-p a tie n t c h e m oth e ra p ya l o n e re su lted in b ony fu sion in on ly 4 6% o f pa tien ts a fte r6 0 m on ths in K o rea (M ed ica l R esearch C ounc il 19 76 ).T he rad ica l op era tion gave b ette r re su lts in H ong K ong ,

w h ere 9 0% of pa tien ts ach ieved bony fu sion a fter 60m on ths (M ed ica l R esea rch C oun cil 198 2) . H ow eve r,th e re w a s on ly a sm a ll d iffe rence be tw een th e o u t-pa tien tch em othe rap y g ro up in R hod es ia (7 1% fu sion after 36m on ths) and the rad ical su rge ry g rou p in Sou th A frica(8 1% fusion a fte r 36 m on ths) (M ed ical R esearch C ounc il19 78a , b ) .

R e c o v e r y f rom parap are sis in pa tien ts w ith sp in altu b e rc u lo s is a lso seem s to be sim ila r w h icheve r treatm en tis u sed . In S o u th A frica , 6 9% of pa tien ts trea ted b yrad ica l su rg ery had com ple te neu ro log ica l recove ry at 3 6m on ths com pared with 73% of p atien ts in K orea and inR hodesia o n am bu lato ry ch em othe rap y on ly (M ed ica lR esea rch C oun cil l9 78b ).

A ne w su rg ica l app roach , th e K a la fong p ro cedu re ,

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is p ro p o s e d to im p ro v e th e re s u lts o f s u rg ic a l tre a tm e n to f sp in al tub ercu los is . I t co nsists o f an te r io r deb rid em en tw ith decom p ressio n of the sp ina l co rd (H odgson andS to ck 1956 ), os teo tom y and/o r soft tissue re lease and avascu la r rib ped ic le b one gra ft (R ose , O w en andS a n d e r s o n 1975 ; B rad fo rd 19 80) . Th is is fo llow ed , e ithe ru n d e r th e sam e anaes the tic (com bin ed one -stag e p roce-d u r e ) o r 14 days la te r, b y pos ter io r m ultileve l o steo tom ies,s p in a l in s tru m e n ta tio n a n d fu s io n . T h e a u th o r do es n o tc la im o rig in ality fo r the in d iv idua l techn iqu es , bu t ra the rpropo ses a new com bin atio n of m e thod s.

PAT IEN TS AND M ETHODSA p ro sp ec ti ve s t u d y w as m ad e of 19 pa tien ts w ith sp ina ltu be rcu lo sis p resen ting a t the K a la fo ng H osp ital from1984 to 1 988 . T he c rite ria fo r en try to th e stu dy w ere th atthe re w as h isto lo g ica l con firm a tio n o f sp in al tu be rcu lo sisa n d th a t n e u ro lo gic al invo lv em ent w as sev ere enough topreven t th e p atien t from w alk ing in dependen tly , ev enw ith the a id o f cru tches. T he re w ere five m ale s an d 14fem a le s, w ith an ave rag e age of 25 .2 y ea rs (rang e 2 to5 6) . S even pa tien ts w ere 12 years o f age o r y ounge r andth ree p atien ts w ere over 50 .

Neuro lo g ical fu nc tion o n adm issio n w as c la ssifieda c c o r d i n g to F ranke l e t al (19 69) : th ree p atien ts w ereg rade A (com ple te m o to r and sen so ry d efic it), seveng r a d e B (sen sory sp aring bu t no m o tor fun ctio n) and n ineg rade C (m o tor spa ring , bu t fun ction ally use less). S ix teenpa tien ts h ad been p ara lysed fo r an ave rage o f6 .2 m on ths(rang e 2 w eeks to 36 m on ths) ; th e o th er th ree h ad aninaccu rate o r incom p lete h isto ry . O n ly one p atien t (case2) h a d h a d a su dden de te rio ra tion o fneu ro log ical fun ctio np rio r to adm ission , n ecess ita tin g an em ergen cy de -c o m p r e s s i o n .A nte roposte rio r and late ra l rad iog raphs and tech-ne tium -9 9m bone scans o f the en tire v er teb ral co lum nw ere o b ta ined to ex clu de in vo lv em en t at m o re than on ele v e l. T h e re w ere no fa lse nega tiv e scan s and no secondnon -con tig uous le s io ns w ere de tected .

K y p h o s i s w as m easu red from the upp er end-p la te o fth e firs t u n in v o lv e d p ro x im al ve rteb ra , to the low er end -p la te o fth e f irs t u n in vo lv ed d ista l ve rteb ra . O n adm iss ionth is av eraged 5 6#{176 }rang e 12#{176}o 8 5# {1 76 }),v er a m ean of th reeve rteb ra l leve ls . H ype rex tension v iew s con firm ed tha tthe de form ity w as rig id in all the p a tien ts . D estru ction o fv ertebra l b od ie s, as show n on late ra l tom ograph s, w asreco rded as the to ta l num ber o f ve rteb rae, o r pa r ts o fve r teb rae , tha t had b een d es troy ed by tub ercu los is . T heav erage w as 1 .9 ve rteb rae (rang e 1 to 4 ) .

Ther e w ere c o mp lic a tio ns re la ted to tub ercu lo sisan d pa rap leg ia in fo u r p a tie n ts : th ree had asso cia tedp u lm o n a ry tu b e rc u lo s is a n d one had tw o c om p lic atio nsof p a ra p le g ia , a p re s s u re so re ov er th e g rea te r trochan te ran d flex io n con trac tu re s o f bo th h ips and knees, w h ichw e r e treated be fore sp in al surge ry w as pe rform ed .

A s soon as u rine , spu tum and stom ach asp ira te

s p e c im en s h a d b e e n c o lle c te d f or m ic ro sc op y a nd c u ltu re ,fo ur-d rug ch em oth erapy w ith rifam pin , ison iaz id , e th am -buto l, and pyrazinam id e w as started . A ll fou r drugs w ereg iv en as sing le o ral d oses once eve ry 24 hou rs fo r a pe rio dof 1 2 m on th s.R ib se lectio n . T he rib to b e used as th e p ed ic led boneg ra ft is se lec ted be fo re su rg ery . S ince an te rio r decom p res-s ion an d d e b rid e m e n t is a lw a y s p e rfo rm e d fo r ac tivesp ina l tub ercu losis , the abscess w a ll m ust b e in cis edlo n g i tu d in a l ly to reach the a ffec ted v ertebrae . T h isn ecessita te s d iv ision of the in tercosta l ve sse ls w he re theya re incorpora ted in to , and dense ly adheren t to , th eabscess w a ll. T he b lo o d s u p p ly to th e r ib s la te ra l to su chan in cisio n is th ere fo re a lso in te rrup ted . T he in tercosta lv es se ls tha t c ro ss an ter io r ly o ve r the f irs t un in vo lv edupper and low er v erteb rae a re no t d is tu rbed , so a ribw hich a rticu la te s w ith th e transve rse p ro cess o f e ithe r o fthese c an be used as th e b on e g ra ft. A s w e ll a s p la inra d io g ra p h s , w h ic h g iv e s o m e in d ic a tio n o f th e ex ten t o fbone and soft tissu e invo lv em en t, tom ography , com putedtom og raphy or m agnetic re son an ce im aging are essen tialto estab lish w ithou t doubt th e first no rm a l prox im a l andd ista l v e rteb rae beyond th e tu be rcu lo us p rocess.Opera tiv e techn iqu e. O pera tio n is pe rform ed unde ra d d itio n a l p ro p h y la c tic an tib io tic co ve r, u sing a firs t-gene ration cepha losporin . H ypotensiv e anaesth esia isu sed to g iv e a 25% red uc tion ofthe m ean a rte r ial p re ssu re .

Fo r th e an te rio r pro cedu re, a th oraco tom y is doneu sing the techn ique of B rad fo rd (1 98 0) to m ob ilise a r ibon its v ascu la r p e d ic le fo r the bone g raft (F ig . 1 ). T hean te r io r deb ridem en t and d ecom pression a re pe rfo rm edby the tech n iqu e desc r ib ed b y H odg son and S tock (1 95 6).A ll pa tho log ical tissue , p us and debris in bone and softtissue a re rem oved un til no rm a l b leed in g cance llous bo nea n d s o ft tissue s a re exp osed th ro ughou t the fie ld . T hedura is exp osed an d decom p ressed b o th an te rio rly andlate rally . A dhesion s are freq uen tly fou nd at the ap ex o fthe de form ity , ancho ring the du ra , p u lling it po ste rio rlyin to the apex of the cu rve and p rev en tin g an te rio rd i s p l a c e m e n t and exp an sion of th e du ra an d sp in al co rd .A m eticu lou s an terio r and latera l relea se o f all adh esionsis the re fore done be fore correction o f the kyphosis isattem pted . A ll b on e and so ft tissu e w hich m ay p rev en treduc tio n of th e kyphosis is a lso rem oved or d iv id ed .

T he poste rio r p rocedure is p e rf or m ed 10 to 14 daysaf te r th e an te rio r o pe ra tion an d red uc tion o fthe ky phosisis ach iev ed b y shorten ing the pos ter io r co lum n o f thes p i n e . This d o e s n o t a lte r th e leng th o f th e an te rio rc o lu m n o r the to rso , because th e an terio r s tru t g ra ft ac tsas a p ivo t. In th e no rm a l tho rac ic sp in e, sho rten in g ofthe poste r io r co lum n is lim ited by im pac tion of thein fe rio r fa c ets on a ridg e b elow the supe rio r facets . U singr o n g e u r s , the sp inou s p rocess, p a rts o f th e la m in a e an dpa rts o f the in fe rio r facets a re resec ted , and th e po ste rio re le m e n ts a re shaped so th a t they can glide over eachothe r a n d th u s a llo w s h o rte n in g to take p la c e .

A t al l th e leve ls w h ere spon tan eo us fu sion had

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F ig . 2 F ig . 3 F ig . 4 F ig . 5

68 8 J . A . LOUW

TH E JOURNAL O F BONE AND JO IN T SURGERY

occurred , V -sh ap ed osteo tom ies w ere m ade . T he o steo -tomies w e re c lo s e d u s in g e ith e r Harring ton com pressionor Synth es in tern al fix ato r in strum en ta tion in adults , andsub lam in ar M ersilene tap e a tta ched to a Luque rec tan g lei n c hi ld re n.The one -s tag e p rocedure . T he pa tien t is posit ion ed w ithth e righ t sid e d ow n and secu red to the op era ting tab le ,great ca re b eing tak en to a lign th e sp ine correc tly byp lac in g sandb ags cepha lad to the ilia c c re st. A n an te ro -p o s te rio r ra d io g ra p h is tak en to ensu re tha t no la te ra lcu rvatu re ha s been c rea ted . A n te r io r deb ridem en t an d

Tab l e I. S om e de tails of pa tien ts and re su lts

decom p ress io n is then ca rried ou t, bu t b e fore the ribgra ft is inse rted , the poste rio r p rocedu re is com pleted .T he ope rating tab le is ti lted from sid e to side to facilita teaccess to b o th w ounds.

T he aim of th e one -stag e com b in ed an te rio r andpo sterio r p rocedure is to ob ta in m axim um co rrec tio n o fthe kypho sis by e longa tio n o f the an te rio r co lum n andsim ultan eous shorten ing o f the po sterio r co lum n in su cha w a y th a t th e sp ina l co rd is a t th e im ag ina ry axis ofro tation . T he sp in al co rd is kep t unde r con stan t d irectv is io n fro m b o th a n te rio r a n d p o s te rio r a s p e c ts to e nsu re

Age and LevelofHyper trophyofnb(% o for ig inal

A ngula don In degre esNeu r o l(Frankel)

o gic al st atu s

Las tPos t-opfollow-up

Case sex p ath olo gy diam eter) P re-op Po st-o p Lates t Pre-op fo llow -up p eriod (m th )1 45 F T6 50 60 46 46 B D 472 35 M T5to8 N il 3 6 20 23 A E 403 4 F TlOtol2 35 67 30 22 C E 394 14 F T6and l 57 55 38 42 A E 405 3 F T6tolO 10 0 80 50 73 C E 406 36 M L l N il 5 3 28 28 B E 337 52 F T 8and9 10 0 45 26 28 B E 78 35 F T 8and9 42 34 20 23 A E 129 45 F T l2andL l Ni l 6 0 25 28 C E 37

10 35 M Tland lO 25 70 45 50 B E 22II 2 M T7to9 10 0 85 57 55 C E 2112 23 F T7to9 42 40 14 14 B E 2313 54 F T8and 9 27 12 12 12 B E 1914 56 M LI a nd 2 64 30 8 8 C E 2215 S F L9to12 90 85 35 40 C E 1816 12 F T7 to9 30 54 15 25 C E 1217 3 F T6and7 N il 6 8 35 40 C E 1218 3 F T6and l 43 85 15 25 C E 619 18 F T8 toll N il 4 6 6 6 B E 6

Pho tog raphs and rad iog raphs tak en on adm issio n and in tra-o perativ ely af ter w ound clo su re to show th e dram a tic im provem ent in kypho ticdeform ity ach iev ed by a one -stage anterio r and pos terior p rocedu re.

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Fig . 6 b F ig . 6 c

SPINA L TUBERCULOS IS W ITH NEUROLOG ICA L DEFIC IT 68 9

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tha t ne ithe r d istrac tion n or com pres sion occu rs . T hekyphosis is reduced by ante rio rly d irec ted pressu re onthe ap ex of the k yphos and po ste rio r tractio n bo thp rox im a lly an d d is ta lly . T h e L uqu e rec tang le used w ithsu b lam ina r M ersilen e tape fo r ch ild ren un de r five yea rso fage an d su b lam ina r w ire s fo r o lde r ch ild ren and adu lts ,p rov ides a good th ree -p o in t p re ssu re system . R edu ctio nis e n h a n c e d b y u s in g a la m in e c to m y s p re a d e r a n te r io rly .A fte r th e poste r io r p rocedure has b een com ple ted , th ev a s c u l a r rib g raf t is in ser ted an te r io rly . Imm ed ia ted ra m atic im pro v em en t o fthe ky pho tic de fo rm ity is usu al(F ig s 2 to 5 ).

T h e a n te rio r a n d p o s te rio r p ro c e d u re s w ere pe r-fo rm ed in tw o stages in 1 3 p atien ts , an d as a com b inedp ro c e d u re in the o the r six . H a rrin g ton com p ressio ninstrum en tatio n w as used fo r po ster io r f ixa tion in 10cases, sub lam in ar M ersilen e tape attached to a rectang lerod in fou r cases (G ain es and A berna th ie 1 986 ),s u b la m in a r w ire s and a rec tan g le rod in o ne case and theSyn thes in te rna l fix ato r in o ne case (D ick 1 987 ).S u b lam ina r M ersilene tape a lon e w as used in th reech ild ren fo r com pres sion o f the p oste r io r co lum n . T heinstrumen tat ion a n d fu s io n ex ten ded from tw o n o r m a lve rteb rae abov e the tub ercu lou s focus to tw o be low it in1 4 case s and from one ab ove to one b e low in the o the rf ive.

F ig . 6 a

Posto pe ra tive ly , the pa tien ts req u ired in tens ive ca reu n til th eir gene ral cond ition w as stab le. W hen th ew ounds h ad h ealed , the p atien ts , w ea ring a sp ina l b raceaf ter a t w o- st ag e proced ure o r a hyp erex tensio n cas t af te ra on e-stage com b ined o pe ra tion , s ta r ted ac tiv e reh ab ili-ta tion . P atien ts w ere d ischa rg ed w hen th ey cou ld w a lki n d e p e n d e n t l y w ith the a id o f cru tches. F o llow -u p w asm o n th ly fo r 1 2 m o n th s , th re e -m o n th ly d u rin g the secon dy ea r a n d s ix -m on th ly the rea f ter . R ad io g rap hs o f thesp ine w ere o b ta ined m on th ly un til bo ny fu sion w ase v i d e n t , and then a t each clin ica l rev iew .

RESULTSD etails o f th e 19 p atien ts are g iv en in T ab le I. T heave rag e b lood losse s w ere 674 m l fo r th e an te r io ro pe ra tion , 55 6 m l fo r th e po ste rio r and 878 m l fo r th eo ne -s tag e com b ined procedu re . T he ave rag e fo llow -u pw as 25 .5 mon th s .

Th ree stages o f h ealin g o f th e bon e g ra ft w ererecog n ised . In the ear ly po stop era tive pe rio d n o newbon e is seen , and the re is a ly tic area a ro und the rib g ra ft.In the secon d stage the re is ca llu s fo rm a t io n be tw een theg ra ft an d v e rteb rae bu t no b rid g ing trabecu lae . In th eth i rd stage the re are trab ecu lae in con tin u ity b etw eengraft and v e rteb rae , w ith n o ly tic lin e s.

Latera l radio graph s of a 56-y ear-o ld m an . F ig ure 6a - On adm iss ion the re w as a 30#{176}yphosis. F ig ure 6b -After the anterio r p rocedu re, w ith the rib graft in pos itio n . F igure 6 c - Six m on ths postope rat ive ly the kypho sish as been redu ced to 8#{176} .he re is b ony fusion and 63% hypertrophy of th e rib .

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Fig . 7a F ig . 7b F ig . 7c

F ig . 7 d

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THE JOURNAL OF BONE AND JO IN T SURGERY

Fig . 7eL ate ral radio graphs and photograph s o f a 5 -year-o ld girl. F igure 7a - On adm ission th ere wa s an an gulation o f85#{176} .ig ure 7b - Im m edia tely after a on e-s tag e comb in ed p rocedu re, the kypho sis is redu ced to 35#{176} .igu re 7c- A t one year pos to pera tiv ely there is 40#{176}ngu lation , b ony fus io n and 90% hypertrophy ofthe rib gra ft. F igu re7d - The paraly sed p atien t on adm ission . F igu re 7e - N eu rological ly in tac t w ith a no rm a l spin al curve at oney e ar p o st op e ra ti ve ly .

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The one-s tage com b ined K ala fong procedu re a llow s th ere d u c t io n of a long -stan d ing rig id ky pho sis , ev en in thethoracic sp ine , and ev en in ad u lts (F ig . 9 ). T h e m o stfea red com p lication , sp ina l co rd d am age , is avo id ed by

Fig . 8 a F ig . 8 b F ig . 9 a F ig . 9bL ate ral rad iog raphs of an 18 -year-o ld g irl. F ig ure 9a - Pre-operat iveangu lat ion w as 460. F igure 9b - Three m onth s p ostoperat ive ly , a fter aone -stage pro cedure , near-ana tom ica l reduction is sh own .

SPINAL TUBERCULOS IS W ITH NEUROLOG ICAL DEF IC IT 69 1

VOL . 72-B , N o. 4 , JULY 1990

T he rad iograph s w ere sep ara te ly rev iew ed by tw oin dependen t sen io r rad io log ists w ho w ere asked toid en tify th e ea r lies t film w hich sh ow ed the th ird( c o m p l e t e ) stage o f bo ny hea ling . T h is w as seen a t anave rag e o f 3 .3 m on ths (rang e 1 .5 to 1 0 ) . B ony fu sion w asp re sen t in 14 (73% ) a t th ree m on ths, 1 8 a t six m on ths,a n d in a ll 1 9 b y 10 m onths . Th e re w as no rad io log ica lev id en ce o f e rosion o r d estru ctio n o f th e vascu la ris ed ribg raf t in a n y p a tie n t. T he poste rio r fusio n w as com ple tein a ll p a tie n ts b y 1 0 m on th s.

Th e av e rage p re -o pe ra tive ang u la tion o f 56 #{176 }asred uced to 27 .6 #{1 76}osto pe ra tive ly (ran ge 8 #{176}o 5 7 # {1 7 6 }) ,5 0 .7%correction. A t th e m ost recen t fo llow -up , the ave rag eangu lat ion w as 30 .9 #{1 76} , lo ss o f co rrec tion o f 5 .9% (3 .3# {1 76} )(s ee F ig . 6 ) .

Th e si x pa tien ts trea ted w ith a o ne -stage com bin edprocedure had a m ean angu latio n o f 6 7 .5#{176 }be fo reoperat ion a nd 2 2.6 #{1 76 }o s to p e ra t iv e ly , a 66 .5% reduc tio n .A t th e la te st fo llow -up , th e ave rag e angula tio n w as 26 .3#{176} ,a 5 .5% (3 .7#{176})oss o fco rrec tion (F ig . 7 ), s till le av ing a 6 1%correction.

Cosm e tic im prov em en t w as ra ted by th e p atien ts (o rpa ren ts) as exce llen t in 1 2 and good in f ive , the o the r tw ohav ing o n ly an insig n if ican t kyp hos on pre sen ta tion . A n

i m p o r t a n t fea tu re o f the redu c tio n o f ky pho sis w as there s to ra tio n o f n o rm a l s p in e ba lance (F ig . 8 ) .

H ypertrophy o fthe rib p ed ic le gra ft w as reco rded ass ign if ican t w h en its p ostop e ra tive d iam ete r o n a late ralrad iog raph had in creased by a t leas t 25% . W e usedc o n s t a n t d istances to elim ina te an y m agn ific a tion erro ra nd used the w id th o f th e ve rteb ra a t the u ppe r end ofthe g raft a s a con tro l b etw een the seria l rad iograph s.S ign ific an t hy pe rtrop hy w as seen in 14 o f the 19 pa tien ts ,th e ave rage be ing 57 .5% .

Neu ro lo g ica l recove ry from adm ission to th e la te stfo l lo w -u p ave rag ed 2 .6 g rad es on the F rankel sca le : 1 8p atien ts had n orm al n eu ro log ica l fun ctio n w hile th en ine teen th w alk ed w ith the a id of c ru tches (case 1). F u llneuro log ical recov ery w as ach ieved by 47% at th reem o n t h s po stope rativ ely , 7 0% at six m on ths, 88% at n inem on ths an d in 95% at 14 m on ths. N o p atien t w as m adew orse by the su rg ica l trea tm en t.C om plica tio ns . T he re w ere m ino r com p lication s in tw ocases : o ne deve lop ed b ila te ra l b roncho pn eum on ia p ost-opera tiv ely , b u t responded favourab ly to in travenousan tib io tic s and p hysio the rapy ; the o th er, a gross ly ob esew om an o f 120 kg , h ad w ound breakdow n a t th e iliacc re st do nor site , bu t second ary w ound su tu re w assat isfacto ry .

L ateral rad iog raphs o f a 4 -year-o ld gir l. F igure 8a - O n adm ission , theth ora colum bar kypho sis w as 67#{176} .igu re 8b - At 36 m onth s p os top era -tively , th e kyphosis w as 22#{176} ,nd the spin e w as w e ll-b alanced.

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THE JOURNAL O F BONE AND JO INT SURGERY

m eticu lo us a tten tio n to the to ta l re lea se o f all an ter io ra n d la te ra l a d h e s io n s , a llo w in g th e s p in a l c o rd to m o v efo rw ard u nh in de red during th e red uc tion ofth e kyphos is .

S e g m e n t a l rec tang le instrum en tatio n is p re ferred toth e H arrin g ton com press ion sy stem , since it no t on lyp ro v id e s a v ery e ffectiv e th ree -p o in t system , bu t a lsoa llo w s fo r s h o rte n in g o f th e poste rio r co lum n. Fo r sm a llch ild ren w ith so ft im m atu re sp ine s, a rec tan g le w iths u b la m in a r M e rs ile n e ta p e is the on ly ava ilab le effectiveinstrumentation. In ch ild ren , a late inc rea se in kyphos isa f ter an te r io r fu sion alo ne is p reven ted by pe rfo rm ing ap oste rio r fusion , w h ich a lso inc lud es a p oste rio r ep i-p hyseo desis . T he p oste r io r in strum en ta tion he lps tom a in ta in the co rrectio n un til the fusio n is so lid .

I 3 6 9 12 15 18 21 24 21 31 33 36

Postoperative p er io d in m o n ths

F ig . 1 0Bony fus ion in the K alafo ng (continuous ) and M RC (da sh) ser ies (se etext) .

T he va riab le clin ical p ic tu re of sp ina l tu be rcu losis(M ed ica l R esea rch C ounc il 197 4 , 1 976 ; L ifeso , W eaveran d H ard er 19 85) neces sitate s com parison of the resu ltsof the p resen t stud y w ith those fo r the sam e race an d inth e sam e par t ofthe w o rld . U n fortuna te ly , on ly one studyin South A frica (M ed ica l R esea rch C ounc il l978b)in clu ded pa tien ts w ith CN S in vo lv em en t. F rom th is itw as co nc luded tha t an ter io r deb ridem en t, decom p ressio nan d bone g ra f ting p rodu ced the best su rg ical re su lts .C om paring 20 p atien ts w ith C NS invo lvem en t in theM RC study w ith th e 19 pa tien ts w ho had th e K a lafongo p e ra tio n , b o n y fu sion w as seen in only 5% at s ix m on th spostop e ra tive ly , a s aga in st 95% resp ec tive ly . A t 1 2m on th s all th e K a lafong pa tien ts h ad bony fusion , a s

ag a inst 25% in the M RC stu dy (F ig . 10 ). B o th th e B res lowand the M an te l-C ox te sts con firm ed th at the d iffe ren cesw ere h igh ly sign ifican t (p < 0 .001 ). In the K a la fo ngg roup , the re w as a m ean 44 .8% reduction o fthe kypho sis ,as aga ins t a m ean de ter io ra tion o f 5 2% from adm iss ionto th e la te s t fo llow -up in the M RC study . C om p le ten eu ro log ica l recov e ry w as seen in 47% of K a la fong and13% of M RC pa tien ts a fte r th ree m on th s ; 71% K ala fongand 33% M RC afte r six m on ths ; 9 5% K ala fo ng an d 50%M RC afte r 15 m on ths . T hese d iffe ren ces a re sign ifican tat p < 0 .0 01 (B reslow and M an tel-C ox tests ).

A sim ilar techn iqu e o f an te rio r d ecom p ress io n w asused in bo th se r ies , bu t th e K a lafon g m eth od prod ucedea rlier and m o re com ple te n eu ro log ica l recov ery , po ssib lybecause the r ig id fix atio n o f the in vo lv ed po rtio n o f thesp ine a llo w e d m o re unin te rrup ted recovery , s in ce m ove-m ent in and a round th e sp in a l co rd w as sti ll po ssib le inth e M RC cases afte r an te rio r s tru t g ra ftin g a lone .S om etim es th is m a y e v e n rend er the sp ine m ore un stab leth an b efo re su rgery .

D e s p i t e the ex ce llen t re su lts o f th e K a la fo ng p ro ce -dure , the re m ay be doub t w he the r a ll the add ition al effo rta nd thea tre tim e is jus tified in adu lt p atien ts w here thecosm etic re su lt m ay be less im portan t th an the pa ralysis .H ow ever, in th e ea rlie r M RC study o f an te rio r fu siona l o n e , th ere w as an i nc rease in kyp hosis to 61 #{176}ve r tw ole v e ls , a n d th is is im p o rta n t enough to n ecessita tecorrection.

A no th er issu e w hich need s d iscussion is w he th er av ascu lar ised bo ne g ra ft h as su ffic ien t advan tages ove r an on-vascu la ris ed g raf t to ju stify the m ore d ifficu lt andlo ng e r ope ra tion . Sound bony fu sion is the best ev idenceofhealing - and 95% ofthe vascu la rised g ra f ts had hea ledby s ix m o n th s a s a g a in s t o n ly 5% o f th e p a tie n ts in th eold er M RC g roup w ith non-v ascu larised g ra fts . F urth er-m ore , the re w as no in c rease in the kypho tic angu la tionin an y adu lt pa tien t w ith a v a sc u la r is e d gra ft a f ter bo nyfusio n at an ave rage o f 3 .3 m on th s po stop era tive ly . T h iss o lid , e a rly b o n y fu s io n s e e m s to p ro v id e enough ev iden ceto s u p p o rt th e use o f a vascu la r ised bon e graf t in sp ina ltuberculosis pa tien ts . In our se rie s th ese advan tag es w ereg a in e d w ith n o s ig n ific a n t c o m plic a tio n s .

I am gra tefu l to D r P . J . B eck er of th e Inst itu te for B ios tatistic s, S outhAfr ican M edic al R e sea rch C ouncil, fo r h is a ssistance w ith th e sta tist icalan aly sis. I further w ish to acknow ledg e Profe sso r P . A . Fourie and D rI. van de W erk e for the eva lua tion o fth e rad io graph s.N o benef its in any form have b een receiv ed o r w il l be rece ivedfrom a comm erc ial p arty re lated dire ctly or indirect ly to th e sub jec t oft hi s a rt ic le .

REFERENCES

B rad ford DS . A nte rio r v ascular p ed icle bone gra ftin g fo r th e tre atm en tofkyphos is . Spine 1 98 0; 5 :3 18 -2 3.

D ick W . Th e fixateu r in terne as a v ersatile im plant fo r sp ine su rgery .Spine 1 9 87 ; 1 2 :8 82 -9 00 .

F ranke l HL , H an co ck DO , H y slop G , et * 1 . Th e value of p os turalreduc tio n in the in itia l m anagem en t o f clo sed in jur ies o f the spin ew ith paraplegia and tetraplegia . Parap /eg ia 1 96 9; 7 :1 79 -9 2.

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Ga in e s RW Jr , Aberna th ie DL . M ersilen e tap es as a subst itu te fo r w ir ein segm ental sp inal instrum en tation fo r child ren . Sp ine 1986;11:907-13.

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Jenk ins DHR , Hodgson AR , Y au A CM , D w yer AP , O M ab ooey G .Stabilizat ion of the spin e in the surgic al trea tm ent of severe sp ina ltub erculo sis in children . C /in O rtho p 1 97 5; 1 10 :6 9- 80 .

L ifeso RM , W ea ver P , H ard er EH . T ub ercu lou s spondyli tis in adu lts . JBon e Jo in t S urg [Am ] 1985 ; 6 7-A :140 13 .

M edica l R esearch Council. A con tro lled tr ia l of anterior sp ina l fusionan d d eb ridem ent in th e surg ica l m anagem ent of tubercu los is o fthe spine in patien ts o n standa rd ch em oth erapy : a stu dy in H ongKong . BrJS u rg 1 97 4; 6 1: 85 3- 66 .

M edic al R e sea rch Council. A fiv e-y ear assessm ent o f contro lled tr ials ofin -p atien t and ou t-p atien t tre atm en t and of pla ster -of -Pa ris jacketsfor tub erculo sis o fth e spine in ch ild ren on standa rd ch em oth erapy:stu die s in M asan and Pu san , K o rea. J Bo ne Jo in t Surg [B r] 1976;58-B:399-4l 1.

Medical R e sea rch Counc il. F ive-yea r assessm ents of controlled tria ls o fam bula tory tre atm ent, debridem en t and an ter ior sp ina l fu sion inth e m anagem ent of tub ercu lo sis o f the sp in e : s tud ies in Bulaw ayo(Rhode sia ) and in H ong Kong. J Bo ne Jo in t Su rg [B r] 1978 a ; 60 -B:l63-77.

M ed ical R esearch Counc il. A contro lled tr ial of anterio r sp in al fusionand d#{233}bridem ent in the surg ica l m anagem ent of tubercu los is o fthe sp ine in p atien ts on s tandard ch em oth erapy : a study in tw ocen tre s in South A fr ica . Seventh rep or t o f th e M ed ical R esearchCounc il W orkin g Par ty on Tube rcu losis of th e Spine. Tuberc/e1 97 8b ; 5 9 : 79 -1 05 .

M ed ica l R esearch C ouncil . A ten -year assessm ent of a contro lled tr ialcom paring d eb ridem ent an d an te rio r sp ina l fus io n in the m anage-m en t o f tu bercu los is of the sp ine in pa tien ts on s tandardchem o therap y in H ong Kong. J Bon e Jo in t Su rg [B r] 1982 ; 64-B : 39 3 -8 .

Rose GK , O w en R , Sanderson JM . T ran sp os ition o f r ib w ith bloodsupply for the stabil isat ion o f a sp ina l k yphos . J Bon e Jo in t Su rg[B r ] 1 97 5; 5 7- B:l l2 .