Isolated Caries spine in children – DR R L Shahu

Abstract

Background

Pulmonary tuberculosis in infants and children in India is quite common and skeletal tuberculosis accounts for 10-20% of all extra pulmonary cases. Tuberculosis of spine or caries spine is a serious disease and if not treated adequately, carries high morbidity and mortality. This study was undertaken to highlight the occurrence of bone destruction, spinal deformity and neural complications in children if not diagnosed early and treated properly.

Materials and Methods

A prospective study of 18 children with the diagnosis of caries spine was done during the period of July 2005 to July 2010. All the children were within 10 years of age. Out of 18, 11 were male and 7 were female with the mean age of 5.2 years. Pulmonary involvement of tuberculosis were not found in all the children. Out of 18, 12 children were neurological deficit and 5 were having gibbus deformity. Out of 18 children, 10 were treated conservatively and 8 by operations. Diagnosis was based on clinical features, history of contact with tuberculous patient, abnormalities on chest and spine X-rays and magnetic resonance imaging studies of spine. Results

Total number of patients studied was 18. Among them 18 (100%) cases of low back pain, constitutional symptoms 14 (71%), Para spinal abscesses 7 (39%), neurological deficit 12 (66.7%) and spinal deformity 5 (27.8%). 55.5% patients were treated with conservatively and 45.5% were treated operatively. All patients were treated according to DOTS strategy, and 7 (39%) underwent surgical drainage of abscesses. The entire patient with paraplegia recovered by 5 to 16 months except one who was lost to follow up. Non paraplegia patients were mobilized at 5 months. This procedure helped in early cure with bony fusion, quick recovery from spinal cord dysfunction when associated with pressure on the spinal cord and prevented progressive vertebral destruction responsible for kyphotic deformity.

Conclusions In caries spine conservative treatment will continue to be successful in majority of cases but when indicated, especially in patients with neurological deficit, good decompression and fusion should be done promptly and neurological deficit due to tuberculosis of spine

is reversible in majority of cases especially if decompression is done promptly. Good fusion and stabilization can prevent pain and late deformity

Key words: Caries spine, Gibbus, Para spinal abscess, Paraplegia.

Introduction

SPINAL tubercular infection is the most common and dangerous form of skeletal tuberculosis. It constitutes 1/3 to 1/2 of all bone and joint tuberculosis. It is a result of hematogenous dissemination from primary focus in the lungs, lymph nodes, etc1. Thoracic and lumbar spine are commonly affected area. 10-40% of patients with thoracic spine tuberculosis may get neurological deficit. Urgent Measures are needed to halt progression of destruction and deformity and especially to prevent and overcome paraplegia. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcome for each individual case of Pott’s disease 2.

Materials and Methods

Between July 2005 to July 2010, a total of 8 patients underwent surgical treatment with spinal decompression. Out of 8 patients, bone grafting done in 5 patients having gibbus deformity. Out of 18, 10 patients were kept on conservative treatment with antitubercular drugs. The mean follow up was 14 months (range 12 to 19 months). Inclusion criteria: 1.Children were within 2-10 years of age, 2. Isolated caries spine with and without neurological deficit. 3. Early onset of paraplegia is included. Exclusion criteria: 1.Extra spinal tuberculosis is excluded. 2. Let onset of paraplegia is excluded. Tuberculosis diagnosis was confirmed by a combination of clinical and Para clinical findings. Laboratory examinations included: CBC, ESR, PPD, smear and culture of gastric lavage and abscess discharge for AFB, chest X-ray and CT-scan, abdominal CT-scan, spinal X-rays, and spinal MRI All patients benefited from antituberculous chemotherapy. The regimen adopted was 2SRHZ/10RH in all cases: Streptomycin (1 mg/kg/day), Rifampicin (10 mg/kg/day), Isoniazid (5 mg/kg/day) and Pyrazinamide (30 mg/kg/day) were administrated during 2 months and then Rifampicin and Isoniazid were continued during the following 10 months. A hepatic assessment of the control was systematically carried out every 3 months until the end of the treatment protocol. Average preoperative treatment in all paraplegics was 3 weeks and that in non paraplegics 18 weeks. Streptomycin was discontinued in all the children after 20 weeks.

INDICATIONS FOR SURGERY

1. Caries spine without neurological deficit• Large abscess.• Large destruction not responding to ATT - Pain ++.• Spine at risk in children.2. Caries spine with neurological deficit• All indications recommended in middle path regime• Significant neurological deficit with demonstrable

Operative procedure: Para spinal transthoracic approach reached from the left side was used for upper thoracic spine. This approach was used in 3 patients.Oblique transthoracic approach from left side was used for lower thoracic spine. This approach was used in 3

patients. For all thoraco-lumber lesions, trans-thoracic retroperitoneal approach was used. Table 5This approach was used in 2 patients. The third rib was excised to reach the first to fourth vertebral bodies. To approach fifth thoracic to eleventh thoracic vertebral bodies the rib that felt to the level of the lesions in mid axillary line. In all children either with or with out paraplegia the vertebral lesion was thoroughly excised till the spinal cord was exposed after the abscess was well evacuated. The intervertebral gap following excision of the lesion was bridged with autogenous bone grafts. Figure 3 After correcting the kyphotic deformity to the possible degree, Rib grafts were used in 5 patients. The common pathology responsible for paraplegia in all the children was pus and granulation tissue.

Observations: Out of the 18 children with caries spine in this study the youngest was 2 years and the oldest was 10 years old. Maximum numbers of patient were between 2 to 3 years of age. Table 1.The male were 11 and female were 7. All the children came from low socio economic groups and poor hygienic sourroundings.The exact duration of disease could not be ascertained properly. It varied from 2 months to one year. Out of the 18 children 4 had lesions in upper thoracic spine, 9 in lower thoracic and 5 in thoracolumber spine. Table 2,3 None of them presented with more than one lesion. Minimum 2 and maximum 3 vertebral bodies were affected. Figure 1, 2 Out of 18 children, 12 had neurological deficit at the time of admission. Out of 12, 8 had complete upper motor neuron type of paraplegia with bladder and bowel involvement, and 4 had Para paresis without bladder and bowel involvement. The onset of paraplegia was sudden in 4 and gradual in 8 patients. Skiagrams of 7 children with thoracic lesions showed Para vertebral abscess. In 5 children with thoracic lesions showed gibbus deformity. Table 3

Ethical and legal procedureThe protocol was approved by an ethics committee and thus meets the standards of the Declaration of Helsinki in its revised version of 1975 and amendments made to it in 1983, 1989 and 1996 (JAMA 1997; 277:925–6).

Results: All the 12 children with partial and complete paraplegia, recovered fully,4 of them in 6 months, 6 at 10 months and 2 at 12 months. Eighteenth children were followed-up from 10 to 20 months at monthly intervals after they were discharged as inpatients. All those children without paraplegia were ambulated 5 months after surgery and those with paraplegia were ambulated soon after the recovery from neurological deficit, ranging from 5 to 16 months. In all the 5 children the bone grafts had taken up in 3 to 4 months time. There was no slipping of the graft in any of the children. Figure 3,4 Posterior spinal fusion was not done in any of the patients to augment the stability of the spine. There was no mortality or recrudescence of the disease in any of the 18 children at follow-up.

Discussion:

Pott's paraplegia resulting in severe spinal deformity is a disastrous complication, which is difficult to treat by chemotherapy alone and/or by surgical decompression. 3,4 It is generally accepted that Pott's paraplegia in early spinal tuberculosis can be cured effectively through chemotherapy alone.5,6 In our series 4 patients out of 12 patients of pott’s paraplegia were successfully treated with chemotherapy alone. Hsu et al. recommended surgical decompression of the compressed cord at the level of active tuberculous focus and kyphosis since this resulted in good neurological results.7

Paraplegia together with residual spinal deformity is one of the most disastrous complications of Pott's disease.3,4,6,8,9,10,11 Up to now, there have been numerous papers which dealt with Pott's paraplegia12,13,14,15,16 however, there are only a few papers, which addressed Pott's paraplegics complicated by severe spinal deformity.11,12,15 In our series 5 patients out of 18 had gibbus deformity. An accurate assessment of the disease activity is necessary in order to achieve a successful outcome before any initiation of treatment. A single radiographic assessment of activity is notoriously difficult because a patient does not always show clinical evidence of activity. Generally, it has been believed that chemotherapy alone is an inappropriate method for managing paraplegia in patients with advanced tuberculosis and deformity,1,7,16 since paraplegia usually resolves rapidly after adequate decompression. Many surgeons believe that it is inappropriate to require a patient to lie paralyzed for extended periods waiting for a cure through conservative care, and prefer management by anterior decompression and fusion with bone graft.1,7,10,16

Therefore, the afore-mentioned treatment protocol has been well accepted, and was used for paraplegic patients with mild and moderate degrees of spinal deformity. In our series 8 patients had paraplegia with bladder and bowel involvement with Para spinal abscess and 4 patients had Para paresis without involvement of bladder and bowel. Decompression was done in 8 patients with paraplegia and rests were treated

conservatively. All the patients recovered fully due to early diagnosis and treated promptly. However, those principles could not effectively solve the neurological problems in Pott's paraplegic patients with severe spinal deformity. Chemotherapy was instituted first, but when patients were unresponsive, and had worsening neurology, decompression surgery was indicated. In these patients, radical decompressive surgery carried a high neurological risk with only a small chance of recovery. In previous studies, the senior author of this study had listed the factors influencing the neurological recovery rate in Pott's paraplegics.5,6 The recovery rate is influenced by many factors such as: the patient's general condition, the patient's age, the condition of the spinal cord, the level, duration and severity of paraplegia, the time of onset before the initiation of treatment, the type of treatment, and the patient's drug sensitivity. Paralysis persisting longer than 6 months is unlikely to improve. Late paralysis with inactive disease and significant kyphosis is much less responsive to treatment as found in this current series. Paralysis caused by vascular embarrassment has a worse prognosis. Patients with an atrophic spinal cord assessed by a preoperative MRI usually do poorly after decompression. In treating adult patients with chronic Pott's paraplegics with severe spinal deformity, decompression surgery should be avoided to prevent damage to the circulation and the compressed spinal cord. However, for child paraplegics, more promising results may be obtained through decompression surgery. That is, neurological recovery was better in children who had decompression surgery than in adults who received chemotherapy alone or in combination with decompression surgery. It is noteworthy to remind treating physicians and surgeons that paraplegics with a severely deformed spine showed a different neurological response to chemotherapy treatment or combined chemotherapy and surgical treatments than those paraplegics with mild to moderate degrees of spinal deformity. When surgical decompression is chosen as a last choice of treatment, each patient should be cautioned about the high neurological risk and the slim chance of neurological recovery by surgery even under the cover of chemotherapy.6,17 Adult paraplegic with severe spinal deformities had poorer spinal cord conditions than those with milder deformities.5,18 Thus, it is essential to assess the condition of the spinal cord through plain X-rays, myelograms, C-T myelograms and MRI before any treatment commences. It is strongly recommended that a spinal cord circulation study be conducted wherever possible. In two cases of this current series, the authors attempted to combine decompression surgery with posterior corrective and instrumented stabilization surgery because of segmental instability after decompression surgery. In one case, the deformity was corrected successfully and neurological recovery ensued, while in the other cases, there was no neurological recovery despite effective decompression and a relatively good correction of the deformity. For corrective surgery the risk of neurological damage by operative distraction was related both to the severity of the original deformity and to the degree of correction. For posterior instrumented corrective surgery, the length of the vertebral canal and vertebral column should be considered. A short cord may be placed at more risk in idiopathic scoliosis by posterior instrumented correction because of the short vertebral canal in comparison to the vertebral column. Thus, anterior surgery excising the body and discs may lengthen the vertebral canal relatively, and is less dangerous to the

spinal cord.19 A preoperative measurement of the vertebral canal and column length might help to quantify the risk of neurological damage. In this study, it was found that the patients with active tuberculosis, who showed a neurological response after the start of chemotherapy, achieve more favorable result when surgery was combined, In our series all the children with partial paralysis made complete recovery in 4 months time. Of the 8 children with complete paraplegia, 6 recovered in 10 months and 2 in 12 months.

"Conflict of interest: None."

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Table 1: Tuberculosis in different age and sex.

Serial Age in years Present series Sex Number M F__________________________________________________________ 1 0-1 0 0 0

2 2-3 6 4 2 3 4-5 3 1 2 4 6-7 5 4 1 5 8-10 4 2 2

Total 18 11 7___________________________________________________________

Table 2: Site of caries spine in different age

Age _____________________________

Site of infection 0-1 2-3 4-5 6-7 8-10 Total __________________________________________________________

Cervical 0 0 0 0 0 0

Upper thoracic 0 0 1 2 1 4

Lower thoracic 0 2 2 3 2 9

Thoraco lumber 0 4 0 0 1 5

___________________________________________________________

Table 3: Site of caries spine in different sex

Sex _________________Site of infection Male Female _____________________________________

Cervical 0 0

Upper thoracic 2 2

Lower thoracic 6 3

Thoraco lumber 3 2 _____________________________________

Table 4: Signs and symptoms in caries spine

_____________________________

Back pain 18 Constitutional symptoms 14

Pulmonary symptoms 0

Para spinal abscesses 7

Neurologic deficits 12

Spinal deformity 5

__________________________________

Table 5: Management of caries spine

No. of patient on No. of patient on Conservative Operative Treatment Treatment _______________________________________________

10 3- Para spinal transthoracic approach

3- Oblique transthoracic approach 2- trans-thoracic retroperitoneal approach_________________________________________________

Figure 1. Preoperative skiagram of anteroposterior and lateral view showing caries spine of D12 L1 vertebrae, destruction and collapse of L1 vertebra and intervening discs with gibbus deformity in lateral view.

Figure 2. Sagital view of magnetic resonance imaging showing caries spine of D12 L1 vertebrae, destruction and collapse of L1 vertebra and intervening discs with Para vertebral and psoas abscess.

2‘

Figure 3. Postoperative skiagram of anteroposterior and lateral view showing D12 L1 collapse is filled with rib graft to correct gibbus deformity.

Figure 4. Postoperative skiagram showing corrected gibbus deformity.