Childs Nerv Syst DOI 10.1007/s00381-015-2694-6
ORIGINAL PAPER
Treatment of pediatric spinal tuberculosis abscess with percutaneous drainage and low-dose local antituberculous therapy: a preliminary report Xin Hua Yin 1 & Hong Qi Zhang 1 & Xiong Ke Hu 1 & Jin Song Li 1 & Yong Chen 1 & Ke Feng Zeng 1
Received: 7 October 2014 / Accepted: 30 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Objective The purpose of this study was to evaluate the outcomes of computed tomography (CT) guidance using percutaneous catheter with low-dose drainage local chemotherapy (modified PCD) and antituberculous therapy (ATT) for the treatment of spinal tuberculosis in children. Methods Twenty-seven children suffering from spinal tuberculosis were treated with modified PCD and ATT in our institute from 2002 to 2012. We describe our treatment, which involves CT-guided percutaneous puncture and local chemotherapy (continuous low-dose (20 mL) irrigation). The patients were evaluated based on the Frankel scoring system, the kyphotic Cobb angle, and the erythrocyte sedimentation rate (ESR). Results All patients were followed up for an average of 31.00 ±13.94 months. No sinus formation was detected. All patients responded well to this treatment. The ESR values were decreased to normal at last follow-up. The neurological functions show significant improvement after operation. Preoperatively, the kyphotic angle was 22.89±7.06°, and it was measured as 21.19±8.73° at the last visit. Conclusions Our results showed that percutaneous intubation and low-dose irrigation under CT guidance (modified percutaneous catheter drainage (MPCD)) and ATT are easy, safe, efficient, and less invasive methods for the treatment of spinal tuberculosis in children.
* Hong Qi Zhang [email protected] 1
Department of Spine Surgery, Xiangya Hospital of Central South University, Xiangya Road 87, Changsha, China
Keywords Spinal tuberculosis . Percutaneous catheter drainage . Children . Minimally invasive . Anti-tuberculous therapy
Introduction Spinal tuberculosis, the most common form of extrapulmonary tuberculosis, is one of the most prevalent infectious diseases and an important cause of morbidity and mortality in China. Pediatric patients are among the most vulnerable groups due to their immature immune status. Childhood tuberculosis (TB) accounts for approximately 15–40 % of all TB cases [1–5]. The plight of children with tuberculosis is widely recognized and is increasingly becoming a priority for national tuberculosis control programs [6]. Considering the particularity of pediatric growth, approaches in the treatment of pediatric spinal tuberculosis have fluctuated between nonoperative and operative approaches over the years. Furthermore, the threshold for surgery appears low when dealing with patients with early upper motor signs, abscesses, and kyphosis of any proportion; tuberculous spondylodiscitis in adults can be conservatively managed in a vast majority of cases [7]. There is limited research in the treatment of spinal TB in children, which remains controversial. More than two centuries ago, Potts observed that when sinuses formed and abscesses were drained, spine TB symptoms could be alleviated. As technologies have developed, percutaneous catheter drainage has become an important clinical form of treatment for spinal TB. Matsumoto et al. consider that CT-guided percutaneous drainage within the intervertebral space can be effective for patients with pyogenic spondylodiscitis and a secondary psoas abscess, given that said psoas abscess communicates with the intradiscal abscess [8]. Furthermore, Cantasdemir et al. reported 22 iliopsoas abscesses in 21 patients that were treated with percutaneous catheter
Childs Nerv Syst
drainage (PCD). Additionally, PCD was an effective treatment of 21 out of the 22 iliopsoas abscesses [9]. Dave et al. reported 29 patients with dorsolumbar spondylodiscitis lacking gross neural deficits with psoas abscess. PCD was reported to be successful in all cases. Additionally, back and radicular pain improved in all cases [10]. However, the utility of PCD in the treatment and prevention of pediatric spinal tuberculosis is described as case reports are published as rarities in the mainstream academic journals. In our research, we take into account the impact of corporal development, age, compliance, and many other factors. We also treat the children with modified percutaneous catheter drainage (MPCD): during drainage, the catheters were irrigated with little doses of saline solution (20 mL) containing isoniazid (0.2 g). The purpose of this study was to assess the utility of modified PCD in the management of pediatric spinal tuberculosis associated with bony involvement that impacts the bones but does not result in serious vertebral deformity or instability.
Materials and methods The study was approved by the Ethics Committee of Medical Research at Xiangya Hospital of Central South University, China, and written informed consent was obtained from all participants and their parents. All patients received conservative treatment (standard oral antituberculous chemotherapy and bed rest) after diagnosis for 2 weeks before the CTguided drainage. A total of 27 children(11 males, 16 females; age range 2–10 years; mean age 4.55±2.02 years) with spinal TB in whom conservative treatment had failed were hospitalized and underwent computed tomography (CT)-guided drainage in addition to standard medical therapy by the same senior surgeon (Zhang Hong qi) in our hospital from 2002 to 2012 (Table 1). All children had evidence of vertebral destruction and narrowed intervertebral spaces. Twenty-seven cases were complicated by abscesses, 10 cases showed evidence of cavity formation, and 5 cases had sequestra. Two children had a history of previous surgery, which consisted simply of recurrent resection of lesions. The diagnosis of tuberculosis was first made by clinical symptoms associated with laboratory (ESR) and radiologic findings (plain radiographs, CT, and magnetic resonance imaging (MRI)) and then verified by histopathological examination after MPCD in in 24 out of 27 patients. Patient’s clinical symptoms included thoracodorsal pain, malaise, night sweats, and lower fever with weight loss and variable degree of local deformity angle. The Frankel scoring system was used to assess the neurological deficits, and 3 patients were identified as grade B, 8 patients were of grade C, and 16 patients were of grade D. The erythrocyte sedimentation rate (ESR) ranged from 37 to 72 mm/h (average 50.81±
8.82 mm/h). The kyphosis angle ranged from 12° to 39°, with an average of 22.89±7.06. The following are the patient selection criteria for percutaneous drainage: (1) chemotherapy fails, (2) there is no obvious spinal instability (kyphosis angle 30°), (4) large hollow or significant sequestrum formation, and (5) MPCD fails. In our opinion, specific approach of every patient is decided by the characteristics of every patient.
Antituberculosis therapy Prior to operation, the patients were administrated the following antituberculosis drugs: isoniazid (5 mg/kg; maximum 300 mg/day), rifampicin (15 mg/kg; maximum 600 mg/day), ethambutol (15–25 mg/kg; maximum 2 g/day), and pyrazinamide (15–30 mg/kg; maximum 2 g/day). It was not until the ESR and temperature returned to normal or had significantly decreased that the surgery was carried out.
Surgical method Fifteen minutes prior to PCD, the patients were given 10 % chloral hydrate by coloclysis. All drainage procedures were performed under local anesthesia. The patients were placed in a prone or lateral position. After CT scanning was performed, the appropriate CT scan was selected and, from a review of these preliminary images, the depth, angle, and distance from the skin of each focus were measured. The level of needle entry and direction of the approach were designed to provide the most direct route for drainage and CT guidance during surgery. An 18-gauge needle was inserted into the target intervertebral space. Subsequently, aspiration was performed to confirm the presence of purulent material, following confirmation that the tip of the needle was located in the target space by CT scan. Once the puncture had been successfully carried out, a stiff guide wire was promptly inserted into the intervertebral space. Finally, proper dilation was performed according to the catheter size, and a pigtail drainage catheter was inserted over the guide wire until its tip reached the lesion’s center, at which point the guide wire was removed. All drainage catheters were inserted into abscess cavities with the Seldinger technique. The pus obtained before chemotherapy was sent for culture with chemosensitivity testing and histopathologic
Childs Nerv Syst Table 1 Summarized data for all the patients
Case no.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Mean±SD
Age
2 5 4 6 3 2 7 2 4 4 5 5 7 7 6 2 3 5 5 3 3 3 5 2 10 6 7 4.55±2.02
Gender
Level of lesion
F M M F F F M M F F
T C L L L T T L L T
M M F F M F M F M F F F M M F F F
T L L L T L T L L L T T C L T L T
OR time (min) 50 60 75 80 60 55 90 65 50 90 60 85 85 70 65 80 70 80 70 55 75 90 80 85 70 70 80 72.03±12.88
Drainage time (days) 21 25 23 27 24 28 35 30 21 25 24 21 32 28 22 26 27 23 21 24 23 21 25 22 23 28 23 24.89±3.59
Follow-up (months) 12 28 50 48 60 34 28 37 18 23 26 37 55 51 40 12 24 48 36 35 12 24 22 20 18 21 18 31.00±13.94
OR time operative time
examination. Histologic examination of biopsy specimens obtained in these patients revealed a necrotizing granulomatous reaction compatible with tuberculosis antituberculous.
Postoperative treatments Early ambulant activity is our preferred method of treatment. Generally speaking, patients were allowed to mobilize after 24 h postoperatively, with the assistance of a brace. Furthermore, requirements for bed rest depended on the child’s condition during the lavage period. Children that experienced residual weakness or pain and ever bone destruction in the affected vertebral body were strictly confined to bed for 14– 21 days (mean duration of 16 days). Children that experienced little or no pain and spine stability were allowed to walk with the braces after 24 h. A plastic orthosis was given to each child, which was continued for 6–8 months on average
postoperatively at least. The drug used for local chemotherapy was isoniazid (20 mL saline+isoniazid 0.2 g); an infusion tube was inserted into the lesion twice daily, following local irrigation, and then 0.1 g isoniazid was inserted into the lesion. The catheter was kept in place until the body temperature and ESR returned to normal on at least three consecutive days; it was also essential that the patient showed clinical improvement and no radiologic evidence of abscesses on follow-up. All cases received systemic chemotherapy (antituberculous therapy (ATT)) simultaneously with local chemotherapy. Drug therapy was continued for more than 9–12 months, postoperatively, using combinations of different drugs, according to the chemosensitivity testing in children. The patients’ liver function was monitored on a regular basis. It was considered of utmost importance that all children avoided participation in strenuous exercise. All children were examined clinically and radiologically at 3, 6, and 12 months after MPCD and then again at the final follow-up.
Childs Nerv Syst
Follow-up index and statistical analysis A paired t-test was used to analyze and evaluate the preoperative and postoperative ESR, Frankel score system, and kyphosis according to the Cobb angle [11]. Customarily, a significant P value was defined as 0.05 using SPSS version 17.0 for Windows. Discrepancy of the normal distribution was evaluated by a rank-sum test with a significance level of 0.05.
Results After surgery, with an average follow-up of 31.00 ± 13.94 months (range 12–60 months), the mean duration of drainage was 24.89±3.59 days (21–35 days) in the 27 children. The pigtail catheters were smoothly placed, and wounds were healed without chronic infection or sinus formation. All children had significant improvement in constitutional symptoms postoperatively only 4 out of 27 children experienced recurrent back pain during the follow-up. In turn, the four patients underwent surgery for stabilization of the spine. Regarding the two cases of recurrence, one reason for recurrence was due to premature removal of the drain by 7 days in one child. The other case of recurrence was due to poor compliance, following local chemotherapy. The two cases of recurrence were °cured by the second MPCD. The mean local deformity angle before treatment was 22.89±7.06°, while the average was 21.19±8.73° at last visit (P
ORIGINAL PAPER
Treatment of pediatric spinal tuberculosis abscess with percutaneous drainage and low-dose local antituberculous therapy: a preliminary report Xin Hua Yin 1 & Hong Qi Zhang 1 & Xiong Ke Hu 1 & Jin Song Li 1 & Yong Chen 1 & Ke Feng Zeng 1
Received: 7 October 2014 / Accepted: 30 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Objective The purpose of this study was to evaluate the outcomes of computed tomography (CT) guidance using percutaneous catheter with low-dose drainage local chemotherapy (modified PCD) and antituberculous therapy (ATT) for the treatment of spinal tuberculosis in children. Methods Twenty-seven children suffering from spinal tuberculosis were treated with modified PCD and ATT in our institute from 2002 to 2012. We describe our treatment, which involves CT-guided percutaneous puncture and local chemotherapy (continuous low-dose (20 mL) irrigation). The patients were evaluated based on the Frankel scoring system, the kyphotic Cobb angle, and the erythrocyte sedimentation rate (ESR). Results All patients were followed up for an average of 31.00 ±13.94 months. No sinus formation was detected. All patients responded well to this treatment. The ESR values were decreased to normal at last follow-up. The neurological functions show significant improvement after operation. Preoperatively, the kyphotic angle was 22.89±7.06°, and it was measured as 21.19±8.73° at the last visit. Conclusions Our results showed that percutaneous intubation and low-dose irrigation under CT guidance (modified percutaneous catheter drainage (MPCD)) and ATT are easy, safe, efficient, and less invasive methods for the treatment of spinal tuberculosis in children.
* Hong Qi Zhang [email protected] 1
Department of Spine Surgery, Xiangya Hospital of Central South University, Xiangya Road 87, Changsha, China
Keywords Spinal tuberculosis . Percutaneous catheter drainage . Children . Minimally invasive . Anti-tuberculous therapy
Introduction Spinal tuberculosis, the most common form of extrapulmonary tuberculosis, is one of the most prevalent infectious diseases and an important cause of morbidity and mortality in China. Pediatric patients are among the most vulnerable groups due to their immature immune status. Childhood tuberculosis (TB) accounts for approximately 15–40 % of all TB cases [1–5]. The plight of children with tuberculosis is widely recognized and is increasingly becoming a priority for national tuberculosis control programs [6]. Considering the particularity of pediatric growth, approaches in the treatment of pediatric spinal tuberculosis have fluctuated between nonoperative and operative approaches over the years. Furthermore, the threshold for surgery appears low when dealing with patients with early upper motor signs, abscesses, and kyphosis of any proportion; tuberculous spondylodiscitis in adults can be conservatively managed in a vast majority of cases [7]. There is limited research in the treatment of spinal TB in children, which remains controversial. More than two centuries ago, Potts observed that when sinuses formed and abscesses were drained, spine TB symptoms could be alleviated. As technologies have developed, percutaneous catheter drainage has become an important clinical form of treatment for spinal TB. Matsumoto et al. consider that CT-guided percutaneous drainage within the intervertebral space can be effective for patients with pyogenic spondylodiscitis and a secondary psoas abscess, given that said psoas abscess communicates with the intradiscal abscess [8]. Furthermore, Cantasdemir et al. reported 22 iliopsoas abscesses in 21 patients that were treated with percutaneous catheter
Childs Nerv Syst
drainage (PCD). Additionally, PCD was an effective treatment of 21 out of the 22 iliopsoas abscesses [9]. Dave et al. reported 29 patients with dorsolumbar spondylodiscitis lacking gross neural deficits with psoas abscess. PCD was reported to be successful in all cases. Additionally, back and radicular pain improved in all cases [10]. However, the utility of PCD in the treatment and prevention of pediatric spinal tuberculosis is described as case reports are published as rarities in the mainstream academic journals. In our research, we take into account the impact of corporal development, age, compliance, and many other factors. We also treat the children with modified percutaneous catheter drainage (MPCD): during drainage, the catheters were irrigated with little doses of saline solution (20 mL) containing isoniazid (0.2 g). The purpose of this study was to assess the utility of modified PCD in the management of pediatric spinal tuberculosis associated with bony involvement that impacts the bones but does not result in serious vertebral deformity or instability.
Materials and methods The study was approved by the Ethics Committee of Medical Research at Xiangya Hospital of Central South University, China, and written informed consent was obtained from all participants and their parents. All patients received conservative treatment (standard oral antituberculous chemotherapy and bed rest) after diagnosis for 2 weeks before the CTguided drainage. A total of 27 children(11 males, 16 females; age range 2–10 years; mean age 4.55±2.02 years) with spinal TB in whom conservative treatment had failed were hospitalized and underwent computed tomography (CT)-guided drainage in addition to standard medical therapy by the same senior surgeon (Zhang Hong qi) in our hospital from 2002 to 2012 (Table 1). All children had evidence of vertebral destruction and narrowed intervertebral spaces. Twenty-seven cases were complicated by abscesses, 10 cases showed evidence of cavity formation, and 5 cases had sequestra. Two children had a history of previous surgery, which consisted simply of recurrent resection of lesions. The diagnosis of tuberculosis was first made by clinical symptoms associated with laboratory (ESR) and radiologic findings (plain radiographs, CT, and magnetic resonance imaging (MRI)) and then verified by histopathological examination after MPCD in in 24 out of 27 patients. Patient’s clinical symptoms included thoracodorsal pain, malaise, night sweats, and lower fever with weight loss and variable degree of local deformity angle. The Frankel scoring system was used to assess the neurological deficits, and 3 patients were identified as grade B, 8 patients were of grade C, and 16 patients were of grade D. The erythrocyte sedimentation rate (ESR) ranged from 37 to 72 mm/h (average 50.81±
8.82 mm/h). The kyphosis angle ranged from 12° to 39°, with an average of 22.89±7.06. The following are the patient selection criteria for percutaneous drainage: (1) chemotherapy fails, (2) there is no obvious spinal instability (kyphosis angle 30°), (4) large hollow or significant sequestrum formation, and (5) MPCD fails. In our opinion, specific approach of every patient is decided by the characteristics of every patient.
Antituberculosis therapy Prior to operation, the patients were administrated the following antituberculosis drugs: isoniazid (5 mg/kg; maximum 300 mg/day), rifampicin (15 mg/kg; maximum 600 mg/day), ethambutol (15–25 mg/kg; maximum 2 g/day), and pyrazinamide (15–30 mg/kg; maximum 2 g/day). It was not until the ESR and temperature returned to normal or had significantly decreased that the surgery was carried out.
Surgical method Fifteen minutes prior to PCD, the patients were given 10 % chloral hydrate by coloclysis. All drainage procedures were performed under local anesthesia. The patients were placed in a prone or lateral position. After CT scanning was performed, the appropriate CT scan was selected and, from a review of these preliminary images, the depth, angle, and distance from the skin of each focus were measured. The level of needle entry and direction of the approach were designed to provide the most direct route for drainage and CT guidance during surgery. An 18-gauge needle was inserted into the target intervertebral space. Subsequently, aspiration was performed to confirm the presence of purulent material, following confirmation that the tip of the needle was located in the target space by CT scan. Once the puncture had been successfully carried out, a stiff guide wire was promptly inserted into the intervertebral space. Finally, proper dilation was performed according to the catheter size, and a pigtail drainage catheter was inserted over the guide wire until its tip reached the lesion’s center, at which point the guide wire was removed. All drainage catheters were inserted into abscess cavities with the Seldinger technique. The pus obtained before chemotherapy was sent for culture with chemosensitivity testing and histopathologic
Childs Nerv Syst Table 1 Summarized data for all the patients
Case no.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Mean±SD
Age
2 5 4 6 3 2 7 2 4 4 5 5 7 7 6 2 3 5 5 3 3 3 5 2 10 6 7 4.55±2.02
Gender
Level of lesion
F M M F F F M M F F
T C L L L T T L L T
M M F F M F M F M F F F M M F F F
T L L L T L T L L L T T C L T L T
OR time (min) 50 60 75 80 60 55 90 65 50 90 60 85 85 70 65 80 70 80 70 55 75 90 80 85 70 70 80 72.03±12.88
Drainage time (days) 21 25 23 27 24 28 35 30 21 25 24 21 32 28 22 26 27 23 21 24 23 21 25 22 23 28 23 24.89±3.59
Follow-up (months) 12 28 50 48 60 34 28 37 18 23 26 37 55 51 40 12 24 48 36 35 12 24 22 20 18 21 18 31.00±13.94
OR time operative time
examination. Histologic examination of biopsy specimens obtained in these patients revealed a necrotizing granulomatous reaction compatible with tuberculosis antituberculous.
Postoperative treatments Early ambulant activity is our preferred method of treatment. Generally speaking, patients were allowed to mobilize after 24 h postoperatively, with the assistance of a brace. Furthermore, requirements for bed rest depended on the child’s condition during the lavage period. Children that experienced residual weakness or pain and ever bone destruction in the affected vertebral body were strictly confined to bed for 14– 21 days (mean duration of 16 days). Children that experienced little or no pain and spine stability were allowed to walk with the braces after 24 h. A plastic orthosis was given to each child, which was continued for 6–8 months on average
postoperatively at least. The drug used for local chemotherapy was isoniazid (20 mL saline+isoniazid 0.2 g); an infusion tube was inserted into the lesion twice daily, following local irrigation, and then 0.1 g isoniazid was inserted into the lesion. The catheter was kept in place until the body temperature and ESR returned to normal on at least three consecutive days; it was also essential that the patient showed clinical improvement and no radiologic evidence of abscesses on follow-up. All cases received systemic chemotherapy (antituberculous therapy (ATT)) simultaneously with local chemotherapy. Drug therapy was continued for more than 9–12 months, postoperatively, using combinations of different drugs, according to the chemosensitivity testing in children. The patients’ liver function was monitored on a regular basis. It was considered of utmost importance that all children avoided participation in strenuous exercise. All children were examined clinically and radiologically at 3, 6, and 12 months after MPCD and then again at the final follow-up.
Childs Nerv Syst
Follow-up index and statistical analysis A paired t-test was used to analyze and evaluate the preoperative and postoperative ESR, Frankel score system, and kyphosis according to the Cobb angle [11]. Customarily, a significant P value was defined as 0.05 using SPSS version 17.0 for Windows. Discrepancy of the normal distribution was evaluated by a rank-sum test with a significance level of 0.05.
Results After surgery, with an average follow-up of 31.00 ± 13.94 months (range 12–60 months), the mean duration of drainage was 24.89±3.59 days (21–35 days) in the 27 children. The pigtail catheters were smoothly placed, and wounds were healed without chronic infection or sinus formation. All children had significant improvement in constitutional symptoms postoperatively only 4 out of 27 children experienced recurrent back pain during the follow-up. In turn, the four patients underwent surgery for stabilization of the spine. Regarding the two cases of recurrence, one reason for recurrence was due to premature removal of the drain by 7 days in one child. The other case of recurrence was due to poor compliance, following local chemotherapy. The two cases of recurrence were °cured by the second MPCD. The mean local deformity angle before treatment was 22.89±7.06°, while the average was 21.19±8.73° at last visit (P
