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Available online at
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Review article
Update on the surgical management of Pott’s disease S. Varatharajah a,c , Y.-P. Charles a,∗,c , X. Buy b,c , A. Walter a,c , J.-P. Steib a,c a
Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, France Service de radiologie interventionnelle, hôpitaux universitaires de Strasbourg, hopitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, France c Fédération de médecine translationnelle (FMTS), université de Strasbourg, 4, rue Blaise-Pascal, 67400 Strasbourg, France b
a r t i c l e
i n f o
Article history: Accepted 27 September 2013 Keywords: Pott’s disease Spinal tuberculosis Abscess Kyphosis Surgical treatment Spondylitis
a b s t r a c t One-third of the world’s population is infected with Mycobacterium tuberculosis. Data reported in 2011 indicate, for the first time, a decline in cases of tuberculosis, despite persistent inequalities across geographic areas and increasing rates of drug resistance. Osteo-articular tuberculosis affects the spine in half the cases. Pharmacotherapy must be combined with surgery in patients with spinal cord or nerve root compression, large abscesses, or marked anterior column osteolysis with kyphosis and instability. The quality of debridement and bony fusion is optimal when the anterior approach is used. Posterior fixation is the best means of achieving reduction followed by stable sagittal alignment over time. New treatment strategies combine conventional surgical methods, closed interventional radiology procedures for drainage and spinal cord decompression, and percutaneous fixation. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction Tuberculosis of the bones and joints remains rare, accounting for only about 1 to 3% of all cases of tuberculosis [1,2], with similar incidence time trends. The latest report from the World Health Organisation (WHO) on tuberculosis control indicates that tuberculosis cases have started to decline worldwide for the first time [3]. Similarly, the WHO Tuberculosis Surveillance and Monitoring Report issued in 2012 indicates a decrease in the incidence of tuberculosis in recent years [4]. Spinal tuberculosis, known as Pott’s disease, accounts for half the cases of osteo-articular tuberculosis [1]. Vertebral inoculation occurs via the haematogenous route and the process then spreads to the intervertebral disk and, in some cases, to the adjacent vertebra. Para-spinal abscesses may develop by direct spread from the vertebral lesion. The thoracic spine is predominantly involved [5]. Pain is the most common presenting manifestation. However, the limited symptoms and absence of specific radiological changes early in the course of the infection often result in diagnostic delays. Computed tomography (CT) and magnetic resonance imaging (MRI) are valuable diagnostic tools. Confirmation of the diagnosis is obtained by identification of the tubercle bacillus in respiratory specimens and/or in samples obtained by abscess aspiration or bone biopsy.
∗ Corresponding author. Tel.: +33 388 116 826; fax: +33 388 115 233. E-mail address: [email protected] (Y.-P. Charles).
The treatment of spinal tuberculosis usually relies on non-surgical means, namely, the administration of four antituberculosis drugs and bracing. Two situations may require surgical treatment: loss of sagittal alignment of the spine due to extensive osteolysis and spread of an abscess into the para-spinal tissues and spinal canal. In a 1960 report on the surgical treatment of cervical, thoracic, and lumbar spinal tuberculosis in 412 patients, Hodgson et al. [6] described the anterior approach with debridement as of fundamental importance. This principle is still applied to some extent in contemporary surgical strategies. Major advances have been achieved in recent years, however, with the use of open internal fixation combined with anti-tuberculosis drugs, the introduction of percutaneous internal fixation, and the development of interventional radiology techniques. Here, our objective was to review recent epidemiological data, diagnostic criteria, and medical and surgical treatments for spinal tuberculosis. 2. Epidemiology The 2011 WHO report indicates a stabilisation in the incidence of newly diagnosed tuberculosis, in contrast to the steady increase noted earlier. In 2010, the incidence of tuberculosis was 8.8 million and the mortality rate 1.4 million. Nevertheless, tuberculosis-related deaths decreased by 40% between 1990 and 2010 [2,7]. Considerable differences exist across geographic regions. In Europe, these differences are ascribable to HIV/AIDS, increasing poverty, inequalities in government funding of tuberculosis control
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Please cite this article in press as: Varatharajah S, et al. Update on the surgical management of Pott’s disease. Orthop Traumatol Surg Res (2014), http://dx.doi.org/10.1016/j.otsr.2013.09.013
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efforts, increased tubercle bacillus resistance to anti-tuberculosis drugs, and immigration from endemic areas. Although the incidence of tuberculosis remains low in France, a few geographic regions and populations are at higher risk: tuberculosis is chiefly seen in large cities and the risk is greatest among intravenous substance users, the homeless, and immigrants [8–10]. Tubercle bacillus identification in sputum samples is the screening test currently used in the WHO tuberculosis control programme but detects only individuals with pulmonary tuberculosis. One-third of the world’s population is believed to harbour the tubercle bacillus. When the test is positive, short-term treatment with anti-tuberculosis drugs is given under direct observation by healthcare providers. The effectiveness of this control programme is obviously limited in patients with non-pulmonary tuberculosis. Thus, the first problem raised by spinal tuberculosis is the frequently long time to diagnosis [11,12]. 3. Diagnosis In France, the intradermal tuberculin test is still used to diagnose latent tuberculosis. This test may be positive in individuals having received the Bacillus Calmette-Guérin (BCG) vaccine, who
Fig. 3. Drainage of the abscess via a video-assisted minimally invasive right anterior approach. Note the osteolysis after debridement (same patient as in Fig. 1).
Fig. 1. Computed tomography, coronal and sagittal views: osteolysis in a 40-yearold patient with T11-T12 spinal tuberculosis.
Fig. 4. Post-operative radiographs showing preservation of sagittal alignment by the T8-L1 posterior fusion (same patient as in Fig. 1). Fig. 2. Magnetic resonance imaging, T2 STIR sagittal view: abscess lying behind the aorta from T8 to L2 (same patient as in Fig. 1).
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Fig. 5. Computed tomography of the neck, coronal and sagittal views: osteolysis and retropharyngeal abscess in a 79-year-old patient with C3-C4 spinal tuberculosis.
Fig. 6. Percutaneous drainage of the abscess via a pre-sterno-cleido-mastoid approach (same patient as in Fig. 5).
Fig. 7. Post-operative radiographs of the cervical spine showing the fusion achieved via a combined posterior and anterior approach (same patient as in Fig. 5).
must therefore be tested using in vitro assays that measure the interferon gamma released into venous blood by infected T cells. The French National Authority for Health (HAS) recognizes the role for these in vitro assays as an alternative to intradermal tuberculin
testing for the diagnosis of extra-pulmonary tuberculosis. In addition, microscopic examination of a variety of specimens (sputum; gastric aspirate, particularly in children; abscess samples, and urine) for presence of the tubercle bacillus can assist in the
Fig. 8. Computed tomography, sagittal and axial views: osteolysis in a 53-year-old patient with T8-T9 spinal tuberculosis.
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should be subjected to histological examination for an epithelioid and giant-cell granuloma [14–16]. Spinal lesions that suggest tuberculosis are vertebral body osteolysis and kyphosis caused by bone destruction. These lesions can be evaluated on standing lateral radiographs and assessed in detail by CT (Fig. 1). Among currently available techniques, MRI has the best sensitivity and offers acceptable specificity for spinal lesions [17]. T2 STIR images can ensure the early detection of inflammatory oedema. In addition, MRI shows the extent of tuberculous abscesses and visualises spinal cord lesions (Fig. 2), allowing their detection before the onset of clinical manifestations. The diagnosis of tuberculous infection cannot be established based on imaging studies alone. Nevertheless, imaging studies are useful to assess the extent of the lesions, guide the collection of samples for tubercle bacillus identification, and assist in defining the best treatment strategy.
4. Medical treatment
Fig. 9. Magnetic resonance imaging, T2-weighted sagittal and axial images showing an abscess within the spinal canal (same patient as in Fig. 8).
diagnosis. Molecular biology techniques may play an adjunctive role in patients with a strong suspicion of clinical tuberculosis but should not be performed routinely, as their sensitivity and specificity are lower than those of cultures [13]. All tissue samples
Anti-tuberculosis drug treatment must be monitored closely to prevent the emergence of multi-resistant strains. From 2005 to 2010, Europe was among the regions with the lowest treatment success rates, i.e., 69% among new patients and 48% among previously treated patients [18]. The recommended treatment starts with four drugs given for 2 months: isoniazid, 5–15 mg/kg; rifampicin, 10–20 mg/kg; ethambutol, 15–25 mg/kg; and pyrazinamide, 30–40 mg/kg. Isoniazid and rifampicin are then given for the next 4 months. Fluoroquinolones are alternative first-line drugs. The latest recommendations indicate that spinal tuberculosis should be treated in the same way as pulmonary tuberculosis (with a longer treatment duration of 1 year in children according to 2010 WHO guidelines). However, when the clinical, laboratory,
Fig. 10. Percutaneous drainage of the caseous necrosis under radiographic and computed tomography guidance (same patient as in Fig. 8).
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Fig. 11. Post-operative radiographs showing the posterior T6-T11 fusion (same patient as in Fig. 8).
and imaging study findings suggest persistent inflammation, most physicians prefer longer treatment duration of 9 months [16,19,20]. 5. Surgical treatment In 1960, at a time when the surgical treatment of spinal tuberculosis was still controversial, Hodgson et al. [6] described the routine use of debridement via the anterior approach, with a 93% fusion rate. In 1961, the French Society for Orthopaedic Surgery and Traumatology (SOFCOT) emphasised the predominant role for medical treatment while acknowledging the existence of two strategies, namely, routine local surgery and medical treatment alone with four anti-tuberculosis drugs and a brace [21,22]. However, published studies indicate widespread use of combined medical and surgical treatment: thus, in a review of case-series published
Fig. 12. Computed tomography, sagittal view: anterior T7-T10 fibular graft (same patient as in Fig. 8).
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Fig. 13. Computed tomography of the thoraco-lumbar spine, sagittal view: osteolysis and kyphosis in a 48-year-old patient with T11-T12 spinal tuberculosis.
between 1980 and 2011, surgery was performed in 75% of patients [5]. At present, the need for surgery is recognised [23–25] in patients with evidence of spinal cord or nerve root compression, extensive abscess formation, spinal instability due to osteolysis with kyphosis, and failure of medical treatment. In patients without evidence of neurological compromise, the treatment consists in anti-tuberculosis drugs and bracing, provided the sagittal alignment of the spine is preserved [26]. Imaging studies must be obtained at regular intervals throughout the treatment to look for worsening of the kyphosis. If vertebral body osteolysis results in anterior column collapse, the need for instrumental correction and fusion should be discussed. The rate of neurological complications is estimated at 10 to 40% [27]. Emergency surgical decompression is indicated only in patients with evidence of spinal cord compression and usually involves laminectomy followed by internal fixation and posterior fusion at the thoraco-lumbar spine or by corporectomy at the cervical spine. In patients with extensive abscess formation but no neurological deficit, the anterior approach remains the reference standard [28–31]. This approach allows direct debridement of the pre-vertebral and intra-spinal focus of infection (Fig. 3). Pharmacokinetic studies have established that surgery improves the effectiveness of anti-tuberculosis drugs when debridement is optimal [32,33]. In addition, same-stage anterior grafting plays a key role in filling the lytic defect and strengthening the anterior column [34,35]. At the thoraco-lumbar spine, posterior fixation must be performed also to correct the kyphosis and ensure long-term stability of the spine in the sagittal plane (Fig. 4). Garg et al. [36] and Kumar et al. [37] advocated using the posterior approach alone to perform spinal canal decompression and abscess drainage during the same stage as internal fixation and fusion. Zhang et al. [38] described a similar technique involving the addition of a bony graft implanted into the anterior lytic defect via the posterior approach in order to stabilise the entire spinal segment, thereby preventing loss of correction with kyphosis. At the cervical spine, abscess drainage, corporectomy, and internal fixation are usually performed via the anterior approach alone. Additional posterior stabilisation is required only in patients with extensive bone destruction (Figs. 5–7). In sum, the surgical management of
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Fig. 14. Magnetic resonance imaging, T2-weighted sagittal and axial views: extension of the abscess about the spine (same patient as in Fig. 13).
typical spinal tuberculosis rests on two principles: debridement with spinal cord decompression and stabilisation of the spine. These principles are also followed in some developing countries, where surgical treatment can prevent the long-term development of severe kyphosis [39]. An alternative that may deserve consideration in some cases is percutaneous needle aspiration of the caseous necrosis to ensure decompression [40]. This procedure may be of value in patients with severe osteolysis responsible for spinal instability, a situation that requires posterior fixation as the first surgical step (Fig. 8). Spinal canal decompression by laminectomy must be performed with the patient in the prone position, which can increase the tension on the spinal cord. Furthermore, the introduction of Kerisson forceps into the tight space of the canal increases the risk of spinal cord compression (Fig. 9). Aspiration of the caseous necrosis under CT guidance decreases the size of the collection and obviates the need for laminectomy (Fig. 10). In addition, posterior spinal stabilisation can be achieved with less risk of propagation of the infection along the internal fixation material (Fig. 11). A second stage of video-assisted surgery via a minimally invasive anterior approach is then performed to ensure debridement and bony grafting (Fig. 12). Finally, Wimmer described a percutaneous fixation
technique [41] that might constitute a less invasive alternative. This technique may deserve evaluation in high-risk patients with spinal tuberculosis (Figs. 13–15). 6. Conclusion Spinal tuberculosis (Pott’s disease) predominantly affects the thoracic spine and is often diagnosed late. Worldwide surveillance data published since 2011 point to stabilisation of the incidence of active tuberculosis. The treatment relies chiefly on anti-tuberculosis drugs with the same regimens as for pulmonary tuberculosis, although a treatment-duration of 9 months is often used in everyday practice. In the absence of a neurological emergency, surgery is indicated to prevent secondary spinal cord compression in patients with extensive abscess formation and/or sagittal spinal collapse. Both the anterior and the posterior approaches can be used. For thoraco-lumbar lesions, we usually start with the posterior approach to stabilise the spine. Decompression by percutaneous aspiration of the caseous necrosis decreases the risk of intra-operative neurological complications in high-risk patients. A minimally invasive anterior approach is then used to perform optimal debridement and to implant a bony graft designed to achieve long-term stability of the spine. At the cervical level, debridement and spinal stabilisation are performed via the anterior approach alone. Additional posterior fusion is required only in patients with marked osteolysis responsible for severe instability. Declaration of interest The authors declare that they have no conflicts of interest concerning this article. References
Fig. 15. Post-operative radiographs showing reduction of the sagittal malalignment by percutaneous T8-L2 fixation and anterior grafting with a Harms cage (same patient as in Fig. 13).
[1] Tuli SM. Tuberculosis of the spine: a historical review. Clin Orthop Rel Res 2007;460:29–38. [2] Tuli SM. Historical aspects of Pott’s disease (spinal tuberculosis) management. Eur Spine J 2013;22(Suppl 4):529–38. [3] Global tuberculosis control: WHO Report 2011. Available at http://www.euro. who.int (accessed on 15/08/2012). [4] European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe, Report 2012. Available at http://www.euro.who.int (accessed on 15/08/2012). [5] Ferrer MF, Torres LG, Ramirez OA, et al. Tuberculosis of the spine. A systematic review of case series. Int Orthop 2012;36:221–31.
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[6] Hodgson AR, Stock FE, et al. Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 1960;48:172–8. [7] Dara M, Dadu A, Kremer K, et al. Epidemiology of tuberculosis in WHO European Region and public health response. Eur Spine J 2013;22(Suppl 4): 549–55. [8] WHO European Ministerial Forum. Berlin Declaration on tuberculosis, 22 October 2007. Available at http://www.euro.who.int (accessed on 15/08/2012). [9] French Institute for Public Health Surveillance. Weekly Epidemiological Report, 6 July 2010. Available at www.invs.sante.fr (accessed on 15/08/2012). [10] Millet JP, Moreno A, Fina L, et al. Factors that influence current tuberculosis epidemiology. Eur Spine J 2013;22(Suppl 4):539–48. [11] Regional Committee for Europe. Consolidated action plan to prevent and combat multi-drug and extensively drug-resistant tuberculosis in the WHO European Region 2011-2015. Available at http://www.euro.who.int (accessed on 15/08/2012). [12] Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J 2013;22(Suppl 4):556–66. [13] Colmenero JD, Ruiz-Mesa JD, Sanjuan-Jimenez R, et al. Establishing the diagnosis of tuberculous vertebral osteomyelitis. Eur Spine J 2013;22(Suppl 4):579–86. [14] HAS. Test de détection de la production d’interféron gamma pour le diagnostic des infections tuberculeuses. Avis sur les actes professionnels 2006. Available at http://www.has-sante.fr (accessed on 15/08/2012). [In French]. [15] Sarmiento OL, Weigle KA, Alexander J, et al. Assessment by meta-analysis of PCR for diagnosis of smear-negative pulmonary tuberculosis. J Clin Microbiol 2003;41:3233–40. [16] Doctors without borders. Tuberculosis – practical guide for clinicians, nurses, laboratory technicians, and medical auxiliaries, 3rd edition, 2010. Available at http://www.refbooks.msf.org (accessed on 15/08/2012). [17] Rivas-Garcia A, Sarria-Estrada S, et al. Imaging findings of Pott’s disease. Eur Spine J 2013;22(Suppl 4):567–78. [18] WHO European Ministerial Forum. Tuberculosis in the WHO European Region. FACT SHEET 2012. Available at http://www.euro.who.int (accessed on 15/08/2012). [19] Donald PR. The chemotherapy of osteo-articular tuberculosis with recommendations for treatment of children. J Infect 2011;62:411–39. [20] Rajasekaran S, Khandelwal G. Drug therapy in spinal tuberculosis. Eur Spine J 2013;22(Suppl 4):587–93. [21] Symposium de la SOFCOT sur le mal de Pott, 1961, direction J. Debeyre. Available at www.aott.org.tr(accessed on 15/08/2012). [In French]. [22] Cheung WY, Luk KDK. Clinical and radiological outcomes after conservative treatment of TB spondylodiscitis: is the 15 years’ follow-up in the MRC study long enough? Eur Spine J 2013;22(Suppl 4):594–602. [23] Guerado E, Cervan AM. Surgical treatment of spondylodiscitis. An update. Int Orthop 2012;36:413–20.
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[24] Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med 2011;34:440–54. [25] Mak KC, Cheung KMC. Surgical treatment of acute TB spondylitis: indications and outcomes. Eur Spine J 2013;22(Suppl 4):603–11. [26] Di Martino A, Papapietro N, Lanotte A, Russo F, Vadalà G, Denaro V. Spondylodiscitis: standards of current treatment. Curr Med Res Opin 2012;28:689–99. [27] Jain AK, Kumar J. Tuberculosis of spine: neurological deficit. Eur Spine J 2013;22(Suppl 4):624–33. [28] Kapoor S, Kapoor S, Agrawal M, et al. Thoracoscopic decompression in Pott’s spine and its long-term follow-up. Int Orthop 2012;36:331–7. [29] Lü G, Wang B, Li J, et al. Anterior debridement and reconstruction via thorascoscopy-assisted mini-open approach for the treatment of thoracic spinal tuberculosis: minimum 5-year follow-up. Eur Spine J 2012;21:463–9. [30] Luk KDK. Commentary: instrumentation in the treatment of spinal tuberculosis, anterior or posterior? Spine J 2011;11:734–6. [31] Li M, Du J, Meng H, et al. One-stage surgical management for thoracic tuberculosis by anterior debridement, decompression and autogenous rib grafts, and instrumentation. Spine J 2011;11:726–33. [32] Ge Z, Wang Z, Wei M. Measurement of the concentration of three antituberculosis drugs in the focus of spinal tuberculosis. Eur Spine J 2008;17:1482–7. [33] Liu P, Zhu Q, Jiang J. Distribution of three antituberculous drugs and their metabolites in different parts of pathological vertebrae with spinal tuberculosis. Spine 2011;36:E1290–5. [34] Zhang HQ, Guo CF, Xiao XG, et al. One-stage surgical management for multilevel tuberculous spondylitis of the upper thoracic region by anterior decompression, strut autografting, posterior instrumentation, and fusion. J Spinal Disord Tech 2007;20:263–7. [35] Qureshi MA, Khalique AB, Afzal W, et al. Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis. Eur Spine J 2013;22(Suppl 4):618–23. [36] Garg B, Kandwal P, Nagaraja UB, et al. Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: a retrospective analysis. Indian J Orthop 2012;46:165–70. [37] Kumar MN, Joseph B, Manur R. Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting. Eur Spine J 2013;22:624–32. [38] Zhang H, Sheng B, Tang M, et al. One-stage surgical treatment for upper thoracic spinal tuberculosis by internal fixation, debridement, and combined interbody and posterior fusion via posterior-only approach. Eur Spine J 2013;22:616–23. [39] Djientcheu VP, Mouafo Tambo FF, Ndougsa IS, et al. The role of surgery in the management of Pott’s disease in Yaoundé. A review of 43 cases. Orthop Traumatol Surg Res 2013;99:419–23. [40] Abbas A, Rizvi SR, Mahesri M, et al. Conservative management of spinal tuberculosis: initial series from Pakistan. Asian Spine J 2013;7:73–80. [41] Wimmer C. Percutaneous fusion technique on the thoracolumbar spine with the Expedium LIS. Oper Orthop Traumatol 2008;20:511–24 [In German].
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ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2014) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Review article
Update on the surgical management of Pott’s disease S. Varatharajah a,c , Y.-P. Charles a,∗,c , X. Buy b,c , A. Walter a,c , J.-P. Steib a,c a
Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, France Service de radiologie interventionnelle, hôpitaux universitaires de Strasbourg, hopitaux universitaires de Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex, France c Fédération de médecine translationnelle (FMTS), université de Strasbourg, 4, rue Blaise-Pascal, 67400 Strasbourg, France b
a r t i c l e
i n f o
Article history: Accepted 27 September 2013 Keywords: Pott’s disease Spinal tuberculosis Abscess Kyphosis Surgical treatment Spondylitis
a b s t r a c t One-third of the world’s population is infected with Mycobacterium tuberculosis. Data reported in 2011 indicate, for the first time, a decline in cases of tuberculosis, despite persistent inequalities across geographic areas and increasing rates of drug resistance. Osteo-articular tuberculosis affects the spine in half the cases. Pharmacotherapy must be combined with surgery in patients with spinal cord or nerve root compression, large abscesses, or marked anterior column osteolysis with kyphosis and instability. The quality of debridement and bony fusion is optimal when the anterior approach is used. Posterior fixation is the best means of achieving reduction followed by stable sagittal alignment over time. New treatment strategies combine conventional surgical methods, closed interventional radiology procedures for drainage and spinal cord decompression, and percutaneous fixation. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction Tuberculosis of the bones and joints remains rare, accounting for only about 1 to 3% of all cases of tuberculosis [1,2], with similar incidence time trends. The latest report from the World Health Organisation (WHO) on tuberculosis control indicates that tuberculosis cases have started to decline worldwide for the first time [3]. Similarly, the WHO Tuberculosis Surveillance and Monitoring Report issued in 2012 indicates a decrease in the incidence of tuberculosis in recent years [4]. Spinal tuberculosis, known as Pott’s disease, accounts for half the cases of osteo-articular tuberculosis [1]. Vertebral inoculation occurs via the haematogenous route and the process then spreads to the intervertebral disk and, in some cases, to the adjacent vertebra. Para-spinal abscesses may develop by direct spread from the vertebral lesion. The thoracic spine is predominantly involved [5]. Pain is the most common presenting manifestation. However, the limited symptoms and absence of specific radiological changes early in the course of the infection often result in diagnostic delays. Computed tomography (CT) and magnetic resonance imaging (MRI) are valuable diagnostic tools. Confirmation of the diagnosis is obtained by identification of the tubercle bacillus in respiratory specimens and/or in samples obtained by abscess aspiration or bone biopsy.
∗ Corresponding author. Tel.: +33 388 116 826; fax: +33 388 115 233. E-mail address: [email protected] (Y.-P. Charles).
The treatment of spinal tuberculosis usually relies on non-surgical means, namely, the administration of four antituberculosis drugs and bracing. Two situations may require surgical treatment: loss of sagittal alignment of the spine due to extensive osteolysis and spread of an abscess into the para-spinal tissues and spinal canal. In a 1960 report on the surgical treatment of cervical, thoracic, and lumbar spinal tuberculosis in 412 patients, Hodgson et al. [6] described the anterior approach with debridement as of fundamental importance. This principle is still applied to some extent in contemporary surgical strategies. Major advances have been achieved in recent years, however, with the use of open internal fixation combined with anti-tuberculosis drugs, the introduction of percutaneous internal fixation, and the development of interventional radiology techniques. Here, our objective was to review recent epidemiological data, diagnostic criteria, and medical and surgical treatments for spinal tuberculosis. 2. Epidemiology The 2011 WHO report indicates a stabilisation in the incidence of newly diagnosed tuberculosis, in contrast to the steady increase noted earlier. In 2010, the incidence of tuberculosis was 8.8 million and the mortality rate 1.4 million. Nevertheless, tuberculosis-related deaths decreased by 40% between 1990 and 2010 [2,7]. Considerable differences exist across geographic regions. In Europe, these differences are ascribable to HIV/AIDS, increasing poverty, inequalities in government funding of tuberculosis control
1877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.otsr.2013.09.013
Please cite this article in press as: Varatharajah S, et al. Update on the surgical management of Pott’s disease. Orthop Traumatol Surg Res (2014), http://dx.doi.org/10.1016/j.otsr.2013.09.013
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efforts, increased tubercle bacillus resistance to anti-tuberculosis drugs, and immigration from endemic areas. Although the incidence of tuberculosis remains low in France, a few geographic regions and populations are at higher risk: tuberculosis is chiefly seen in large cities and the risk is greatest among intravenous substance users, the homeless, and immigrants [8–10]. Tubercle bacillus identification in sputum samples is the screening test currently used in the WHO tuberculosis control programme but detects only individuals with pulmonary tuberculosis. One-third of the world’s population is believed to harbour the tubercle bacillus. When the test is positive, short-term treatment with anti-tuberculosis drugs is given under direct observation by healthcare providers. The effectiveness of this control programme is obviously limited in patients with non-pulmonary tuberculosis. Thus, the first problem raised by spinal tuberculosis is the frequently long time to diagnosis [11,12]. 3. Diagnosis In France, the intradermal tuberculin test is still used to diagnose latent tuberculosis. This test may be positive in individuals having received the Bacillus Calmette-Guérin (BCG) vaccine, who
Fig. 3. Drainage of the abscess via a video-assisted minimally invasive right anterior approach. Note the osteolysis after debridement (same patient as in Fig. 1).
Fig. 1. Computed tomography, coronal and sagittal views: osteolysis in a 40-yearold patient with T11-T12 spinal tuberculosis.
Fig. 4. Post-operative radiographs showing preservation of sagittal alignment by the T8-L1 posterior fusion (same patient as in Fig. 1). Fig. 2. Magnetic resonance imaging, T2 STIR sagittal view: abscess lying behind the aorta from T8 to L2 (same patient as in Fig. 1).
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Fig. 5. Computed tomography of the neck, coronal and sagittal views: osteolysis and retropharyngeal abscess in a 79-year-old patient with C3-C4 spinal tuberculosis.
Fig. 6. Percutaneous drainage of the abscess via a pre-sterno-cleido-mastoid approach (same patient as in Fig. 5).
Fig. 7. Post-operative radiographs of the cervical spine showing the fusion achieved via a combined posterior and anterior approach (same patient as in Fig. 5).
must therefore be tested using in vitro assays that measure the interferon gamma released into venous blood by infected T cells. The French National Authority for Health (HAS) recognizes the role for these in vitro assays as an alternative to intradermal tuberculin
testing for the diagnosis of extra-pulmonary tuberculosis. In addition, microscopic examination of a variety of specimens (sputum; gastric aspirate, particularly in children; abscess samples, and urine) for presence of the tubercle bacillus can assist in the
Fig. 8. Computed tomography, sagittal and axial views: osteolysis in a 53-year-old patient with T8-T9 spinal tuberculosis.
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should be subjected to histological examination for an epithelioid and giant-cell granuloma [14–16]. Spinal lesions that suggest tuberculosis are vertebral body osteolysis and kyphosis caused by bone destruction. These lesions can be evaluated on standing lateral radiographs and assessed in detail by CT (Fig. 1). Among currently available techniques, MRI has the best sensitivity and offers acceptable specificity for spinal lesions [17]. T2 STIR images can ensure the early detection of inflammatory oedema. In addition, MRI shows the extent of tuberculous abscesses and visualises spinal cord lesions (Fig. 2), allowing their detection before the onset of clinical manifestations. The diagnosis of tuberculous infection cannot be established based on imaging studies alone. Nevertheless, imaging studies are useful to assess the extent of the lesions, guide the collection of samples for tubercle bacillus identification, and assist in defining the best treatment strategy.
4. Medical treatment
Fig. 9. Magnetic resonance imaging, T2-weighted sagittal and axial images showing an abscess within the spinal canal (same patient as in Fig. 8).
diagnosis. Molecular biology techniques may play an adjunctive role in patients with a strong suspicion of clinical tuberculosis but should not be performed routinely, as their sensitivity and specificity are lower than those of cultures [13]. All tissue samples
Anti-tuberculosis drug treatment must be monitored closely to prevent the emergence of multi-resistant strains. From 2005 to 2010, Europe was among the regions with the lowest treatment success rates, i.e., 69% among new patients and 48% among previously treated patients [18]. The recommended treatment starts with four drugs given for 2 months: isoniazid, 5–15 mg/kg; rifampicin, 10–20 mg/kg; ethambutol, 15–25 mg/kg; and pyrazinamide, 30–40 mg/kg. Isoniazid and rifampicin are then given for the next 4 months. Fluoroquinolones are alternative first-line drugs. The latest recommendations indicate that spinal tuberculosis should be treated in the same way as pulmonary tuberculosis (with a longer treatment duration of 1 year in children according to 2010 WHO guidelines). However, when the clinical, laboratory,
Fig. 10. Percutaneous drainage of the caseous necrosis under radiographic and computed tomography guidance (same patient as in Fig. 8).
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Fig. 11. Post-operative radiographs showing the posterior T6-T11 fusion (same patient as in Fig. 8).
and imaging study findings suggest persistent inflammation, most physicians prefer longer treatment duration of 9 months [16,19,20]. 5. Surgical treatment In 1960, at a time when the surgical treatment of spinal tuberculosis was still controversial, Hodgson et al. [6] described the routine use of debridement via the anterior approach, with a 93% fusion rate. In 1961, the French Society for Orthopaedic Surgery and Traumatology (SOFCOT) emphasised the predominant role for medical treatment while acknowledging the existence of two strategies, namely, routine local surgery and medical treatment alone with four anti-tuberculosis drugs and a brace [21,22]. However, published studies indicate widespread use of combined medical and surgical treatment: thus, in a review of case-series published
Fig. 12. Computed tomography, sagittal view: anterior T7-T10 fibular graft (same patient as in Fig. 8).
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Fig. 13. Computed tomography of the thoraco-lumbar spine, sagittal view: osteolysis and kyphosis in a 48-year-old patient with T11-T12 spinal tuberculosis.
between 1980 and 2011, surgery was performed in 75% of patients [5]. At present, the need for surgery is recognised [23–25] in patients with evidence of spinal cord or nerve root compression, extensive abscess formation, spinal instability due to osteolysis with kyphosis, and failure of medical treatment. In patients without evidence of neurological compromise, the treatment consists in anti-tuberculosis drugs and bracing, provided the sagittal alignment of the spine is preserved [26]. Imaging studies must be obtained at regular intervals throughout the treatment to look for worsening of the kyphosis. If vertebral body osteolysis results in anterior column collapse, the need for instrumental correction and fusion should be discussed. The rate of neurological complications is estimated at 10 to 40% [27]. Emergency surgical decompression is indicated only in patients with evidence of spinal cord compression and usually involves laminectomy followed by internal fixation and posterior fusion at the thoraco-lumbar spine or by corporectomy at the cervical spine. In patients with extensive abscess formation but no neurological deficit, the anterior approach remains the reference standard [28–31]. This approach allows direct debridement of the pre-vertebral and intra-spinal focus of infection (Fig. 3). Pharmacokinetic studies have established that surgery improves the effectiveness of anti-tuberculosis drugs when debridement is optimal [32,33]. In addition, same-stage anterior grafting plays a key role in filling the lytic defect and strengthening the anterior column [34,35]. At the thoraco-lumbar spine, posterior fixation must be performed also to correct the kyphosis and ensure long-term stability of the spine in the sagittal plane (Fig. 4). Garg et al. [36] and Kumar et al. [37] advocated using the posterior approach alone to perform spinal canal decompression and abscess drainage during the same stage as internal fixation and fusion. Zhang et al. [38] described a similar technique involving the addition of a bony graft implanted into the anterior lytic defect via the posterior approach in order to stabilise the entire spinal segment, thereby preventing loss of correction with kyphosis. At the cervical spine, abscess drainage, corporectomy, and internal fixation are usually performed via the anterior approach alone. Additional posterior stabilisation is required only in patients with extensive bone destruction (Figs. 5–7). In sum, the surgical management of
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Fig. 14. Magnetic resonance imaging, T2-weighted sagittal and axial views: extension of the abscess about the spine (same patient as in Fig. 13).
typical spinal tuberculosis rests on two principles: debridement with spinal cord decompression and stabilisation of the spine. These principles are also followed in some developing countries, where surgical treatment can prevent the long-term development of severe kyphosis [39]. An alternative that may deserve consideration in some cases is percutaneous needle aspiration of the caseous necrosis to ensure decompression [40]. This procedure may be of value in patients with severe osteolysis responsible for spinal instability, a situation that requires posterior fixation as the first surgical step (Fig. 8). Spinal canal decompression by laminectomy must be performed with the patient in the prone position, which can increase the tension on the spinal cord. Furthermore, the introduction of Kerisson forceps into the tight space of the canal increases the risk of spinal cord compression (Fig. 9). Aspiration of the caseous necrosis under CT guidance decreases the size of the collection and obviates the need for laminectomy (Fig. 10). In addition, posterior spinal stabilisation can be achieved with less risk of propagation of the infection along the internal fixation material (Fig. 11). A second stage of video-assisted surgery via a minimally invasive anterior approach is then performed to ensure debridement and bony grafting (Fig. 12). Finally, Wimmer described a percutaneous fixation
technique [41] that might constitute a less invasive alternative. This technique may deserve evaluation in high-risk patients with spinal tuberculosis (Figs. 13–15). 6. Conclusion Spinal tuberculosis (Pott’s disease) predominantly affects the thoracic spine and is often diagnosed late. Worldwide surveillance data published since 2011 point to stabilisation of the incidence of active tuberculosis. The treatment relies chiefly on anti-tuberculosis drugs with the same regimens as for pulmonary tuberculosis, although a treatment-duration of 9 months is often used in everyday practice. In the absence of a neurological emergency, surgery is indicated to prevent secondary spinal cord compression in patients with extensive abscess formation and/or sagittal spinal collapse. Both the anterior and the posterior approaches can be used. For thoraco-lumbar lesions, we usually start with the posterior approach to stabilise the spine. Decompression by percutaneous aspiration of the caseous necrosis decreases the risk of intra-operative neurological complications in high-risk patients. A minimally invasive anterior approach is then used to perform optimal debridement and to implant a bony graft designed to achieve long-term stability of the spine. At the cervical level, debridement and spinal stabilisation are performed via the anterior approach alone. Additional posterior fusion is required only in patients with marked osteolysis responsible for severe instability. Declaration of interest The authors declare that they have no conflicts of interest concerning this article. References
Fig. 15. Post-operative radiographs showing reduction of the sagittal malalignment by percutaneous T8-L2 fixation and anterior grafting with a Harms cage (same patient as in Fig. 13).
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