One-stage Posterior Surgical Treatment for Lumbosacral ...m1.wyanokecdn.com/0beb5600e93c7c0eb054bccf60bd7149.pdf14/M/38 L3-L4 Pulmonary tuberculosis Yes Yes E L3:1; L4:8 Yes L2-L3,

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abstractFull article available online at Healio.com/Orthopedics. Search: 20130724-28

The treatment goals of tuberculous spondylitis are to eradicate infection and to pre-vent or treat instability, deformity, and neurologic deficit. The purpose of this study was to evaluate the clinical outcomes following chemotherapy with 1-stage poste-rior debridement, correction, and instrumentation and fusion for the treatment of lumbosacral tuberculosis with major vertebral body loss and kyphosis. Fourteen patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis underwent 1-stage posterior surgery. Clinical assessments included low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores, neurologic deficit, erythrocyte sedimentation rate, and C-reactive protein level. Radiographic param-eters included kyphosis angle, anteroposterior translation, local scoliosis, lumbar lordosis, pelvic parameters, sagittal offset, and fusion. Thorough debridement was performed. Patients were followed for an average of 39.3 months. Constitutional symptoms, low back ache, and functional outcome improved in all patients post-operatively. At final follow-up, Frankel Grade improved by 0 to 2 grades, mean ky-phosis angle improvement was 44.3°, and satisfactory spinopelvic and sagittal bal-ance were achieved. Spinal posterolateral fusion was obtained in all patients and no fixation loosening was found at 2-year follow-up. Differences existed between the pre- and postoperative radiographic parameters (P,.05). Correction loss at last follow-up was not statistically significant (P..05). No surgical complications or infec-tion recurrence occurred. Tuberculosis can be cured and effective correction of kypho-sis can be achieved for lumbosacral tuberculosis with major vertebral body loss and kyphosis by performing 1-stage posterior surgery and chemotherapy.

The authors are from the Department of Orthopedics, West China Hospital, Sichuan University, Chendu; and the Department of Orthopedics (LS), Shanxi Academy of Medical Sciences, Xhanxi Da Yi Hospital, Taiyuan, China.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Limin Liu, MD, Department of Orthopedics, West

China Hospital, Sichuan University, Guoxuexiang No. 37, Wuhouqu, Chendu 610041, China ([email protected]).

doi: 10.3928/01477447-20130724-28

One-stage Posterior Surgical Treatment for Lumbosacral Tuberculosis With Major Vertebral Body Loss and KyphosisLin Sun, MD; YueMing Song, PhD; LiMin Liu, MD; Quan gong, MS; Chunguang Zhou, MD

Figure: Postoperative radiograph of the entire spine at final follow-up 39 months postopera-tively showing solid posterolateral fusion, well- maintained kyphosis angle and local scoliosis, and a sagittal offset of 18.32 mm.

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Tuberculosis is a common infec-tion in developing nations, and active immunization has signifi-cantly reduced the disease burden in many countries.1 The involvement of bones and joints develops in approximately 10% of patients with tuberculosis, of whom half have tuberculous spondylitis.2 For pa-tients with tuberculous spondylitis, the infection causes collapse and loss of ver-tebral body, leading to kyphosis and sagit-tal imbalance.2

The treatment goals of tuberculous spondylitis are to eradicate infection and prevent or treat instability, deformity, and neurologic deficit. The options of treatment are chemotherapy or chemo-therapy with surgery.3,4 For tuberculosis spondylitis of the lumbosacral segment (L3 and lower levels5), various methods of debridement and fusion have been re-ported, including debridement with ante-rior fusion, posterior fusion, single-stage anterior and posterior fusion, and poste-rior fusion followed by anterior fusion.3,6-9 Posterior debridement with instrumenta-tion and fusion is an effective procedure for treating lumbosacral tuberculosis without major vertebral body loss.7-9 However, few reports have been published on performing 1-stage posterior surgery to treat lumbosacral tuberculosis with major vertebral body loss and kyphosis.

In this retrospective series of 14 pa-tients with lumbosacral tuberculosis with major vertebral body loss and kyphosis who underwent chemotherapy, poste-rior debridement, correction, and short-segment instrumentation and fusion, the authors describe their experience and evaluate its results in terms of pain relief, improvement in function, and correction of kyphosis and sagittal balance.

Materials and MethodsThis study was approved by the insti-

tutional review board. Written informed consent was obtained from all patients preoperatively. Between November 2007 and August 2010, fourteen patients with

lumbosacral tuberculosis, major vertebral body loss, and kyphosis were enrolled in this retrospective study. Inclusion criteria were progressive tuberculosis spondylitis at L3 and lower levels; major vertebral body loss; kyphosis angle more than 10° at a lumbosacral segment; and previous posterior debridement, correction, and short-segment instrumentation and fu-sion. Exclusion criteria were previous lumbosacral surgery or trauma at L3 and lower levels, history of adolescent scolio-sis or kyphosis, ankylosing spondylitis, and failure to comply with standard post-operative chemotherapy. The diagnosis of tuberculosis spondylitis was guided by symptoms, elevation of erythrocyte sedi-mentation rate (ESR) and C-reactive pro-tein (CRP) level, computed tomography (CT), and magnetic resonance imaging (MRI). The final diagnosis was confirmed via the postoperative pathological studies. A senior spine surgeon (L.L.) performed all surgeries. Data were collected by 2 independent spinal surgeons (Q.G., C.G.) who were not involved in surgery or pa-tient management, and the means were obtained. Interobserver reliability was good (ka50.71~0.93).

Chemotherapy was started immedi-ately after the diagnosis of tuberculous spondylitis. Indications for surgery were pronounced instability with major ver-

tebral body loss and spinal kyphosis, neurologic deficit, and huge abscess. Clinical and radiologic assessments were performed preoperatively, postopera-tively, and during regular follow-up but were reviewed retrospectively for study purposes. Clinical assessments included constitutional symptoms, low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores,10 and neu-rologic deficit. Constitutional symptoms mainly included general fatigue, night sweats, and fever with weight loss. The measurement of low back ache used a pain visual analog scale with a score of 0 to 10. The Oswestry Disability Index score was the sum of the points from the answers to 10 questions on disability (each received 0 to 5 points).11 Neurologic deficit was assessed according to Frankel classifica-tion.8 Erythrocyte sedimentation rate and CRP level were obtained for all patients.

Radiographs and CT scans of the lumbosacral spine and the entire spine (standing) were obtained for all patients. Vertebral body loss was measured on sagittal CT scans. Each vertebra was di-vided into 10 equal parts based on the vertical height, and the loss of height on each vertebra was added to find the amount of vertebral loss.5,7 Major verte-bral loss was defined as more than 5 parts on the summation.7

Figure 1: Lateral radiograph showing the kyphosis angle (angle between the lines along the posterior border of the first normal vertebra above the level of the lesion and the posterior border of sacrum) (A). Sagittal computed tomography scan showing the anteroposterior translation measurement method using the following formula: (a/b3100%) (B). Anteroposterior radiograph showing local scoliosis measured by drawing 2 lines: 1 on the superior margin of the upper first uninvolved vertebra and the other correcting both sides of the posterior inferior iliac spine (C).

1B1A 1C

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The kyphosis angle at the lumbosacral segment was measured on lateral radio-graphs. Lines were drawn along the poste-rior border of the first normal vertebra above the level of lesion and the posterior border of the sacrum (Figure 1A). The posterior angle was expressed as a plus (1) sign and the an-terior angle as a minus (2) sign.

Anteroposterior translation was mea-sured by determining the ratio between the slipped posterior distance of the first cephalad-involved vertebral body and the anteroposterior diameter of the top of the last caudal-involved vertebral body as seen on sagittal CT scans (Figure 1B).

Local scoliosis was measured by draw-ing 2 lines: 1 on the superior margin of the upper first uninvolved vertebra and the other connecting both sides of the poste-rior inferior iliac spine on anteroposterior radiographs (Figure 1C). Global lumbar

lordosis (Cobb’s angle from the L1 up-per endplate to the S1 upper endplate on the lateral radiographs) was also mea-sured. Pelvic parameters included pelvic incidence, sacral slope, and pelvic tilt.12 Global lumbar lordosis and pelvic param-eters were not analyzed for patients with S1 vertebral body loss. Sagittal offset was measured between the C7 sagittal plumb line and the posterior-superior corner of the normal sacrum on lateral radiographs of the entire spine, with a plus (1) sign indicating anterior displacement and a minus (2) sign indicating posterior dis-placement. Anterior interbody fusion and posterolateral fusion were assessed on CT scans of the lumbosacral spine.

Surgical TechniqueAfter placing the patient in a prone

position on the operating table, which

was flexed in a reverse V shape, the pos-terior midline approach was used while the patient was under general anesthe-sia. Intraoperatively, while under C-arm guidance, pedicle screws were inserted in 1 or 2 segments above and below the involved bodies and partly in 1 involved body if the pedicle screw channel of the involved body was not destructed and the screw hold in the body was strong enough. Complete laminectomy was performed at the involved levels. Temporary fixation with a unilateral rod was performed on 1 side. Facetectomy was then performed at the involved levels on the other side. If the pedicle was free from the involved verte-bral body, the transverse process and ped-icle were excised at their bases. The pus was drained, and the sequestra, infected disk, endplates, and soft tissue were thor-oughly debrided. The sclerotic bone of

Table 1

Patient Characteristics and Instrumented Fusion Levels

Patient No./Sex/Age, y Level Medical History

Constitutional Symptomsa

Low Back Ache

Frankel Classification

Vertebral Body Lossb

Paravertebral Abscess

Instrumented Fusion Level

1/M/42 L4-L5 No No Yes D L4:6; L5:8 Yes L2-L3, S1-S2

2/F/44 L5-S1 L1 fracture with paraplegia Yes Yes A L5:9; S1:2 Yes L3-L4, S1-S2

3/F/50 L3-L4 Pulmonary tuberculosis Yes Yes D L3:9; L4:8 Yes L1-L2, L5, S1

4/F/10 L4-L5 Patent ductus arteriosus Yes Yes E L4:6; L5:9 Yes L2-L3, S1

5/F/24 L5 No No Yes D L5:10 Yes L3-L4, S1

6/F/36 L3-L5 Pulmonary tuberculosis No Yes C L3:5; L4:10; L5:4

Yes L1-L2, S1-S2

7/M/28 L5-S1 No Yes Yes E L5:10; S1:1 Yes L3-L4, S1-S2

8/F/22 L4-S1 No Yes Yes D L4:4; L5:10; S1:8

Yes L2-L3, S1-S2

9/F/27 L4-5 Pulmonary tuberculosis No Yes C L4:2; L5:8 Yes L3-L4, S1-S2

10/M/41 L3-L5 No Yes Yes D L3:2; L4:10; L5:7

Yes L2-L3, S1-S2

11/F/34 L4-S1 No Yes Yes C L4:2; L5:10; S1:1

Yes L3-L4, S1-S2

12/M/47 L4-L5 Digestive tuberculosis Yes Yes D L4:6; L5:7 Yes L2-L3, S1-S2

13/F/37 L4 No No Yes D L4:9 Yes L2-L3, L5, S1

14/M/38 L3-L4 Pulmonary tuberculosis Yes Yes E L3:1; L4:8 Yes L2-L3, L5, S1aSymptoms include general fatigue, malaise, night sweats, and fever with weight loss. bVertebral body loss was measured on sagittal scan of computed tomography, and each vertebra was divided into 10 equal parts based on the vertical height. For example, L5:10 indicates that the vertebral body loss of L5 was all 10 parts.

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the residual vertebral body was curetted, but no additional osteotomy of the verte-bral body was performed. These materials were sent for histopathologic examination and antibiotic sensitivity testing. Then, posterior debridement was performed on the other side. After completing the pos-terior debridement, the cavities between the residual bodies were irrigated. The an-terior two-thirds of the space was packed with iliac cancellous bone autograft mixed with streptomycin (1000 mg), and gelatinous sponges were used to prevent the morselized bone from moving into the spinal canal.

Three steps were performed to cor-rect the kyphosis, including extending the operating table slowly to the neutral po-sition, using a cantilever beam technique to introduce the rods, and performing instrumental compression. A temporary titanium rod was alternated from side to side during correction to avoid translation at the osteotomy site. C-arm fluoroscopy was used to examine the consequence of correction. After correction, shorten-ing of the spine was permitted. Pedicle screws were then fixed to precontoured rods on both sides, and 1 cross-link was used between 2 rods. For spinal fusion, the authors performed strict iliac cancel-lous bone autografting after posterolateral spinal element decortications at the fixa-tion segments.

Postoperatively, all patients were placed on strict bed rest for 3 weeks. A lower lum-bar orthosis was given to all patients, which was continued for an average of 6 months postoperatively. All patients received a 4-drug chemotherapy regimin of isoniazid (5 mg/kg), rifampicin (10 mg/kg), pyriz-inamide (25 mg/kg), and streptomycin (20 mg/kg) for 2 months. This was fol-lowed by the 3-drug chemotherapy regi-men of isoniazid (5 mg/kg), rifampicin (10 mg/kg), and pyrizinamide (25 mg/kg) for another 10 months.

The paired t test was used for the anal-ysis of the preoperative and final follow-up clinical assessments. Mann-Whitney U

2E2D 2F 2G

2B2A 2C

Figure 2: Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), T1- (D) and T2-weighted (E) sagittal magnetic resonance images, and anteroposterior (F) and lateral (G) radiographs of the entire spine showing that the L5 vertebral body was destroyed. Preoperatively, the kyphosis angle was 13.39°, anteroposterior transla-tion was 68.00%, local scoliosis was 19.5°, and sagittal offset was 31.21 mm.

3A 3B 3CFigure 3: Images of a 24-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and sagittal computed tomography scan (C) showing a kyphosis angle of 225.89°, anteroposterior translation of 6.71%, and local scoliosis of 4.38°.

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test was used to evaluate the differences in the Scoliosis Research Society-22 scores. Repeated analysis of variance test was used to compare the preoperative, postoperative, and final follow-up values of the radiologic assessments, and the Bonferroni test was used when the P value was less than .05. A P value less than .05 was considered statistically significant.

resultsFive men and 9 women with an aver-

age age of 34.3 years (range, 10-50 years) were included in the analysis. The clinical characteristics of the included patients are shown in Table 1.

Surgery was successful for all patients, and no large vessel injury or spinal nerve injury occurred. Mean6SD operative time was 283662 minutes, and mean6SD estimated intraoperative blood loss was 12646527 mL. Thorough debridement of the tuberculosis lesion was performed. The range of instrumented fusion levels and patient clinical data are shown in Table 1. Two patients had caudal instru-mentation at only 1 level (S1) because 1 was a child and the other had difficulty during screw placement at S2. A bicorti-cal fixation technique at S1 was provided for the 2 patients. Histopathologic exami-nation results suggested tuberculosis in all patients. The organism was isolated

4A 4B 4D4C 4EFigure 4: Images of a 24-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), and anteroposterior (D) and lateral (E) radiographs of the entire spine at final follow-up 36 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, anteroposterior translation, local scoliosis, and a sagittal offset of 4.93 mm.

5A 5B

5E 5F

5C

5DFigure 5: Images of a 22-year-old woman with lumbosacral tuberculosis. Preoperative anteroposterior (A) and lateral (B) radiographs, sagittal computed tomography scan (C), sagittal magnetic resonance image (D), and anteroposterior (E) and lateral (F) radiographs of the entire spine showing loss of vertebral body height at L4 (loss of 4 parts), L5 (loss of 10 parts), and S1 (loss of 8 parts), a kyphosis angle of 52.61°, local scoliosis of 5.76°, and sagittal offset of 61.40 mm.

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and antibiotic sensitivity was performed in 9 of 14 patients. Average follow-up was 39.3 months (range, 24-56 months) (Figures 2-7).

Constitutional symptoms, low back ache, and postoperative functional out-come improved in all patients. The visual analog scale, Oswestry Disability Index, and Scoliosis Research Society-22 scores were significantly different at final follow-up compared with preoperatively (P,.05) (Table 2). Frankel Grade improved by 0 to 2 grades at final follow-up. Eight pa-tients with preoperative neurologic deficit had complete recovery of neurological function within 6 months postoperatively. One patient with Frankel Grade A had no recovery; he underwent surgery for an L1 fracture with paraplegia 7 years pre-viously. Two other patients with preop-erative Frankel Grade C only recovered to Frankel Grade D at final follow-up. Erythrocyte sedimentation rate normal-ized within 3 months in 6 patients and within 6 months in 8 patients postopera-tively, and CRP returned to normal levels for all patients within 3 months postop-eratively. Significant differences were found in ESR and CRP levels between the preoperative and final follow-up values (Table 2). No recurrent infection occurred and no multidrug-resistant bacillus types were observed in this series.

7C

7DFigure 7: Images of a 22-year-old woman with lumbosacral tuberculosis. Anteroposterior (A) and lateral (B) radiographs, transverse (C) and sagittal (D) computed tomography scans, and anteroposterior (E) and lateral (F) radiographs of the entire spine at final follow-up 39 months postoperatively showing solid posterolateral fusion, a well-maintained kyphosis angle, local scoliosis, and a sagittal offset of 18.32 mm.

7A 7B

7E 7F

6A 6B 6C 6DFigure 6: Images of a 22-year-old woman with lumbosacral tuberculosis. Postoperative anteroposterior (A) and lateral (B) radiographs and transverse (C) and sagittal computed tomography scans (D) showing a kyphosis angle of 213.12° and local scoliosis of 2.04°.

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Postoperatively, average shortening of the lumbosacral spine was 1.5 vertebral bodies (range, 0.9-2.3 vertebral bodies) and 1.7 intervertebral disks (range, 0-2 intervertebral disks). Average kyphosis angle improvement was 45.8° (range, 34.9°-53.1°). Complete spinal postero-lateral fusion was obtained in all pa-tients and no loosening or breakage of the pedicle screws was found at 2-year follow-up, but interbody fusion was not obtained (solid anterior fusion rate, 0). Although some correction loss (average reduction, 2.1°) occurred at last follow-up, it was not statistically significant (P..05). Satisfactory spinopelvic bal-ance and sagittal balance were achieved. Preoperative, postoperative, and final follow-up kyphosis angle, AP transla-tion, local scoliosis, global lumbar lor-dosis, pelvic incidence, sacral slope, pelvic tilt, and sagittal offset were noted (Table 3). Significant differences existed in these pre- and postoperative values (P,.05), except in the pelvic incidence. These parameters were well maintained at final follow-up (P..05).

Postoperative complications consisted of 1 wound infection and 1 bed sore that was not severe. The wound infection was cured with no additional antibiotic thera-py, and the bed sore was treated with local wound care.

discussion Tuberculosis spondylitis preferentially

affects the anterior structures of the verte-bral column in more than 90% of patients with lumbosacral tuberculosis.13 Collapse and major vertebral body loss causes spi-nal instability and kyphosis. Tuberculous spondylitis is a main cause of kyphosis in the developing world.14 Lumbosacral re-gion involvement occurs in 10% to 15% of all patients with tuberculous spondyli-tis.7 Stability and lordosis of the lumbar and lumbosacral spine are necessary for normal spinal biomechanical function. Instability leads to low back pain and disability.

Kyphosis in the lumbosacral region presents several biomechanical disadvan-tages. These patients often cannot stand erect despite compensatory hip extension, knee flexion, and overwork of the erector spinal musculature. The results are muscle

fatigue and low back pain. Studies have also shown a direct correlation between decrease in lordosis of the lumbar and lumbosacral spine with the severity of low back pain.5 Spinal tuberculosis causes pus to accumulate in the prevertebral and

Table 2

Clinical Assessmenta

Clinical Assessment Preoperative Final Follow-up P

Low back ache visual analog scale 7.4360.76 0.5060.53 .000

Oswestry Disability Index, %b 81.1465.61 24.5765.74c .000

Erythrocyte sedimentation rate, mm/h 26.45616.57 10.2164.82c .016

C-reactive protein, mg/L 25.83628.68 3.1861.34c .007

Scoliosis Research Society-22 scoresb

Function and activity 1.8161.2 3.7361.47c .001

Pain 2.4461.79 4.5061.76c .017

Self-image and appearance 2.2562.08 4.0261.27c .028

Mental health 3.556.0.83 4.3661.29 .143

Satisfaction with management NA 4.4461.97 NA

Abbreviation: NA, not available. aData presented as mean6SD. bThe value of 1 patient who underwent surgery for L1 fracture with paraplegia was not available. cP,.05 indicates a statistically significant difference in the final follow-up value compared with the preoperative value.

Table 3

Radiologic Assessment

Mean6SD

Radiologic Assessment Preoperative Postoperative Final Follow-up P

Kyphosis angle, deg 21.6869.77 224.1668.72a 222.6768.32 .000

AP translation, % 47.87629.10 3.7565.97a 4.8066.32 .000

Local scoliosis, deg 10.5766.61 2.3861.30a 3.0461.60 .001

Global lumbar lordosis, deg 6.16628.27 23.98614.67a 26.13613.73 .046

Pelvic incidence, degb 50.3269.34 50.4168.73 50.58610.49 NA

Sacral slope, degb 6.58622.74 29.8268.56a 28.96610.45 .003

Pelvic tilt, degb 43.76617.93 19.8467.39a 20.6869.64 .000

Sagittal offset, mmc 48.24611.28 NA 9.7465.72a .000

Abbreviations: AP, anteroposterior; deg, degrees; NA, not available. aP,.05 indicates a statistically significant difference between the postoperative and final follow-up values compared with the preoperative value. bThe values of 4 patients with vertebral body loss of S1 were not available. cThe value of 1 patient who underwent surgery for L1 fracture with paraplegia was not available.

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paravertebral spaces. Pus accumulation can lead to pressure over the cauda equina and the cauda equina nerve roots, and the neurologic deficit is further aggravated by the kyphosis.

In the current series, patients had ma-jor vertebral body loss of the lumbosacral spine. More than 9 parts of loss were ob-served on CT scans in accordance with the method reported by Rajasekaran et al5 in which each vertebra was divided into 10 equal parts based on the vertical height and the kyphosis angle was more than 10°. The paravertebral abscess was pres-ent in all patients, and neurologic deficit was found in 10 (71%) patients. Major vertebral body loss of the lumbosacral spine, a kyphosis angle greater than 10°, paravertebral abscess, and neurologic deficit are indications for surgery and the difficulties faced intraoperatively.

Various approaches have been reported for lumbosacral tuberculosis.3,8,15 Song et al16 reported that an average improvement of 9.5° in the lumbosacral angle and that bone fusion could be obtained for lumbo-sacral tuberculosis by performing antero-lateral surgery. Surgery via an anterior ap-proach has the advantage of direct access to the site of inflammation and rapid bony union but is associated with approach-related morbidity.3 An anterior parame-dian transperitoneal approach carries the risk of morbidity to major neurovascular structures. It is difficult to decompress the cauda equina nerve roots via anterior ap-proaches. Moreover, anterior instrumen-tation is not advisable at the L4-L5 and L5-S1 segments, and anterior decompres-sion usually requires supplementation with posterior instrumented stabilization.8 Average operative time, blood loss, and length of stay following the 2-stage pro-cedure are greater than those following the 1-stage approach.7,15

Posterior surgery could effectively treat lumbosacral tuberculosis without major vertebral body loss.7,8 Bezer et al7 reported that by performing transpedicular drainage with posterior instrumentation and fusion,

debridement was obtained and average ky-phosis decreased to 5.4° postoperatively from the preoperative value of 17.5° for lumbosacral tuberculosis without major vertebral body loss. Bezer et al17 also re-ported that posterior transpedicular decan-cellation osteotomy effectively corrected posttuberculosis kyphosis (average kypho-sis angle improvement, 17.7°).

The current authors analyzed the fea-sibility of the current 1-stage posterior surgery performed as follows: (1) the posterior approach is relatively easier and safer; (2) debridement via a posterior approach is relatively complete because the destruction and loss of the vertebral body usually leads to vertebral posterior wall damage and freeing of the pedicle; (3) the satisfactory correction of kypho-sis could be achieved via osteotomy of the spinal rear structure with no need for additional osteotomy of the involved body for the preoperative major vertebral body loss; (4) the posterior instrumenta-tion and fusion at L4-S1 could be effec-tively achieved; and (5) the nerve roots are continuously visible during debride-ment, decompression, and kyphosis cor-rection. Thorough debridement, satisfac-tory kyphosis correction (average kypho-sis angle improvement at final follow-up, 44.3°), and satisfactory spinopelvic bal-ance and sagittal balance were achieved for all patients.

The ultimate goal of spinal deformity reconstructive surgery is to obtain solid fu-sion at the instrumented segments. Zaveri and Mehta8 reported that 13 patients with lumbar tuberculous spondylodiskitis had definitive fusion and 2 patients had prob-able fusion after undergoing posterior transforaminal debridement, interbody fusion, and instrumentation. Kim et al18 reported that complete bony fusion was obtained for 23 patients with tuberculosis of the lower lumbar spine who underwent posterior instrumentation and anterior in-terbody arthrodesis. Karaeminogullari et al19 reported good restoration and main-tenance of lumbar lordosis by using com-

bined posterior and anterior fusion for lumbar tuberculosis.

In the current study, cancellous auto-graft from the iliac crest was used in pref-erence to a structural tricortical graft due to irregularity of the vertebral surface, the de-sire to preserve as much of the viable bone that remained after debridement as possi-ble, and the technical difficultly associated with placing a structural graft at this level. Although solid anterior fusions may not be evident in all patients, solid posterolateral fusion was achieved in all patients, and no correction loss or implant failure occurred.

Similar to most of the studies report-ed,4,7,8,15,18,20-22 the current authors ob-tained an encouraging cure rate of tuber-culosis spondylitis and improvement in neurologic status postoperatively. Patients had satisfactory recovery of neurological deficit (Frankel Grade improvement, 0-2 grades) and healing of the tuberculosis spondylitis (100%). Standard chemo-therapy regimens are vital to the complete cure of tuberculosis spondylitis.

The sample size in the current study was relatively small; a larger study is needed to further assess the effects of the surgery. Also, a longer follow-up time is needed to determine how well the correc-tions are maintained in these patients.

conclusionTuberculosis cure and effective kypho-

sis correction can be successfully achieved by performing 1-stage posterior debride-ment, osteotomy correction, and short-segment instrumentation and fusion and chemotherapy in patients with lumbosa-cral tuberculosis with major vertebral body loss and kyphosis.

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