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Orthopaedics & Traumatology: Surgery & Research 100
(2014) 233–239
Available online at
ScienceDirectwww.sciencedirect.com
eview article
pdate on the surgical management of Pott’s disease
. Varatharajaha,c, Y.-P. Charlesa,∗,c, X. Buyb,c, A. Waltera,c,
J.-P. Steiba,c
Service de chirurgie du rachis, hôpitaux universitaires de
Strasbourg, 1, place de l’Hôpital, BP 426, 67091 Strasbourg cedex,
FranceService de radiologie interventionnelle, hôpitaux
universitaires de Strasbourg, hopitaux universitaires de
Strasbourg, 1, place de l’Hôpital,P 426, 67091 Strasbourg cedex,
FranceFédération de médecine translationnelle (FMTS), université de
Strasbourg, 4, rue Blaise-Pascal, 67400 Strasbourg, France
a r t i c l e i n f o
rticle history:ccepted 27 September 2013
eywords:
a b s t r a c t
One-third of the world’s population is infected with
Mycobacterium tuberculosis. Data reported in 2011indicate, for the
first time, a decline in cases of tuberculosis, despite persistent
inequalities across geo-graphic areas and increasing rates of drug
resistance. Osteo-articular tuberculosis affects the spine in
ott’s diseasepinal tuberculosisbscessyphosisurgical
treatmentpondylitis
half the cases. Pharmacotherapy must be combined with surgery in
patients with spinal cord or nerveroot 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. Posteriorfixation is the best
means of achieving reduction followed by stable sagittal alignment
over time. Newtreatment strategies combine conventional surgical
methods, closed interventional radiology proceduresfor drainage and
spinal cord decompression, and percutaneous fixation.
. Introduction
Tuberculosis of the bones and joints remains rare, accountingor
only about 1 to 3% of all cases of tuberculosis [1,2], with simi-ar
incidence time trends. The latest report from the World
Healthrganisation (WHO) on tuberculosis control indicates that
tuber-ulosis cases have started to decline worldwide for the first
time3]. Similarly, the WHO Tuberculosis Surveillance and
Monitoringeport issued in 2012 indicates a decrease in the
incidence of tuber-ulosis in recent years [4].
Spinal tuberculosis, known as Pott’s disease, accounts for
halfhe cases of osteo-articular tuberculosis [1]. Vertebral
inoculationccurs via the haematogenous route and the process then
spreadso the intervertebral disk and, in some cases, to the
adjacent ver-ebra. Para-spinal abscesses may develop by direct
spread fromhe vertebral lesion. The thoracic spine is predominantly
involved5]. Pain is the most common presenting manifestation.
How-ver, the limited symptoms and absence of specific
radiologicalhanges early in the course of the infection often
result in diag-ostic delays. Computed tomography (CT) and magnetic
resonance
maging (MRI) are valuable diagnostic tools. Confirmation of
theiagnosis is obtained by identification of the tubercle bacillus
in
espiratory specimens and/or in samples obtained by abscess
aspi-ation or bone biopsy.
∗ Corresponding author. Tel.: +33 388 116 826; fax: +33 388 115
233.E-mail address: [email protected] (Y.-P.
Charles).
877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All
rights reserved.ttp://dx.doi.org/10.1016/j.otsr.2013.09.013
© 2014 Elsevier Masson SAS. All rights reserved.
The treatment of spinal tuberculosis usually relies
onnon-surgical means, namely, the administration of four
anti-tuberculosis drugs and bracing. Two situations may require
surgicaltreatment: loss of sagittal alignment of the spine due to
extensiveosteolysis and spread of an abscess into the para-spinal
tissuesand spinal canal. In a 1960 report on the surgical treatment
ofcervical, thoracic, and lumbar spinal tuberculosis in 412
patients,Hodgson et al. [6] described the anterior approach with
debride-ment as of fundamental importance. This principle is still
appliedto some extent in contemporary surgical strategies. Major
advanceshave been achieved in recent years, however, with the use
of openinternal fixation combined with anti-tuberculosis drugs, the
intro-duction of percutaneous internal fixation, and the
development ofinterventional radiology techniques.
Here, our objective was to review recent epidemiological
data,diagnostic criteria, and medical and surgical treatments for
spinaltuberculosis.
2. Epidemiology
The 2011 WHO report indicates a stabilisation in the inci-dence
of newly diagnosed tuberculosis, in contrast to the steadyincrease
noted earlier. In 2010, the incidence of tuberculosiswas 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.
InEurope, these differences are ascribable to HIV/AIDS,
increasingpoverty, inequalities in government funding of
tuberculosis control
dx.doi.org/10.1016/j.otsr.2013.09.013http://www.sciencedirect.com/science/journal/18770568http://crossmark.crossref.org/dialog/?doi=10.1016/j.otsr.2013.09.013&domain=pdfmailto:[email protected]/10.1016/j.otsr.2013.09.013
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2 atology: Surgery & Research 100 (2014) 233–239
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34 S. Varatharajah et al. / Orthopaedics & Traum
fforts, increased tubercle bacillus resistance to
anti-tuberculosisrugs, and immigration from endemic areas. Although
the inci-ence of tuberculosis remains low in France, a few
geographicegions and populations are at higher risk: tuberculosis
is chieflyeen in large cities and the risk is greatest among
intravenous sub-tance users, the homeless, and immigrants
[8–10].
Tubercle bacillus identification in sputum samples is
thecreening test currently used in the WHO tuberculosis control
pro-ramme but detects only individuals with pulmonary
tuberculosis.ne-third of the world’s population is believed to
harbour the
ubercle bacillus. When the test is positive, short-term
treatmentith anti-tuberculosis drugs is given under direct
observation byealthcare providers. The effectiveness of this
control programme
s obviously limited in patients with non-pulmonary
tuberculosis.hus, the first problem raised by spinal tuberculosis
is the fre-uently long time to diagnosis [11,12].
. Diagnosis
In France, the intradermal tuberculin test is still used to
diag-ose latent tuberculosis. This test may be positive in
individualsaving received the Bacillus Calmette-Guérin (BCG)
vaccine, who
ig. 1. Computed tomography, coronal and sagittal views:
osteolysis in a 40-year-ld patient with T11-T12 spinal
tuberculosis.
ig. 2. Magnetic resonance imaging, T2 STIR sagittal view:
abscess lying behind theorta from T8 to L2 (same patient as in Fig.
1).
Fig. 3. Drainage of the abscess via a video-assisted minimally
invasive right anteriorapproach. Note the osteolysis after
debridement (same patient as in Fig. 1).
Fig. 4. Post-operative radiographs showing preservation of
sagittal alignment bythe T8-L1 posterior fusion (same patient as in
Fig. 1).
-
S. Varatharajah et al. / Orthopaedics & Traumatology:
Surgery & Research 100 (2014) 233–239 235
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.
Fa
miTf
ig. 6. Percutaneous drainage of the abscess via a
pre-sterno-cleido-mastoidpproach (same patient as in Fig. 5).
ust therefore be tested using in vitro assays that measure
thenterferon gamma released into venous blood by infected T
cells.he French National Authority for Health (HAS) recognizes the
roleor these in vitro assays as an alternative to intradermal
tuberculin
Fig. 8. Computed tomography, sagittal and axial views:
osteolys
Fig. 7. Post-operative radiographs of the cervical spine showing
the fusion achievedvia a combined posterior and anterior approach
(same patient as in Fig. 5).
testing for the diagnosis of extra-pulmonary tuberculosis.
Inaddition, microscopic examination of a variety of specimens
(spu-tum; gastric aspirate, particularly in children; abscess
samples,and urine) for presence of the tubercle bacillus can assist
in the
is in a 53-year-old patient with T8-T9 spinal tuberculosis.
-
236 S. Varatharajah et al. / Orthopaedics & Traumatolo
Fa
drbs
ig. 9. Magnetic resonance imaging, T2-weighted sagittal and
axial images showingn abscess within the spinal canal (same patient
as in Fig. 8).
iagnosis. Molecular biology techniques may play an adjunctiveole
in patients with a strong suspicion of clinical tuberculosisut
should not be performed routinely, as their sensitivity
andpecificity are lower than those of cultures [13]. All tissue
samples
Fig. 10. Percutaneous drainage of the caseous necrosis under
radiograph
gy: Surgery & Research 100 (2014) 233–239
should be subjected to histological examination for an
epithelioidand giant-cell granuloma [14–16].
Spinal lesions that suggest tuberculosis are vertebral body
oste-olysis and kyphosis caused by bone destruction. These lesions
canbe evaluated on standing lateral radiographs and assessed in
detailby CT (Fig. 1). Among currently available techniques, MRI has
thebest sensitivity and offers acceptable specificity for spinal
lesions[17]. T2 STIR images can ensure the early detection of
inflammatoryoedema. In addition, MRI shows the extent of
tuberculous abscessesand visualises spinal cord lesions (Fig. 2),
allowing their detectionbefore the onset of clinical
manifestations. The diagnosis of tuber-culous infection cannot be
established based on imaging studiesalone. Nevertheless, imaging
studies are useful to assess the extentof the lesions, guide the
collection of samples for tubercle bacillusidentification, and
assist in defining the best treatment strategy.
4. Medical treatment
Anti-tuberculosis drug treatment must be monitored closelyto
prevent the emergence of multi-resistant strains. From 2005to 2010,
Europe was among the regions with the lowest treat-ment success
rates, i.e., 69% among new patients and 48% amongpreviously treated
patients [18]. The recommended treatmentstarts with four drugs
given for 2 months: isoniazid, 5–15 mg/kg;rifampicin, 10–20 mg/kg;
ethambutol, 15–25 mg/kg; and pyraz-inamide, 30–40 mg/kg. Isoniazid
and rifampicin are then givenfor the next 4 months.
Fluoroquinolones are alternative first-line
drugs. The latest recommendations indicate that spinal
tuberculo-sis should be treated in the same way as pulmonary
tuberculosis(with a longer treatment duration of 1 year in children
accordingto 2010 WHO guidelines). However, when the clinical,
laboratory,
ic and computed tomography guidance (same patient as in Fig.
8).
-
S. Varatharajah et al. / Orthopaedics & Traumatology:
Surgery & Research 100 (2014) 233–239 237
Fp
ap
5
lurmtnfls
Fp
ig. 11. Post-operative radiographs showing the posterior T6-T11
fusion (sameatient as in Fig. 8).
nd imaging study findings suggest persistent inflammation,
mosthysicians prefer longer treatment duration of 9 months
[16,19,20].
. Surgical treatment
In 1960, at a time when the surgical treatment of spinal
tubercu-osis was still controversial, Hodgson et al. [6] described
the routinese of debridement via the anterior approach, with a 93%
fusionate. In 1961, the French Society for Orthopaedic Surgery and
Trau-atology (SOFCOT) emphasised the predominant role for
medical
reatment while acknowledging the existence of two
strategies,amely, routine local surgery and medical treatment alone
with
our anti-tuberculosis drugs and a brace [21,22]. However,
pub-ished studies indicate widespread use of combined medical
andurgical treatment: thus, in a review of case-series
published
ig. 12. Computed tomography, sagittal view: anterior T7-T10
fibular graft (sameatient as in Fig. 8).
Fig. 13. Computed tomography of the thoraco-lumbar spine,
sagittal view: osteol-ysis 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
patientswith evidence of spinal cord or nerve root compression,
exten-sive abscess formation, spinal instability due to osteolysis
withkyphosis, and failure of medical treatment. In patients
withoutevidence of neurological compromise, the treatment consists
inanti-tuberculosis drugs and bracing, provided the sagittal
align-ment of the spine is preserved [26]. Imaging studies must
beobtained at regular intervals throughout the treatment to look
forworsening of the kyphosis. If vertebral body osteolysis results
inanterior column collapse, the need for instrumental correction
andfusion should be discussed. The rate of neurological
complicationsis estimated at 10 to 40% [27]. Emergency surgical
decompression isindicated only in patients with evidence of spinal
cord compressionand usually involves laminectomy followed by
internal fixation andposterior fusion at the thoraco-lumbar spine
or by corporectomyat the cervical spine.
In patients with extensive abscess formation but no
neu-rological deficit, the anterior approach remains the
referencestandard [28–31]. This approach allows direct debridement
of thepre-vertebral and intra-spinal focus of infection (Fig. 3).
Phar-macokinetic studies have established that surgery improves
theeffectiveness of anti-tuberculosis drugs when debridement is
opti-mal [32,33]. In addition, same-stage anterior grafting plays a
keyrole in filling the lytic defect and strengthening the anterior
col-umn [34,35]. At the thoraco-lumbar spine, posterior fixation
mustbe performed also to correct the kyphosis and ensure
long-termstability of the spine in the sagittal plane (Fig. 4).
Garg et al. [36]and Kumar et al. [37] advocated using the posterior
approach aloneto perform spinal canal decompression and abscess
drainage dur-ing the same stage as internal fixation and fusion.
Zhang et al.[38] described a similar technique involving the
addition of abony graft implanted into the anterior lytic defect
via the pos-terior approach in order to stabilise the entire spinal
segment,thereby preventing loss of correction with kyphosis. At the
cer-vical spine, abscess drainage, corporectomy, and internal
fixation
are usually performed via the anterior approach alone.
Additionalposterior stabilisation is required only in patients with
extensivebone destruction (Figs. 5–7). In sum, the surgical
management of
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238 S. Varatharajah et al. / Orthopaedics & Traumatology:
Surgery & Research 100 (2014) 233–239
iews:
twTwo
pdwtSwtssutsisai
Fbp
Fig. 14. Magnetic resonance imaging, T2-weighted sagittal and
axial v
ypical spinal tuberculosis rests on two principles:
debridementith spinal cord decompression and stabilisation of the
spine.
hese principles are also followed in some developing
countries,here surgical treatment can prevent the long-term
development
f severe kyphosis [39].An alternative that may deserve
consideration in some cases is
ercutaneous needle aspiration of the caseous necrosis to
ensureecompression [40]. This procedure may be of value in
patientsith severe osteolysis responsible for spinal instability, a
situation
hat requires posterior fixation as the first surgical step (Fig.
8).pinal canal decompression by laminectomy must be performedith
the patient in the prone position, which can increase the
ension on the spinal cord. Furthermore, the introduction of
Keris-on forceps into the tight space of the canal increases the
risk ofpinal cord compression (Fig. 9). Aspiration of the caseous
necrosisnder CT guidance decreases the size of the collection and
obviateshe need for laminectomy (Fig. 10). In addition, posterior
spinaltabilisation can be achieved with less risk of propagation of
the
nfection along the internal fixation material (Fig. 11). A
secondtage of video-assisted surgery via a minimally invasive
anteriorpproach is then performed to ensure debridement and bony
graft-ng (Fig. 12). Finally, Wimmer described a percutaneous
fixation
ig. 15. Post-operative radiographs showing reduction of the
sagittal malalignmenty percutaneous T8-L2 fixation and anterior
grafting with a Harms cage (sameatient as in Fig. 13).
extension of the abscess about the spine (same patient as in
Fig. 13).
technique [41] that might constitute a less invasive
alternative. Thistechnique may deserve evaluation in high-risk
patients with spinaltuberculosis (Figs. 13–15).
6. Conclusion
Spinal tuberculosis (Pott’s disease) predominantly affects
thethoracic spine and is often diagnosed late. Worldwide
surveil-lance data published since 2011 point to stabilisation of
theincidence of active tuberculosis. The treatment relies chieflyon
anti-tuberculosis drugs with the same regimens as for pul-monary
tuberculosis, although a treatment-duration of 9 monthsis often
used in everyday practice. In the absence of a neurolog-ical
emergency, surgery is indicated to prevent secondary spinalcord
compression in patients with extensive abscess formationand/or
sagittal spinal collapse. Both the anterior and the
posteriorapproaches can be used. For thoraco-lumbar lesions, we
usuallystart with the posterior approach to stabilise the spine.
Decompres-sion by percutaneous aspiration of the caseous necrosis
decreasesthe risk of intra-operative neurological complications in
high-riskpatients. A minimally invasive anterior approach is then
used toperform optimal debridement and to implant a bony graft
designedto achieve long-term stability of the spine. At the
cervical level,debridement and spinal stabilisation are performed
via the ante-rior approach alone. Additional posterior fusion is
required only inpatients with marked osteolysis responsible for
severe instability.
Declaration of interest
The authors declare that they have no conflicts of interest
con-cerning this article.
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Update on the surgical management of Pott's disease1
Introduction2 Epidemiology3 Diagnosis4 Medical treatment5 Surgical
treatment6 ConclusionDeclaration of interestReferences