Original Article
83
Video-Assisted Thoracoscopic Anterior Surgery Combined Posterior Instrumentation for Children with Spinal Tuberculosis Changkun Zheng1
Peng Li1
WuSheng Kan1
1 Department of Orthopaedics, Pu Ai Hospital of Tongji Medical
College of Huazhong University of Science and Technology, Wuhan, China
Address for correspondence Changkun Zheng, Department of Orthopaedics, Pu Ai Hospital of Tongji Medical College of Huazhong University of Science and Technology, Hanzheng Street 473 Wuhan 430033, China (e-mail: [email protected]).
Abstract
Keywords
► tuberculosis ► thoracic spine ► video-assisted thoracoscopic surgery ► children
Background The use of thoracoscopy for the treatment of spinal disorders has been applied mostly in adults. However, thoracoscopic decompression of spinal tuberculosis in children has probably been rarely documented. Objective To assess the efficacy of video-assisted thoracoscopic anterior surgery (VATS) combined with posterior instrumentation for children with spinal tuberculosis. Study Design Total 15 consecutive children with spinal tuberculosis with VATS combined with posterior instrumentation were included. Methods Overall 15 cases of spinal tuberculosis were treated with the procedure of posterior internal fixation and anterior debridement by VATS combined with posterior instrumentation between January 2002 and December 2006.There were nine males and six females with an average age of 11.6 years (8–15 y). All patients were given appropriate chemotherapy for 4 to 12 weeks preoperatively and 12 to 15 months postoperatively. All patients were followed up with evaluation of the changes of kyphotic deformity noted. Results All the cases were followed up over an average of 37.3 months (range, 12–48 mo).The wounds were healed without chronic infection or sinus formation. Four patients improved three grades, two patients improved two grades, and seven patients improved one grade. The average neurological recovery in the patients was 1.44 grades on the scale by Frankel et al. The average preoperative kyphosis was 37 degrees (range, 23–59 degrees) and the average postoperative kyphosis was 25 degrees (range, 18–35 degrees) at final follow-up. Also, minimal progression of kyphosis was seen at final follow-up with an average kyphosis of 28 degrees (range, 20–40 degrees); and average loss of correction of 3 degree was seen at final follow-up. Conclusions VATS combined with posterior instrumentation achieve satisfactory results for children with spinal tuberculosis.
Introduction Tuberculosis of the spine is still prevalent in many parts of the world1 and is an endemic. It mainly prevails in the developing countries, but now also increasing in the Western world due to the human immunodeficiency virus epidemic, immigra-
received April 2, 2013 accepted after revision July 16, 2013 published online January 17, 2014
tion, and drug resistance. Tuberculosis is primarily a pulmonary infection, but extrapulmonary manifestations are not uncommon, especially in children. It is known that spinal tuberculosis is more severe, dangerous, and disabling in children than it is in adults. Children represent a high-risk
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1354584. ISSN 0939-7248.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Eur J Pediatr Surg 2014;24:83–87.
VATS Combined Posterior Instrumentation for Children group for acquiring the disease. It still remains a leading cause of paraplegia in developing nations.2–5 Conservative treatment with antituberculosis drugs and external immobilization is the first choice. Anterior debridement with anterior column support, popularized by Hodgson et al,6 has good results and the authors consider it a valuable surgical option in children with tuberculosis. The thoracic spine is a very difficult site for surgical procedures for such cases due to its special anatomical position. Thoracotomy is associated with high morbidity. The advent of video-assisted thoracoscopic surgery has given a valuable alternative to conventional thoracotomy with minimal morbidity. The use of thoracoscopy for the treatment of spinal disorders has been applied mostly in adults. However, thoracoscopic decompression of spinal tuberculosis in children has probably been rarely documented. The authors therefore, report their experience with video-assisted thoracoscopic anterior surgery (VATS) combined with posterior instrumentation in treatment of thoracic spinal tuberculosis.
Patient Population After the Institutional Review Board approval, from January 2002 to December 2006, 15 consecutive children with single-level (no skip lesion) thoracic with spinal tuberculosis were enrolled in the study. There were nine males and six females. The mean age at the time of diagnosis and treatment initiation was 11.6 years (range, 8–15 y). All patients included in the study had thoracic kyphosis below 60 degrees. The average preoperative kyphosis was 37 degrees (range, 23–59 degrees). The classification of Frankel et al was used to assess the recovery of spinal cord function: type A, complete loss, complete loss of motor and sensory function below the segmental level of the cord lesion; type B, sensory only, some sensation below the level of the lesion, but complete motor paralysis; type C, motor useless, some motor powers present below the lesion, but not sufficient to be of practical use; type D, motor useful, useful motor power below the level of the lesion; and type E, intact, no neurological deficit or symptoms. Preoperative neurological status was Frankel et al7 grade A in two patients, grade B in four patients, grade C in three patients, grade D in four patients, and grade E in two patients (►Table 1; ►Figs. 1 and 2).
Zheng et al. Table 1 Preoperative and postoperative neurological status. Case
Preoperative
Postoperative
1
A
D
2
E
E
3
B
C
4
B
D
5
C
D
6
D
E
7
D
E
8
A
D
9
E
E
10
D
E
11
C
D
12
D
E
13
C
E
14
B
E
15
B
D
Note: The classification of Frankel et al7 was used to assess the recovery of spinal cord function: type A, complete loss, complete loss of motor and sensory function below the segmental level of the cord lesion; type B, sensory only, some sensation below the level of the lesion, but complete motor paralysis; type C, motor useless, some motor powers present below the lesion, but not sufficient to be of practical use; type D, motor useful, useful motor power below the level of the lesion; and type E, intact, no neurological deficit or symptoms.
Pathological evaluation revealed typical caseating necrosis and granulomatous formation in all patients. Acid-fast stains from the local lesion sites for the mycobacterium were positive in seven patients.
Operative The new surgery and its possible complications were explained in detail to patients and their parents. They were also told that an open thoracotomy may be performed if complications occur during VATS. Consent for conversion to open
Preoperative All 15 patients were admitted due to severe back pain or paraparesis, with mean symptom duration of 4.24 months (range, 1–6 mo). All patients received our first-line antitubercular drugs (i.e., isoniazid, rifampicin, ethambutol, and pyrazinamide) for 4 to 12 weeks before the operation and bed rest for at least 3 weeks before surgery. Surgery was planned only if there was no evidence of recovery. The angle of kyphosis was measured on lateral radiographs by drawing a line on the upper surface of the first normal vertebra above the lesion and one through the lower surface of the first normal vertebra below the lesion. Intraoperative specimens taken from the lesion site revealed tuberculous spondylitis by histological analysis or a positive acid-fast stain in all patients. European Journal of Pediatric Surgery
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No. 1/2014
Fig. 1 Anteroposterior and lateral radiographs of the spine showing destruction of T8–9 vertebrae and paraspinal abscess.
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84
Fig. 2 Magnetic resonance image showing destruction of T8–9 vertebrae and paraspinal abscess.
thoracotomy, if necessary, was obtained from all the patients or parents as appropriate. Patients who had obvious respiratory insufficiency, significant pleural adhesions, and those with the likely inability to tolerate single lung ventilation were not included in the study. Under general anesthesia, the anesthetist used a double-lumen tube for intubation, and the patient was maintained on single lung ventilation. Open posterior instrumentation using a pedicle screw-rod construct was completed first. The portals for screw insertion were made carefully, with C-arm guidance using strict lateral views. Then thoracoscopic-assisted anterior debridement was accomplished with an iliac autograft applied between the vertebrae. The standard three-portal technique was used for abscess drainage and decompression. The spine was usually approached from the right side, depending on the radiological findings (i.e., bulk of abscess and destruction of body). In the upper thoracic vertebra (T2–5), trocar incision for operation was made in the intercostal space along the midaxillary line depending on the site of the lesion. A trocar incision for light was one intercostal space below the first incision. A trocar incision for suction was two intercostal spaces below the first incision. The two incisions were also along the midaxillary line. In the middle thoracic vertebra (T6–9), the trocar incision for operation was made in the intercostal space along the posterior axillary line depending on the site of the lesion. A trocar incision for light was two intercostal spaces above the first incision along the anterior axillary line. A trocar incision for suction was two intercostal spaces below the first incision along the anterior axillary. In the lower thoracic vertebra (T10–12), the trocar incision for operation was made in the intercostal space along the posterior axillary line depending on the site of the lesion. A trocar incision for light was two intercostal spaces above the first incision along midaxillary line. A trocar incision for suction was the same as the operation incision along the midaxillary line. The working portals were enlarged to 4 cm and used as extended manipulating channels. This facilitated the use of conventional spinal instruments for adequate decompression of the cord anterior and iliac grafts. The correct lesion site usually could be located directly but sometimes was covered by the visceral pleura
Zheng et al.
and required separation from any adhering tissue. The mediastinal pleura overlying the lesion was divided longitudinally. The intercostal arteries and veins were ligated. Specimens for acid-fast stain were obtained. The abscess was drained, curetted, and a partial excision of the involved adjacent vertebral body was performed using conventional rongeurs and curettes. The decompressive procedure was performed down to the epidural space and guided with video assistance. The interbody fusion technique was initiated using an iliac autograft applied between the vertebrae by means of an elongated bone impactor. The vertical titanium mesh body was placed for anterior column reconstruction. A chest radiograph was taken immediately after the operation to ensure a fully inflated lung. The average operative time was 237 minutes (range, 153–341 min). As expected, the operative time for each procedure was longer initially and decreased with experience. The average blood loss was 360 mL (range, 200–780 mL) and increased with the operative time. The average postoperative stay was 7 days (range, 5–12 d).
Postoperative The intercostal water-sealed drain in situ allowed for early lung expansion and minimized atelectasis. The intercostal drain was usually removed after 72 hours. All patients were treated with an antituberculous chemotherapy regimen for 12 to 15 months. The usual regimen followed was four drug chemotherapy (rifampicin, isoniazid, ethambutol, and pyrazinamide) for 8 weeks followed by three drugs (rifampicin, isoniazid, and ethambutol) for 6 weeks and two drugs (rifampicin and isoniazid) for the rest of the period. Liver functions and sedimentation rates were monitored carefully at regular intervals.
Result All cases were followed up with an average of 37.3 months (range, 12–48 mo). The wounds were healed without chronic infection, sinus formation, or anterior solid fusion between vertebrae. All patients achieved fusion, and there was no recurrence of the disease in any of the patients at the last follow-up (►Fig. 3).
Neurological Status The classification by Frankel et al7 was used to assess the recovery of spinal cord function. Four patients improved three grades, two patients improved two grades, and seven patients improved one grade (►Table 1). The average neurological recovery in the patients was 1.44 grades on the scale by Frankel et al.
Deformity The average preoperative kyphosis was 37 degrees (range, 23–59 degrees) and the average postoperative kyphosis was 25 degrees (range, 18–35 degrees) at final follow-up. At final follow-up, minimal progression of kyphosis was seen, with an average kyphosis of 28 degrees (range, 20–40 degrees). An average loss of correction of 3 degree was seen at final follow-up. European Journal of Pediatric Surgery
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No. 1/2014
85
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VATS Combined Posterior Instrumentation for Children
VATS Combined Posterior Instrumentation for Children
Fig. 3 Lateral radiographs of the spine at 1-year follow-up.
Complications Postoperative complications occurred in three patients. Two had prolonged intercostal a drainage tube in situ for 5 days due to a persistent air leak, which resolved without any further intervention. Pneumonitis occurred in one patient, but this responded well to antibiotics. No intercostal neuralgia occurred in the patients and there were no mortalities.
Discussion Tuberculosis is a reemerging infectious disease. Tuberculosis of the musculoskeletal system is a secondary form of tuberculosis, resulting from a secondary spread of bacilli from a primary focus. The spine constitutes almost 50% of the total number of cases of osteoarticular tuberculosis.8 It frequently causes neurological deficit, kyphotic deformity, and even paraplegia. The thoracic regions are most commonly affected in spinal TB15. Spinal tuberculosis continues to be a scourge in the developing world. It is considered a leading cause of paraplegia and carries significant morbidity.9,10 Chemotherapy is important for children with tuberculosis. Therapeutic options include chemotherapy alone or in combination with surgery. There is a role for treatment of spinal tuberculosis with chemotherapy alone with or without immobilization. Chemotherapy even in radical surgery is the basic treatment of spine tuberculosis. Prolonged administraEuropean Journal of Pediatric Surgery
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No. 1/2014
Zheng et al. tion is necessary to prevent subsequent relapse of the tuberculous process, which is otherwise a frequent occurrence.11 Indications for surgery includes neurological deficits, spinal instability, severe and progressive kyphosis, no response to chemotherapeutic treatment, nondiagnostic biopsy, and large paraspinal abscess.9,10 The spinal cord is compressed by tubercular pathology, such as inflammatory focus, debris, and caseation from the anterior aspect. Therefore, the logical method to adequately decompress the spinal cord is through the anterior approach. Radical anterior surgery led to complete neurological recovery in the majority of cases.11 Surgical treatment of tuberculosis of the spine remains controversial. Indications for surgery vary from one center to another.9,11–13 There is a wide spectrum of treatment options available for children with tuberculosis. A judicious use of conservative therapy and operative decompression when indicated is the usual approach. For spinal tuberculosis, adequate debridement, decompression, and anterior graft placement can be achieved by either anterolateral decompression or the transpleural transthoracic approach.14,15 Both approaches have significant morbidity and even mortality.16 The role of VATS of the spine was established nearly a decade ago.17 The procedure has been used mainly in adults. Perhaps there are few reports in the literature on thoracoscopic decompression of spinal tuberculosis in children.13–15,22 Traditional surgery for children with spinal tuberculosis often involves a large surgical incision, cutting the multimuscle, and resection of one or two ribs. After surgery, patients often show intense wound pain, slow recovery, complications, long hospital stays, and large amount of bleeding. VATS is able to achieve adequate decompression. Despite a rather long learning curve expected for a minimally invasive surgical procedure, we could achieve effective decompression of the spine and recovery. It avoids excessive procedure-related soft tissue trauma in patients and provides a good alternative to other treatment modalities. It is an effective, minimally invasive procedure for decompression of tubercular dorsal spondylitis. VATS for decompression of spinal tuberculosis leads to decreased perioperative morbidity, and reduced analgesic and homologous blood requirements, compared with the open thoracotomy procedure. Landreneau et al18 found that many patients undergoing open thoracotomy required adjunctive pain control measures, such as intercostal block and epidural analgesia, in addition to injectable analgesic. VATS for decompression of spinal tuberculosis allows early discharge of the patient from the hospital and, cosmetically, a more acceptable surgical scar result. Lesions involving the anterior spinal column, from T2 to L1, can be managed by this technique.19 However; thoracoscopy is not indicated for all patients. The contraindications for this technique are patients’ intolerance to one lung ventilation intraoperatively or severe pleural adhesions caused by the lesion or previous surgery. It used a minimally invasive procedure with VATS whose effect is similar to VATS. By avoiding extensive muscle dissection and rib resection, thoracoscopy allows decreased postoperative pain and narcotic requirements when compared with open thoracotomy. This may improve postoperative pulmonary function.
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VATS Combined Posterior Instrumentation for Children
Conflict of Interest None.
2 Rajasekaran S. The natural history of post-tubercular kyphosis in
3
4
5 6
7
8
9 10 11
12 13
14
15
16
17
18
19
20 21
References 1 Lönnroth K, Raviglione M. Global epidemiology of tuberculosis:
prospects for control. Semin Respir Crit Care Med 2008;29(5): 481–491
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children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br 2001;83(7):954–962 Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T. Morphological changes during growth in healed childhood spinal tuberculosis: a 15-year prospective study of 61 children treated with ambulatory chemotherapy. J Pediatr Orthop 2006;26(6):716–724 Salazar GE, Schmitz TL, Cama R, et al; Working Group on TB in Peru. Pulmonary tuberculosis in children in a developing country. Pediatrics 2001;108(2):448–453 Teo HE, Peh WC. Skeletal tuberculosis in children. Pediatr Radiol 2004;34(11):853–860 Hodgson AR, Stock FE. Anterior spine fusion for the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first 100 cases. J Bone Joint Surg Am 1960;42: 295–310 Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969;7(3): 179–192 Mehta JB, Emery MW, Girish M, Byrd RP Jr, Roy TM. Atypical Pott’s disease: localized infection of the thoracic spine due to Mycobacterium avium-intracellulare in a patient without human immunodeficiency virus infection. South Med J 2003;96(7):685–688 Jain AK, Dhammi IK. Tuberculosis of the spine: a review. Clin Orthop Relat Res 2007;460:39–49 Tuli SM. Tuberculosis of the spine: a historical review. Clin Orthop Relat Res 2007;460:29–38 Moon MS, Moon YW, Moon JL, Kim SS, Sun DH. Conservative treatment of tuberculosis of the lumbar and lumbosacral spine. Clin Orthop Relat Res 2002;398(398):40–49 Boachie-Adjei O, Squillante RG. Tuberculosis of the spine. Orthop Clin North Am 1996;27(1):95–103 Yilmaz C, Selek HY, Gürkan I, Erdemli B, Korkusuz Z. Anterior instrumentation for the treatment of spinal tuberculosis. J Bone Joint Surg Am 1999;81(9):1261–1267 Chacko AG, Moorthy RK, Chandy MJ. The transpedicular approach in the management of thoracic spine tuberculosis: a short-term follow up study. Spine 2004;29(17):E363–E367 Zhao J, Lian XF, Hou TS, Ma H, Chen ZM. Anterior debridement and bone grafting of spinal tuberculosis with one-stage instrumentation anteriorly or posteriorly. Int Orthop 2007;31(6):859–863 A five-year assessment of controlled trials of in-patient and outpatient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Fifth report of the Medical Research Council Working Party on tuberculosis of the spine. J Bone Joint Surg Br 1976;58-B(4):399–411 Mangione P, Vadier F, Sénégas J. Thoracoscopy versus thoracotomy in spinal surgery: comparison of 2 paired series [in French]. Rev Chir Orthop Repar Appar Mot 1999;85(6):574–580 Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative painrelated morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56(6):1285–1289 Kapoor SK, Agarwal PN, Jain BK Jr, Kumar R. Video-assisted thoracoscopic decompression of tubercular spondylitis: clinical evaluation. Spine 2005;30(20):E605–E610 Jain AK, Aggarwal PK, Arora A, Singh S. Behaviour of the kyphotic angle in spinal tuberculosis. Int Orthop 2004;28(2):110–114 Oga M, Arizono T, Takasita M, Sugioka Y. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine 1993;18(13):1890–1894 Jin D, Qu D, Chen J, Zhang H. One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J 2004;13 (2):114–121
European Journal of Pediatric Surgery
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Although, the injury to the chest wall is less, thoracoscopy affords the same surgery on the spine as does open thoracotomy. In children, the small chest cavity, narrow rib spacing, and reduced working distance to the spine create additional technical challenges for the thoracoscope. Despite the decreased working space within the chest, anterior thoracoscopic surgery for spinal release and fusion can be performed as safely in children. In the upper thoracic vertebra (T2–5), the trocar incision for operation must be made in the midaxillary line as the scapula block the operations along the posterior axillary line. But for the middle thoracic vertebra (T6–9), the trocar incision for operation was made in the intercostal space along the posterior axillary line. The incision can be nearer to the site of the lesion. Surgical instruments reached the site of the lesion simply and safely. The trocar incision for light and suction along the anterior axillary facilitated lighting. To avoid the diaphragm movement, the trocar incision for operation was made along the posterior axillary line and the trocar incision for light and suction along the midaxillary line for the lower thoracic vertebra. Posterior instrumentation can effectively prevent the excessive growth of the posterior column in children.20 Posterior instrumentation surgery was not a hazard to spinal tuberculosis infection. The adherence property of Mycobacterium tuberculosis to stainless steel was evaluated experimentally.21 Posterior instrumentation was away from the lesion as it can reduce the possibility of infection. Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis. There were no cases of persistence or recurrence of infection after surgery, and the instrumentation provided immediate stability and protected against development of kyphotic deformity.13,22 Many factors determined such a just passable repair of neurological function, the long-term compression of the spinal cord resulting from the delay of diagnosis and surgery, no doubt, was the supreme one. It is important for children to have early diagnosis and early therapy to prevent the spinal tuberculosis. In conclusion, for children with tuberculosis, systemic antituberculosis chemotherapy was the cornerstone, followed in order by tuberculous focus clearance as second, third spinal fusion by bone grafting, and fourth kyphosis correction. VATS for children with spinal tuberculosis combined with posterior instrumentation in treatment of thoracic spinal tuberculosis was feasible and effective.
Zheng et al.
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83
Video-Assisted Thoracoscopic Anterior Surgery Combined Posterior Instrumentation for Children with Spinal Tuberculosis Changkun Zheng1
Peng Li1
WuSheng Kan1
1 Department of Orthopaedics, Pu Ai Hospital of Tongji Medical
College of Huazhong University of Science and Technology, Wuhan, China
Address for correspondence Changkun Zheng, Department of Orthopaedics, Pu Ai Hospital of Tongji Medical College of Huazhong University of Science and Technology, Hanzheng Street 473 Wuhan 430033, China (e-mail: [email protected]).
Abstract
Keywords
► tuberculosis ► thoracic spine ► video-assisted thoracoscopic surgery ► children
Background The use of thoracoscopy for the treatment of spinal disorders has been applied mostly in adults. However, thoracoscopic decompression of spinal tuberculosis in children has probably been rarely documented. Objective To assess the efficacy of video-assisted thoracoscopic anterior surgery (VATS) combined with posterior instrumentation for children with spinal tuberculosis. Study Design Total 15 consecutive children with spinal tuberculosis with VATS combined with posterior instrumentation were included. Methods Overall 15 cases of spinal tuberculosis were treated with the procedure of posterior internal fixation and anterior debridement by VATS combined with posterior instrumentation between January 2002 and December 2006.There were nine males and six females with an average age of 11.6 years (8–15 y). All patients were given appropriate chemotherapy for 4 to 12 weeks preoperatively and 12 to 15 months postoperatively. All patients were followed up with evaluation of the changes of kyphotic deformity noted. Results All the cases were followed up over an average of 37.3 months (range, 12–48 mo).The wounds were healed without chronic infection or sinus formation. Four patients improved three grades, two patients improved two grades, and seven patients improved one grade. The average neurological recovery in the patients was 1.44 grades on the scale by Frankel et al. The average preoperative kyphosis was 37 degrees (range, 23–59 degrees) and the average postoperative kyphosis was 25 degrees (range, 18–35 degrees) at final follow-up. Also, minimal progression of kyphosis was seen at final follow-up with an average kyphosis of 28 degrees (range, 20–40 degrees); and average loss of correction of 3 degree was seen at final follow-up. Conclusions VATS combined with posterior instrumentation achieve satisfactory results for children with spinal tuberculosis.
Introduction Tuberculosis of the spine is still prevalent in many parts of the world1 and is an endemic. It mainly prevails in the developing countries, but now also increasing in the Western world due to the human immunodeficiency virus epidemic, immigra-
received April 2, 2013 accepted after revision July 16, 2013 published online January 17, 2014
tion, and drug resistance. Tuberculosis is primarily a pulmonary infection, but extrapulmonary manifestations are not uncommon, especially in children. It is known that spinal tuberculosis is more severe, dangerous, and disabling in children than it is in adults. Children represent a high-risk
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1354584. ISSN 0939-7248.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Eur J Pediatr Surg 2014;24:83–87.
VATS Combined Posterior Instrumentation for Children group for acquiring the disease. It still remains a leading cause of paraplegia in developing nations.2–5 Conservative treatment with antituberculosis drugs and external immobilization is the first choice. Anterior debridement with anterior column support, popularized by Hodgson et al,6 has good results and the authors consider it a valuable surgical option in children with tuberculosis. The thoracic spine is a very difficult site for surgical procedures for such cases due to its special anatomical position. Thoracotomy is associated with high morbidity. The advent of video-assisted thoracoscopic surgery has given a valuable alternative to conventional thoracotomy with minimal morbidity. The use of thoracoscopy for the treatment of spinal disorders has been applied mostly in adults. However, thoracoscopic decompression of spinal tuberculosis in children has probably been rarely documented. The authors therefore, report their experience with video-assisted thoracoscopic anterior surgery (VATS) combined with posterior instrumentation in treatment of thoracic spinal tuberculosis.
Patient Population After the Institutional Review Board approval, from January 2002 to December 2006, 15 consecutive children with single-level (no skip lesion) thoracic with spinal tuberculosis were enrolled in the study. There were nine males and six females. The mean age at the time of diagnosis and treatment initiation was 11.6 years (range, 8–15 y). All patients included in the study had thoracic kyphosis below 60 degrees. The average preoperative kyphosis was 37 degrees (range, 23–59 degrees). The classification of Frankel et al was used to assess the recovery of spinal cord function: type A, complete loss, complete loss of motor and sensory function below the segmental level of the cord lesion; type B, sensory only, some sensation below the level of the lesion, but complete motor paralysis; type C, motor useless, some motor powers present below the lesion, but not sufficient to be of practical use; type D, motor useful, useful motor power below the level of the lesion; and type E, intact, no neurological deficit or symptoms. Preoperative neurological status was Frankel et al7 grade A in two patients, grade B in four patients, grade C in three patients, grade D in four patients, and grade E in two patients (►Table 1; ►Figs. 1 and 2).
Zheng et al. Table 1 Preoperative and postoperative neurological status. Case
Preoperative
Postoperative
1
A
D
2
E
E
3
B
C
4
B
D
5
C
D
6
D
E
7
D
E
8
A
D
9
E
E
10
D
E
11
C
D
12
D
E
13
C
E
14
B
E
15
B
D
Note: The classification of Frankel et al7 was used to assess the recovery of spinal cord function: type A, complete loss, complete loss of motor and sensory function below the segmental level of the cord lesion; type B, sensory only, some sensation below the level of the lesion, but complete motor paralysis; type C, motor useless, some motor powers present below the lesion, but not sufficient to be of practical use; type D, motor useful, useful motor power below the level of the lesion; and type E, intact, no neurological deficit or symptoms.
Pathological evaluation revealed typical caseating necrosis and granulomatous formation in all patients. Acid-fast stains from the local lesion sites for the mycobacterium were positive in seven patients.
Operative The new surgery and its possible complications were explained in detail to patients and their parents. They were also told that an open thoracotomy may be performed if complications occur during VATS. Consent for conversion to open
Preoperative All 15 patients were admitted due to severe back pain or paraparesis, with mean symptom duration of 4.24 months (range, 1–6 mo). All patients received our first-line antitubercular drugs (i.e., isoniazid, rifampicin, ethambutol, and pyrazinamide) for 4 to 12 weeks before the operation and bed rest for at least 3 weeks before surgery. Surgery was planned only if there was no evidence of recovery. The angle of kyphosis was measured on lateral radiographs by drawing a line on the upper surface of the first normal vertebra above the lesion and one through the lower surface of the first normal vertebra below the lesion. Intraoperative specimens taken from the lesion site revealed tuberculous spondylitis by histological analysis or a positive acid-fast stain in all patients. European Journal of Pediatric Surgery
Vol. 24
No. 1/2014
Fig. 1 Anteroposterior and lateral radiographs of the spine showing destruction of T8–9 vertebrae and paraspinal abscess.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
84
Fig. 2 Magnetic resonance image showing destruction of T8–9 vertebrae and paraspinal abscess.
thoracotomy, if necessary, was obtained from all the patients or parents as appropriate. Patients who had obvious respiratory insufficiency, significant pleural adhesions, and those with the likely inability to tolerate single lung ventilation were not included in the study. Under general anesthesia, the anesthetist used a double-lumen tube for intubation, and the patient was maintained on single lung ventilation. Open posterior instrumentation using a pedicle screw-rod construct was completed first. The portals for screw insertion were made carefully, with C-arm guidance using strict lateral views. Then thoracoscopic-assisted anterior debridement was accomplished with an iliac autograft applied between the vertebrae. The standard three-portal technique was used for abscess drainage and decompression. The spine was usually approached from the right side, depending on the radiological findings (i.e., bulk of abscess and destruction of body). In the upper thoracic vertebra (T2–5), trocar incision for operation was made in the intercostal space along the midaxillary line depending on the site of the lesion. A trocar incision for light was one intercostal space below the first incision. A trocar incision for suction was two intercostal spaces below the first incision. The two incisions were also along the midaxillary line. In the middle thoracic vertebra (T6–9), the trocar incision for operation was made in the intercostal space along the posterior axillary line depending on the site of the lesion. A trocar incision for light was two intercostal spaces above the first incision along the anterior axillary line. A trocar incision for suction was two intercostal spaces below the first incision along the anterior axillary. In the lower thoracic vertebra (T10–12), the trocar incision for operation was made in the intercostal space along the posterior axillary line depending on the site of the lesion. A trocar incision for light was two intercostal spaces above the first incision along midaxillary line. A trocar incision for suction was the same as the operation incision along the midaxillary line. The working portals were enlarged to 4 cm and used as extended manipulating channels. This facilitated the use of conventional spinal instruments for adequate decompression of the cord anterior and iliac grafts. The correct lesion site usually could be located directly but sometimes was covered by the visceral pleura
Zheng et al.
and required separation from any adhering tissue. The mediastinal pleura overlying the lesion was divided longitudinally. The intercostal arteries and veins were ligated. Specimens for acid-fast stain were obtained. The abscess was drained, curetted, and a partial excision of the involved adjacent vertebral body was performed using conventional rongeurs and curettes. The decompressive procedure was performed down to the epidural space and guided with video assistance. The interbody fusion technique was initiated using an iliac autograft applied between the vertebrae by means of an elongated bone impactor. The vertical titanium mesh body was placed for anterior column reconstruction. A chest radiograph was taken immediately after the operation to ensure a fully inflated lung. The average operative time was 237 minutes (range, 153–341 min). As expected, the operative time for each procedure was longer initially and decreased with experience. The average blood loss was 360 mL (range, 200–780 mL) and increased with the operative time. The average postoperative stay was 7 days (range, 5–12 d).
Postoperative The intercostal water-sealed drain in situ allowed for early lung expansion and minimized atelectasis. The intercostal drain was usually removed after 72 hours. All patients were treated with an antituberculous chemotherapy regimen for 12 to 15 months. The usual regimen followed was four drug chemotherapy (rifampicin, isoniazid, ethambutol, and pyrazinamide) for 8 weeks followed by three drugs (rifampicin, isoniazid, and ethambutol) for 6 weeks and two drugs (rifampicin and isoniazid) for the rest of the period. Liver functions and sedimentation rates were monitored carefully at regular intervals.
Result All cases were followed up with an average of 37.3 months (range, 12–48 mo). The wounds were healed without chronic infection, sinus formation, or anterior solid fusion between vertebrae. All patients achieved fusion, and there was no recurrence of the disease in any of the patients at the last follow-up (►Fig. 3).
Neurological Status The classification by Frankel et al7 was used to assess the recovery of spinal cord function. Four patients improved three grades, two patients improved two grades, and seven patients improved one grade (►Table 1). The average neurological recovery in the patients was 1.44 grades on the scale by Frankel et al.
Deformity The average preoperative kyphosis was 37 degrees (range, 23–59 degrees) and the average postoperative kyphosis was 25 degrees (range, 18–35 degrees) at final follow-up. At final follow-up, minimal progression of kyphosis was seen, with an average kyphosis of 28 degrees (range, 20–40 degrees). An average loss of correction of 3 degree was seen at final follow-up. European Journal of Pediatric Surgery
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VATS Combined Posterior Instrumentation for Children
VATS Combined Posterior Instrumentation for Children
Fig. 3 Lateral radiographs of the spine at 1-year follow-up.
Complications Postoperative complications occurred in three patients. Two had prolonged intercostal a drainage tube in situ for 5 days due to a persistent air leak, which resolved without any further intervention. Pneumonitis occurred in one patient, but this responded well to antibiotics. No intercostal neuralgia occurred in the patients and there were no mortalities.
Discussion Tuberculosis is a reemerging infectious disease. Tuberculosis of the musculoskeletal system is a secondary form of tuberculosis, resulting from a secondary spread of bacilli from a primary focus. The spine constitutes almost 50% of the total number of cases of osteoarticular tuberculosis.8 It frequently causes neurological deficit, kyphotic deformity, and even paraplegia. The thoracic regions are most commonly affected in spinal TB15. Spinal tuberculosis continues to be a scourge in the developing world. It is considered a leading cause of paraplegia and carries significant morbidity.9,10 Chemotherapy is important for children with tuberculosis. Therapeutic options include chemotherapy alone or in combination with surgery. There is a role for treatment of spinal tuberculosis with chemotherapy alone with or without immobilization. Chemotherapy even in radical surgery is the basic treatment of spine tuberculosis. Prolonged administraEuropean Journal of Pediatric Surgery
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Zheng et al. tion is necessary to prevent subsequent relapse of the tuberculous process, which is otherwise a frequent occurrence.11 Indications for surgery includes neurological deficits, spinal instability, severe and progressive kyphosis, no response to chemotherapeutic treatment, nondiagnostic biopsy, and large paraspinal abscess.9,10 The spinal cord is compressed by tubercular pathology, such as inflammatory focus, debris, and caseation from the anterior aspect. Therefore, the logical method to adequately decompress the spinal cord is through the anterior approach. Radical anterior surgery led to complete neurological recovery in the majority of cases.11 Surgical treatment of tuberculosis of the spine remains controversial. Indications for surgery vary from one center to another.9,11–13 There is a wide spectrum of treatment options available for children with tuberculosis. A judicious use of conservative therapy and operative decompression when indicated is the usual approach. For spinal tuberculosis, adequate debridement, decompression, and anterior graft placement can be achieved by either anterolateral decompression or the transpleural transthoracic approach.14,15 Both approaches have significant morbidity and even mortality.16 The role of VATS of the spine was established nearly a decade ago.17 The procedure has been used mainly in adults. Perhaps there are few reports in the literature on thoracoscopic decompression of spinal tuberculosis in children.13–15,22 Traditional surgery for children with spinal tuberculosis often involves a large surgical incision, cutting the multimuscle, and resection of one or two ribs. After surgery, patients often show intense wound pain, slow recovery, complications, long hospital stays, and large amount of bleeding. VATS is able to achieve adequate decompression. Despite a rather long learning curve expected for a minimally invasive surgical procedure, we could achieve effective decompression of the spine and recovery. It avoids excessive procedure-related soft tissue trauma in patients and provides a good alternative to other treatment modalities. It is an effective, minimally invasive procedure for decompression of tubercular dorsal spondylitis. VATS for decompression of spinal tuberculosis leads to decreased perioperative morbidity, and reduced analgesic and homologous blood requirements, compared with the open thoracotomy procedure. Landreneau et al18 found that many patients undergoing open thoracotomy required adjunctive pain control measures, such as intercostal block and epidural analgesia, in addition to injectable analgesic. VATS for decompression of spinal tuberculosis allows early discharge of the patient from the hospital and, cosmetically, a more acceptable surgical scar result. Lesions involving the anterior spinal column, from T2 to L1, can be managed by this technique.19 However; thoracoscopy is not indicated for all patients. The contraindications for this technique are patients’ intolerance to one lung ventilation intraoperatively or severe pleural adhesions caused by the lesion or previous surgery. It used a minimally invasive procedure with VATS whose effect is similar to VATS. By avoiding extensive muscle dissection and rib resection, thoracoscopy allows decreased postoperative pain and narcotic requirements when compared with open thoracotomy. This may improve postoperative pulmonary function.
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Conflict of Interest None.
2 Rajasekaran S. The natural history of post-tubercular kyphosis in
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prospects for control. Semin Respir Crit Care Med 2008;29(5): 481–491
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children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br 2001;83(7):954–962 Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T. Morphological changes during growth in healed childhood spinal tuberculosis: a 15-year prospective study of 61 children treated with ambulatory chemotherapy. J Pediatr Orthop 2006;26(6):716–724 Salazar GE, Schmitz TL, Cama R, et al; Working Group on TB in Peru. Pulmonary tuberculosis in children in a developing country. Pediatrics 2001;108(2):448–453 Teo HE, Peh WC. Skeletal tuberculosis in children. Pediatr Radiol 2004;34(11):853–860 Hodgson AR, Stock FE. Anterior spine fusion for the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first 100 cases. J Bone Joint Surg Am 1960;42: 295–310 Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969;7(3): 179–192 Mehta JB, Emery MW, Girish M, Byrd RP Jr, Roy TM. Atypical Pott’s disease: localized infection of the thoracic spine due to Mycobacterium avium-intracellulare in a patient without human immunodeficiency virus infection. South Med J 2003;96(7):685–688 Jain AK, Dhammi IK. Tuberculosis of the spine: a review. Clin Orthop Relat Res 2007;460:39–49 Tuli SM. Tuberculosis of the spine: a historical review. Clin Orthop Relat Res 2007;460:29–38 Moon MS, Moon YW, Moon JL, Kim SS, Sun DH. Conservative treatment of tuberculosis of the lumbar and lumbosacral spine. Clin Orthop Relat Res 2002;398(398):40–49 Boachie-Adjei O, Squillante RG. Tuberculosis of the spine. Orthop Clin North Am 1996;27(1):95–103 Yilmaz C, Selek HY, Gürkan I, Erdemli B, Korkusuz Z. Anterior instrumentation for the treatment of spinal tuberculosis. J Bone Joint Surg Am 1999;81(9):1261–1267 Chacko AG, Moorthy RK, Chandy MJ. The transpedicular approach in the management of thoracic spine tuberculosis: a short-term follow up study. Spine 2004;29(17):E363–E367 Zhao J, Lian XF, Hou TS, Ma H, Chen ZM. Anterior debridement and bone grafting of spinal tuberculosis with one-stage instrumentation anteriorly or posteriorly. Int Orthop 2007;31(6):859–863 A five-year assessment of controlled trials of in-patient and outpatient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Fifth report of the Medical Research Council Working Party on tuberculosis of the spine. J Bone Joint Surg Br 1976;58-B(4):399–411 Mangione P, Vadier F, Sénégas J. Thoracoscopy versus thoracotomy in spinal surgery: comparison of 2 paired series [in French]. Rev Chir Orthop Repar Appar Mot 1999;85(6):574–580 Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative painrelated morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56(6):1285–1289 Kapoor SK, Agarwal PN, Jain BK Jr, Kumar R. Video-assisted thoracoscopic decompression of tubercular spondylitis: clinical evaluation. Spine 2005;30(20):E605–E610 Jain AK, Aggarwal PK, Arora A, Singh S. Behaviour of the kyphotic angle in spinal tuberculosis. Int Orthop 2004;28(2):110–114 Oga M, Arizono T, Takasita M, Sugioka Y. Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine 1993;18(13):1890–1894 Jin D, Qu D, Chen J, Zhang H. One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J 2004;13 (2):114–121
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Although, the injury to the chest wall is less, thoracoscopy affords the same surgery on the spine as does open thoracotomy. In children, the small chest cavity, narrow rib spacing, and reduced working distance to the spine create additional technical challenges for the thoracoscope. Despite the decreased working space within the chest, anterior thoracoscopic surgery for spinal release and fusion can be performed as safely in children. In the upper thoracic vertebra (T2–5), the trocar incision for operation must be made in the midaxillary line as the scapula block the operations along the posterior axillary line. But for the middle thoracic vertebra (T6–9), the trocar incision for operation was made in the intercostal space along the posterior axillary line. The incision can be nearer to the site of the lesion. Surgical instruments reached the site of the lesion simply and safely. The trocar incision for light and suction along the anterior axillary facilitated lighting. To avoid the diaphragm movement, the trocar incision for operation was made along the posterior axillary line and the trocar incision for light and suction along the midaxillary line for the lower thoracic vertebra. Posterior instrumentation can effectively prevent the excessive growth of the posterior column in children.20 Posterior instrumentation surgery was not a hazard to spinal tuberculosis infection. The adherence property of Mycobacterium tuberculosis to stainless steel was evaluated experimentally.21 Posterior instrumentation was away from the lesion as it can reduce the possibility of infection. Posterior instrumental stabilization and anterior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis, and correcting the kyphosis. There were no cases of persistence or recurrence of infection after surgery, and the instrumentation provided immediate stability and protected against development of kyphotic deformity.13,22 Many factors determined such a just passable repair of neurological function, the long-term compression of the spinal cord resulting from the delay of diagnosis and surgery, no doubt, was the supreme one. It is important for children to have early diagnosis and early therapy to prevent the spinal tuberculosis. In conclusion, for children with tuberculosis, systemic antituberculosis chemotherapy was the cornerstone, followed in order by tuberculous focus clearance as second, third spinal fusion by bone grafting, and fourth kyphosis correction. VATS for children with spinal tuberculosis combined with posterior instrumentation in treatment of thoracic spinal tuberculosis was feasible and effective.
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