Decision Making and Outcome Analysis in the Surgical Management of Cervical Spine Tuberculosis

Baskaran, V (2020) Decision Making and Outcome Analysis in the Surgical Management of Cervical Spine Tuberculosis. Masters thesis, Madras Medical College, Chennai.


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BACKGROUND CONTEXT: Cervical spine tuberculosis (TB) is uncommon, accounting for 3% to 5% of spinal TB. Although the development of anti-TB chemotherapy decreased the mortality rate significantly, it may not be applicable for all situations, especially for those with risk of instability, progression of neurologic deficit, and failure of medical treatment. PURPOSE OF THE STUDY: To analyse the outcome of surgical management of patients with cervical spine tuberculosis and to formulate the guidelines on decision making in the management of Cervical spine tuberculosis STUDY DESIGN: This is a retrospective and prospective study over a 7 year period consisting of patients admitted in the Ortho Spine Surgery Unit, Rajiv Gandhi Government General Hospital, Chennai. PATIENT SAMPLE: This study consists of 22 patients (12 males and 10 females; average age, 39 years) with cervical spine tuberculosis who were managed surgically of which 15 patients had regular follow up. Four patients died of non-tuberculous cause during the study period and the remaining three patients were not traceable. The patients in this study were grouped based upon the site of lesion as 1. Atlantoaxial CSTB 2. Subaxial CSTB and 3. Junctional CSTB. Atlantoaxial CSTB: All atlantoaxial tuberculosis patients were managed by posterior approach only after ascertaining that the lateral masses of C1 and pedicles of C2 were found to be intact by CT scan. In 2 patients with involvement of body of C2 vertebra, transoral core needle biopsy was done. In 1 patient through lateral retropharyngeal approach, the cold abscess was drained. In one patient, with involvement of C1 C2 articulations laterally, recon plate stabilisation of the joints was done using the anterior submandibular approach was done. Subaxial CSTB: Anterior cervical decompression, bone grafting and H-plate fixation was done in 5 patients. Iliac crest autograft was used in all these cases. Posterior stabilisation alone was done in 2 patients. Global stabilization (anterior and posterior) was done in 4 patients. Junctional CSTB: Out of 4 patients, posterior stabilization alone was done in 2 patients. In 2 other patients, Global stabilization (anterior and posterior) was done. The average follow-up period was 34.1 months (range 9-70 months). OUTCOME MEASURES: The clinical outcomes of infection activity, deformity, pain, and neurologic recovery were evaluated using erythrocyte sedimentation rate(ESR) value and C-reactive protein (CRP) value, kyphotic angle(), visual analog scale (VAS) pain score, and ASIA scale, respectively. RESULTS: VAS scores dramatically decreased from a mean preoperative score of 7.86 to a mean score of 1.86 at the final follow up. Before surgery detailed neurological examination revealed that there were six patients with grade B, twelve patients with grade C, 3 with grade D, and one with grade E. During the last follow-up examination in 15 patients, 3 patients improved one grade, nine patients improved two grades, two patient improved three grades. Stable bone union was observed in 13 patients (59%) out of 15 patients with complete follow up and the average time required for fusion was 7 months. The kyphosis Cobb angle improved from the preoperative average of 17.65 (range 7.45 to 27.41) to a postoperative average of -0.9 (range -4 to 4) and at the final follow up average of 1.3 (range -2 to 10).There was no significant correction loss during the follow-up period. During the follow-up period, there were no grafts or instrumentation-related stabilization problems. There was no other recurrence of TB infection. CONCLUSION: Most of the atlanto-axial CSTB can be effectively managed by posterior approach alone. Transoral core needle biopsy may be utilized in procuring tissue for the diagnosis of upper CSTB. Approach to the management of sub-axial CSTB is based upon the extend of the disease process as evidenced by vertebral body destruction and the degree of kyphosis. Junctional cervicothoracic spinal tuberculosis due to the biomechanical factors involved and complex anatomy global stabilization and fusion is required as a routine. The duration of administration of anti-tuberculous treatment was around 9 – 12 months, based upon the response to treatment which is gauged by blood investigation (ESR, CRP) and detailed clinic-radiological evaluation.

Item Type: Thesis (Masters)
Additional Information: 221712002
Uncontrolled Keywords: Decision Making, Outcome Analysis, Surgical Management, Cervical Spine Tuberculosis.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 13 Feb 2021 11:59
Last Modified: 13 Feb 2021 11:59

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