Osman GÜVEN, MURAT BEZER, NURİ AYDIN, İsmail Emre KETENCİ

Tüberküloz spondilitinde tedavi stratejisi: 55 hastanın uzun dönem takip sonuçları

Amaç: Bu çalışmada, tüberküloz spondiliti tedavisinde erişkin hastalarda kullandığımız algoritma, hastaların uzun dönem takip sonuçlarıyla birlikte değerlendirildi. Çalışma planı: Tüberküloz spondiliti tanısı konan 55 erişkin hasta (26 erkek, 29 kadın; ort. yaş 50; dağılım 23-71) çalışmaya alındı. Hastalar dört ayrı tedavi grubunda değerlendirildi. Altı hastada cerrahi olmayan (CO) tedavi uygulanırken, 21 hastada posterior debridmanla (PDEF), 17 hastada anterior debridmanla (ADEF) enstrümantasyonlu füzyon uygulandı. On bir hastaya maddi yetersizlik nedeniyle enstrümantasyonsuz acil radikal debridman (RD) uygulandı. Antitüberküloz tedavi tüm gruplarda 12 ay sürdürüldü. Başvuru sırasında 17 hastada (%30.9) nörolojik defisit vardı. Bu hastalar ADEF (n=6) ve RD (n=11) gruplarındaydı. Nörolojik değerlendirmede Frankel skoru kullanıldı. Hastalar kifoz, sagital denge, nörolojik iyileşme ve ameliyattan memnuniyet düzeyi açısından değerlendirildi. Ortalama takip süresi 95.3 ay (dağılım 66-144 ay) idi. Sonuçlar: Tüm hastalarda radyografik olarak başarılı kemik füzyonu sağlandı. Tedaviden hemen sonra tüm cerrahi gruplarında kifoz açısında gerileme görüldü. Ortalama düzelme miktarı ADEF (17.5°) ve PDEF (12.1°) gruplarında RD (4.9°) grubuna göre anlamlı derecede fazla idi (p

Anahtar Kelimeler:

İzleme çalışmaları, Omurilik füzyonu, Tüberküloz, spinal, Debridman, Kifoz, Spondilit, Tedavi sonucu, Hasta memnuniyeti, Hasta seçimi

Treatment strategy in tuberculous spondylitis: Long-term follow-up results of 55 patients

Objectives: We evaluated our treatment algorithm used in adult patients with tuberculous spondylitis together with long-term treatment results. Methods: The study included 55 adult patients (26 males, 29 females; mean age 50 years; range 23 to 71 years) with tuberculous spondylitis. The patients underwent four different treatment methods including non-operative treatment (NO, 6 patients), posterior debridement, fusion and instrumentation (PDFI, 21 patients), anterior debridement, instrumentation and fusion (ADIF, 21 patients), and finally, urgent radical debridement (RD, 11 patients) due to financial limitations of the patients. All the patients received antituberculous therapy for 12 months. On presentation, 17 patients (30.9%) had neurologic deficits (ADIF, 6 patients; RD, 11 patients). Neurologic assessment was made according to the Frankel grading system. The results were evaluated with respect to kyphosis, sagittal balance, neurologic recovery, and patient satisfaction. The mean follow-up period was 95.3 months (range 66 to 114 months). Results: Radiographically, successful bone fusion was achieved in all the patients. Following treatment, all surgically treated groups exhibited decreases in the kyphotic angle. The mean correction was significantly greater in ADIF (17.5°) and PDFI (12.1°) groups compared to the RD group (4.9°) (p<0.05). Final increases in the kyphotic angle were 0.7°, 1.2°, 1.4°, and 1.6° in NO, PDFI, ADIF, and RD groups, respectively. The mean sagittal deviations in the first postoperative month were +2 mm, +11 mm, +12 mm, and +14 mm in NO, PDFI, ADIF, and RD groups, respectively, which remained unchanged till the end of follow-up. Complete neurologic recovery was obtained in all but one patient. All the patients expressed satisfaction with the treatment. No recurrences or reactivation of disease were observed. Conclusion: This study showed that, with appropriate patient selection, the results of NO, PDFI, and ADIF were satisfactory and comparable.

Keywords:

Follow-Up Studies, Spinal Fusion, Tuberculosis, Spinal, Debridement, Kyphosis, Spondylitis, Treatment Outcome, Patient Satisfaction, Patient Selection,

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1. Ghadouane M, Elmansari O, Bousalmame N, Lezrek K, Aouam H, Moulay I. Role of surgery in the treatment of Pott’s disease in adults. Apropos of 29 cases. Rev Chir Orthop Reparatrice Appar Mot 1996;82:620-8. [Abstract]
2. Hsu LC, Leong JC. Tuberculosis of the spine. In: Evarts CM, editor. Surgery of the musculoskeletal system. 2nd ed. New York: Churchill Livingstone; 1990. p. 2299-314.
3. A 10-year assessment of controlled trials of inpatient 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. Ninth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg [Br] 1985;67:103-10.
4. Boachie-Adjei O, Squillante RG. Tuberculosis of the spine. Orthop Clin North Am 1996;27:95-103.
5. Pszolla N, Strecker W, Hartwig E, Kinzl L. Tuberculous spondylitis of the cervical spine. Unfallchirurg 2000;103: 322-5. [Abstract]
6. Travlos J, du Toit G. Spinal tuberculosis: beware the posterior elements. J Bone Joint Surg [Br] 1990;72:722-3.
7. Dove J. Luque segmental spinal instrumentation: the use of the Hartshill rectangle. Orthopedics 1987;10:955-61.
8. Upadhyay SS, Saji MJ, Sell P, Sell B, Hsu LC. Spinal deformity after childhood surgery for tuberculosis of the spine. A comparison of radical surgery and debridement. J Bone Joint Surg [Br] 1994;76:91-8.
9. Guven O, Kumano K, Yalcin S, Karahan M, Tsuji S. A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of spinal tuberculosis. Spine 1994;19:1039-43.
10. Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine 1997;22:1791-7.
11. Moon MS. Combined posterior instrumentation and anterior interbody fusion for active tuberculous kyphosis of the thoraco-lumbar spine. Curr Orthop 1991;5:177-9.
12. Moon MS, Woo YK, Lee KS, Ha KY, Kim SS, Sun DH. Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines. Spine 1995;20:1910-6.
13. Rajasekaran S. The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity. J Bone Joint Surg [Br] 2001;83:954-62.
14. Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg [Am] 1989;71:1314-23.
15. Tuli SM. Results of treatment of spinal tuberculosis by “middle- path” regime. J Bone Joint Surg [Br] 1975;57:13-23.
16. Tuli SM. Severe kyphotic deformity in tuberculosis of the spine. Int Orthop 1995;19:327-31.
17. Guven O, Yalcin S, Karahan M, Esemenli T. Transpedicular drainage of Pott’s abscess. A report of two cases. Am J Orthop 1995;24:421-5.
18. Morscher E, Dick W, Ruckstuhl J, Schuman L, Wolff G. Surgical interventions on the vertebral bodies of the thoracic spine. Arch Orthop Unfallchir 1977;87:185-201. [Abstract]
19. Lee TC, Lu K, Yang LC, Huang HY, Liang CL. Transpedicular instrumentation as an adjunct in the treatment of thoracolumbar and lumbar spine tuberculosis with early stage bone destruction. J Neurosurg 1999;91(2 Suppl):163-9.
20. Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969;7:179-92.
21. Rajasekaran S, Shanmugasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty DK. Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy. Spine 1998;23:1163-7.
22. Garst RJ. Tuberculosis of the spine: a review of 236 operated cases in an underdeveloped region from 1954 to 1964. J Spinal Disord 1992;5:286-300.
23. Tibau R, Fuster S, Auleda J, Ubierna MT, Roca J, Alemany X, et al. Tuberculosis of the neural arch. A report of four cases. Int Orthop 1994;18:119-21.
24. Altman GT, Altman DT, Frankovitch KF. Anterior and posterior fusion for children with tuberculosis of the spine. Clin Orthop Relat Res 1996;(325):225-31.
25. Mukhtar AM, Farghaly MM, Ahmed SH. Surgical treatment of thoracic and lumbar tuberculosis by anterior interbody fusion and posterior instrumentation. Med Princ Pract 2003;12:92-6.
26. Sundararaj GD, Behera S, Ravi V, Venkatesh K, Cherian VM, Lee V. Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine. J Bone Joint Surg [Br] 2003;85:100-6.
27. Chen WJ, Wu CC, Jung CH, Chen LH, Niu CC, Lai PL. Combined anterior and posterior surgeries in the treatment of spinal tuberculous spondylitis. Clin Orthop Relat Res 2002;(398):50-9.
28. Benli IT, Kis M, Akalin S, Citak M, Kanevetci S, Duman E. The results of anterior radical debridement and anterior instrumentation in Pott’s disease and comparison with other surgical techniques. Kobe J Med Sci 2000;46:39-68.
29. Upadhyay SS, Saji MJ, Sell P, Hsu LC, Yau AC. The effect of age on the change in deformity after anterior debridement surgery for tuberculosis of the spine. Spine 1996;21:2356-62.
30. Berven SH, Deviren V, Smith JA, Emami A, Hu SS, Bradford DS. Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy. Spine 2001;26:2036-43.
31. Klockner C, Valencia R. Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine 2003;28:1036-42.
32. Pattisson PR. Pott’s paraplegia: an account of the treatment of 89 consecutive patients. Paraplegia 1986;24:77-91.
33. Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg [Am] 1985;67:1405-13.
34. Vidyasagar C, Murthy HK. Spinal tuberculosis with neurological deficits. Natl Med J India 1996;9:25-7.
35. Moon MS, Ha KY, Sun DH, Moon JL, Moon YW, Chung JH. Pott’s Paraplegia-67 cases. Clin Orthop Relat Res 1996;(323):122-8.
36. Martin NS. Tuberculosis of the spine. A study of the results of treatment during the last twenty-five years. J Bone Joint Surg [Br] 1970;52:613-28.
37. Altman GT, Altman DT, Frankovitch KF. Anterior and posterior fusion for children with tuberculosis of the spine. Clin Orthop Relat Res 1996;(325):225-31.
38. Chen WJ, Chen CH, Shih CH. Surgical treatment of tuberculous spondylitis. 50 patients followed for 2-8 years. Acta Orthop Scand 1995;66:137-42.
39. Boachie-Adjei O, Squillante RG. Tuberculosis of the spine. Orthop Clin North Am 1996;27:95-103.
40. Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg 1995;83:243-7.