Freehand Pedicle Screw Insertion in Spondylitis Tuberculosis Kyphosis Correction Using Cantilever Method: A Breach Rate Analysis of 168 Consecutive Screws (original) (raw)
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Orthopedic Research and Reviews
Background: Kyphosis in spondylitis tuberculosis (STb) is more than just a cosmetic issue. It has a potentially detrimental effect on both spine-associated structures and cardiopulmonary function. It can be corrected in any stage of STb; however, the corrective surgery is challenging, especially in the late case, in which the additional stiffness of the spine can come into consideration. To date, the cantilever technique is still a gold standard for sagittal plane deformity correction. However, no study to date has explored its effectiveness for thoracolumbar kyphotic deformity, especially that caused by spondylitis tuberculosis. Methods: This is a retrospective study of 16 consecutive cases of spondylitis tuberculosis with thoracolumbar kyphosis that underwent corrective surgery in our center in the period of 2020-2021. We aim to evaluate the effectiveness of the cantilever technique that we use for kyphotic correction in thoracolumbar STb patients. Results: At the 3-months follow-up, the mean Cobb angle was 14.6°±10.27°, with the mean gain of 20.90°±12.00° and positively correlate with the thoracolumbar kyphosis (TLK) correction (68.69%, r = 0.654, p = 0.001). The mean thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were 30.6°±13.08°, 39.4°±16.02°, and 1.4±4.09 cm, respectively, with sagittal Cobb difference of 12.70±9.85. Conclusion: The kyphotic Cobb angle reduction by cantilever technique in the thoracolumbar area significantly improved the thoracolumbar kyphosis and realign the spinal sagittal axis. Thus, the cantilever technique remains the gold standard for sagittal plane deformity correction which can be applied for kyphotic deformity correction in thoracolumbar STb cases.
Anterior debridement, strut grafting and instrumentation have an increasing popularity in the treatment of tuberculosis of spine. Anterior fixation can be done either by a plate or a rod system. This study reports on the surgical results of 59 patients with Pott's disease that had anterior radical debridement and anterior fusion and anterior instrumentation with 5 years follow-up. Average age at the time of operation was 46.3 ± 13.5 years. Average follow-up was 84.6 ± 11.3 months. Local kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at the last follow-up visit. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed in MR images. The indication for surgery was either one of the deformity, instability or neurological compromise. Surgical treatment included anterior radical debridement followed by grafting with tricortical auto graft and anterior instrumentation at levels just above and below the diseased segment(s) with either plate (Sofamor-Danek, Z plate, Group A) or rod (Sofamor-Danek, CDH, Group B) systems. There were 23 patients in group A and 36 patients in group B. All patients had similar anti tuberculosis chemotherapy. Patients had similar rehabilitation program after the surgery. The deformity in the sagittal and the coronal plane was measured and presence of significant consolidation, along with the absence of implant failure or correction loss was considered as signs of fusion. The two groups were similar according to age (46.9±14.2 vs. 45.8±13.1), gender, average number of involved levels (1.8±0.5 vs. 1.6± 0.5), location of involved levels, severity of deformity (21.5°± 9.9º vs. 24.8°± 11.9º) and type of autografts (p>0.05 for all parameters). 39.1 % of patients in group A and 41.6 % of patients in group B had neurological compromise with improvement in majority at the end of follow-up. Deformities were corrected to 5.2°±5.7º in group A and 6.1°±6.8º in group B with no significant difference. At the time of latest follow-up there were 1.7°±2.0º correction loss in group A and 1.4°±1.9º in group B with no significant difference in between two groups (p>0.05). Overall, it was observed that, the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (78.5 ± 20.5 %), and was effective in maintaining it with an average İ. T. BENLİ et al. 168 loss of 1.5° ± 1.9°. Of the 24 (44.1 %) patients with neurological symptoms, 20 (83.3 %) had full and 4 (16.7 %) partial recoveries. There was no apparent pseudoarthrosis and implant failure in both groups and all patients demonstrated clinical improvement in tuberculosis infection without recurrences and reactivation. Four major complications occurred in the group A (major vessel complication: 3.4 %, secondary non-specific infection: 3.4 %). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis. There were no significant differences between the two instrumentation systems in terms of sagittal alignment reconstruction and fusion rate. In rod-screw systems, the disadvantages of scoliotic deformity correction through frontal plan in plate performing did not occur and it is though to have the advantage of long instrumentation in multiple level deformities.
European Spine Journal, 2010
We retrospectively studied the cases with tuberculous spondylitis of thoracolumbar region with two or more levels of involvement that underwent posterior instrumentation and fusion and anterior fusion with titanium mesh following anterior decompression using simultaneous successive posterior–anterior–posterior surgery. Among all patients with tuberculous spondylitis accompanied by medium or severe kyphosis, 20 patients who underwent simultaneous successive decompression, fusion and instrumentation with posterior–anterior–posterior surgery between 1999 and 2004 were included in the study. Patients were evaluated for fusion formation and neurological and functional status. Kyphosis angles were measured at early and long-term follow-up. Antituberculosis chemotherapy was initiated in all patients and continued for 9 months; initially as quadruple therapy for 3 months, and then as triple therapy. Average follow-up period was 52.7 months (range 37–94). Solid fusion was achieved in all patients. All patients returned to their previous occupation; 75% (15 subjects) with mild pain or no pain and 15% (3 subjects) with major limitations. There were 11 patients with neurological deficit, 9 of these achieved complete neurological recoveries. Regarding kyphosis angle, an average 35.1° correction (84.8%) was obtained in postoperative period (p < 0.001) and there was no significant correction loss during the follow-up period (p < 0.05). There were no grafts or instrumentation-related stabilization problems. In subjects with tuberculous spondylitis with involvements at two or more levels accompanied by medium and severe kyphosis, decompression, fusion and instrumentation by simultaneous successive posterior–anterior–posterior surgery is an effective and safe management method for effective kyphosis correction with high fusion rates.
Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis
European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2003
The conventional procedure in the treatment of vertebral tuberculosis is drainage of the abscess, curettage of the devitalized vertebra and application of an antituberculous chemotherapy regimen. Posterior instrumentation results are encouraging in the prevention or treatment of late kyphosis; however, a second-stage operation is needed. Recently, posterolateral or transpedicular drainage without anterior drainage or posterior instrumentation following anterior drainage in the same session has become the preferred treatment, in order that kyphotic deformity can be avoided. Information on the use of anterior instrumentation along with radical debridement and fusion is scarce. This study reports on the surgical results of 63 patients with Pott's disease who underwent anterior radical debridement with anterior fusion and anterior instrumentation (23 patients with Z-plate and 40 patients with CDH system). Average age at the time of operation was 46.8+/-13.4 years. Average duration o...
Anterior Instrumentation in Tuberculous Spondylitis
Clinical Orthopaedics & Related Research, 2007
Radical anterior débridement and strut grafting is the gold standard in the surgical treatment of tuberculosis spondylitis. For many years anterior instrumentation was avoided due to concerns about infection until recently. We investigated the effectiveness and safety of anterior instrumentation for different sites of involvement, number of involved levels, and different age groups in 100 consecutive patients (mean age, 44.3 ± 12.4). We measured preoperative, postoperative, and final kyphotic deformities radiographically and looked for the presence of fusion. Patients had a minimum followup of 3 years (average, 4.5 years; range, 3-6 years). Addition of anterior instrumentation was effective in the correction of kyphotic deformity (19.8°± 7.3°) and facilitated solid fusion, with an average loss of 1.6°± 1.8°. Of the 44 patients with neurologic symptoms, 40 (90.9%) achieved full and four (9.1%) achieved partial recovery. There were no apparent pseudarthroses and implant failures. All patients demonstrated clinical healing of tuberculosis without recurrence and reactivation. All domains of the SRS-22 questionnaire showed improvements at the last followup. Anterior instrumentation represents a safe and effective method for the treatment of tuberculosis spondylitis, and it may be the ideal stabilization method thanks to less segment fusion, single approach, and obviating the need for external immobilization. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
The role of debridement and reconstruction of sagittal balance in tuberculous spondylitis
Indian Journal of Orthopaedics, 2012
Background: An accepted comprehensive clinical approach to the deformed spine with tuberculous infection is still lacking. We aimed to determine the usage of a staged algorithm in the treatment of kyphotic spine with tuberculous infection and to present the clinical results of the patients treated with the help of this protocol. Materials and Methods: 54 patients (28 females, 26 males) with a mean age of 39.2 (22-76) years. Preoperative, early postoperative, and followup clinical and radiologic results were evaluated retrospectively. The patients were classified into Kaplan A (kyphotic deformity <30°), Kaplan B (kyphotic deformity 30°-60°) and Kaplan C (kyphotic deformity >60°). They were operated by posterior instrument with anterior debridment (Kaplan A), debridment with anterior bone grafting (Kaplan B) and anterior column resection and bone grafting in Kaplan C. Results: Tuberculous involvement were seen at more than one level in 40 patients and paraspinal abscess were detected in 31. Preoperative focal kyphotic deformity was reconstructed with an average of 19 (9-38) degrees. Twenty-six patients had neurologic compromise with different severities and 12 of them improved after the surgical intervention. Improvement in work ability and pain status was detected in 52% and 61% of the patients, respectively. Wound complications responding to medical care were detected in nine patients. Initial kyphotic deformity was found as an important parameter in selecting the surgical procedure. Conclusion: Regarding resected amount of infected osseous material, as planned preoperatively, have resulted with better concordance between anterior and posterior column heights and better sagittal alignment. We could correct kyphosis and improve sagittal balance with staged algorithm as used by us.
Outcome of minimally invasive surgery in the management of tuberculous spondylitis
Indian Journal of Orthopaedics, 2012
Introduction: With the advancement of instrumentation and minimally access techniques in the field of spine surgery, good surgical decompression and instrumentation can be done for tuberculous spondylitis with known advantage of MIS (minimally invasive surgery). The aim of this study was to assess the outcome of the minimally invasive techniques in the surgical treatment of patients with tuberculous spondylodiscitis. Materials and Methods: 23 patients (Group A) with a mean age 38.2 years with single-level spondylodiscitis between T4-T11 treated with video-assisted thoracoscopic surgery (VATS) involving anterior debridement and fusion and 15 patients (Group B) with a mean age of 32.5 years who underwent minimally invasive posterior pedicle screw instrumentation and mini open posterolateral debridement and fusion were included in study. The study was conducted from Mar 2003 to Dec 2009 duration. The indication of surgery was progressive neurological deficit and/or instability. The patients were evaluated for blood loss, duration of surgery, VAS scores, improvement in kyphosis, and fusion status. Improvement in neurology was documented and functional outcome was judged by oswestry disability index (ODI). Results: The mean blood loss in Group A (VATS category) was 780 ml (330-1180 ml) and the operative time averaged was 228 min (102-330 min). The average preoperative kyphosis in Group A was 38° which was corrected to 30°. Twenty-two patients who underwent VATS had good fusion (Grade I and Grade II) with failure of fusion in one. Complications occurred in seven patients who underwent VATS. The mean blood loss was 625 ml (350-800 ml) with an average duration of surgery of 255 min (180-345 min) in the percutaneous posterior instrumentation group (Group B). The average preoperative segmental (kyphosis) Cobb's angle of three patients with thoracic TB in Group B was 41.25° (28-48°), improved to 14.5°(11°-21°) in the immediate postoperative period (71.8% correction). The average preoperative segmental kyphosis in another 12 patients in Group B with lumbar tuberculosis of 20.25° improved to-12.08° of lordosis with 32.33° average correction of deformity. Good fusion (Grade I and Grade II) was achieved in 14 patients and Grade III fusion in 1 patient in Group B. One patient suffered with pseudoarthrosis/doubtful fusion with screw loosening in the percutaneous group. Conclusion: Good fusion rate with encouraging functional results can be obtained in caries spine with minimally invasive techniques with all the major advantages of a minimally invasive procedures including reduction in approach-related morbidity.
Asian Spine Journal, 2018
To detect the effect of cannulated (poly-axial head) and solid (mono-axial head) screws on the local kyphotic angle, vertebral body height, and superior and inferior angles between the screw and the rod in the surgical management of thoracolumbar fractures. Overview of Literature: Biomechanics studies showed that the ultimate load, yield strength, and cycles to failure were significantly lower with cannulated (poly-axial head) pedicle comparing to solid core (mono-axial head). Methods: The medical charts of patients with thoracolumbar fractures who underwent pedicle screw fixation with cannulated or solid pedicle screws were retrospectively reviewed; the subjects were followed up from January 2011 to December 2015. Results: Total 178 patients (average age, 36.1±12.4 years; men, 142 [84.3%]; women, 28 [15.7%]) with thoracolumbar fractures who underwent surgery and were followed up at Hamad Medical Corporation were classified, based on the screw type as those with cannulated screws and those with solid screws. The most commonly affected level was L1, followed by L2 and D12. Surgical correction of the local kyphotic angle was significantly different in the groups; however, there was no significant difference in the loss of correction of the local kyphotic angle of the groups. Surgical correction of the reduction in the vertebral body height showed statistical significance, while the average loss of correction in the reduction of the vertebral body height was not significantly different. The measurement of the angles made by the screws on the rods was not significantly different between the cannulated (poly-axial head) and solid (mono-axial head) screw groups. Conclusions: Solid screws were superior in terms of providing increased correction of the kyphotic angle and height of the fractured vertebra than the cannulated screws; however, no difference was noted between the screws in the maintenance of the superior and inferior angles of the screw with the rod.