A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of
Master of Medicine in Orthopaedic Surgery
Johannesburg, 2017 / Background: The anterolateral approach to the spine for the surgical management of the Tuberculosis of the spine has been described. The surgical technique has evolved since the gold standard published by Hodgson et al. in 1956. The use of a Titanium Mesh Cage and the anterior instrumentation to construct the anterior column after adequate debridement defined the evolution. The aim of the study is to review the results of the patients that underwent this procedure between January 2012 and December 2015.
Methods: The study was a retrospective study where 60 patients treated with this technique from 2012 – 2015 were reviewed. Sixty-one percent (61%) of the tested patients were HIV positive and 70.4% of the patients were female in the age group of 31-45 years. The surgical procedure was standardised for all the patients irrespective of their HIV status. The clinical and radiological outcomes measured consisted of the patients’ disability using the Oswestry Disability Index (ODI), the Frankel Neurological grading to measure neurological deficits and the Cobb angle to measure Kyphosis. The diagnosis of Tuberculosis of the Spine was confirmed in all the patients.
Results: At a mean follow up period of 21.25 months, the ODI improved from a mean of 95.42% ± 6.57% before surgery to a mean of 8.00% ± 12.15% at the last follow up. There were 58 patients who were unable to walk independently before the surgery (Frankel A or B) but at the last follow up, 52 of the patients had achieved independent ambulation (Frankel D or E). The mean kyphosis was 33.90 ± 12.44 degrees before surgery, and in the immediate post-operative period, the mean kyphosis was 23.69 ± 10.31 degrees, and a mean of 26.27 ± 10.91 degrees was measured at the last follow up. There was a 30.12% correction achieved in the immediate post-operative period and an overall correction of 22.51% at the last follow up reflecting a loss of 7.61% in the kyphosis correction in the period between the immediate post-operative period and the last follow up. Complications were documented in six patients including two deaths unrelated to the procedure.
Discussion: The ODI score showed an improvement as the mean value decreased by 87.42%. This is statistically and clinically significant (p=0.001). According to the work of Solberg et al. (2013) in degenerative spine, the threshold for a success is a mean change of 20% in the
ODI scoring after lumbar disc surgery. Using this value as a proxy, an improvement of 87.42% is an excellent outcome.
Before surgery, fifty-eight patients (96.7%) were non-ambulatory using the Frankel Neurological score. At the last follow up, 53 patients (91.4%) achieved a Frankel score of D or E and independent ambulation. This outcome compares favourably with ones published in the literature.
The overall post-operative kyphosis correction achieved was 26.27 degrees (which translated to 22.51% correction) at the last follow up. This reflects a kyphosis correction loss of 7.61% that was not associated with any neurological deterioration and is therefore of no clinical significance. There were six cases of complications including two deaths unrelated to the procedure but the general debilitation of military Tuberculosis and Nosocomial infection.
Conclusion: The anterior column reconstruction using the Titanium Mesh Cage and Anterior Instrumentation is safe and effective for the surgical management of the Tuberculosis of the Spine. There were good clinical outcomes as measured by the ODI score and the Frankel Neurological Grading system, and even though there was a loss of Kyphosis correction at the last follow up, this was not associated with a negative neurological outcome.
Despite its limitation as a retrospective study, this study demonstrates that the procedure is safe and effective when used as an adjunct to the medical treatment of the Tuberculosis of the Spine. / MT2017
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/23350 |
| Date | January 2017 |
| Creators | Akinjolire, Akinwande |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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