UP-TO DATE REVIEW AND CASE REPORT

Extensive thoracolumbar spinal tuberculosis treatedwith two-stage surgery using a minimally invasive posteriorinstrumentation

Satoshi Kato • Norio Kawahara • Hideki Murakami • Satoru Demura •

Katsuhito Yoshioka • Yoshiyuki Okamoto • Katsuro Tomita • Hiroyuki Tsuchiya

Received: 27 July 2010 / Accepted: 29 October 2010 / Published online: 25 December 2010

� Springer-Verlag 2010

Abstract We report the case of extensive thoracolumbar

tuberculosis involving eight vertebral bodies, and successful

treatment by two-stage surgical procedure using a minimally

invasive posterior instrumentation. There have been few

reports about widespread spinal tuberculosis in recent years.

However tuberculosis is on the rise in the developed coun-

tries. This can be attributred to the increase in HIV and

immigration from countries where tuberculosis is common.

The patient was a 32-year-old female from one of the

developing countries with spinal tuberculosis of T7-L2. The

delay until diagnosis was about one year. Medical and con-

servative treatment for eighteen months was not effective to

her illness. Two-stage surgical treatment (first: anterior

debridement and bone graft; second: minimally invasive

posterior instrumentation) was performed. Anterior

debridement was adequately performed through the right

side thoracotomy at two site, and two weeks after the surgery,

posterior instrumentation without additional arthrodesis was

performed using a minimally invasive approach. Antitu-

berculous chemotherapy was continued for three months

after surgery. Three years after the surgeries, the patient is

now completely asymptomatic and has not had a recurrence.

The infected anterior site healed and bony fusion was suc-

cessfully achieved without kyphotic progression.

Keywords Spinal tuberculosis � Posterior

instrumentation � Two-stage surgery �Minimally invasive surgery

Introduction

The advances in antituberculous chemotherapy in the

1950s allowed the incidence of spinal tuberculosis to

become markedly lower in developed countries, so that

now it is less destructive. However, tuberculosis is on the

rise in the developed countries. This can be attributed to the

increase in HIV and immigration from countries where

tuberculosis is common [1, 2]. In this short communication,

we describe a young woman who had two-stage surgery

using a minimally invasive posterior instrumentation for

thoracolumbar spinal tuberculosis that involved eight ver-

tebral bodies.

Case report

This case relates to a 32-year-old woman from one of the

developing countries in Asia who had continuous back pain

from the time she had given birth to her first baby. It took

about 1 year to diagnose her illness as spinal tuberculosis,

and then she received, in her country, a combination of

multi-antituberculous chemotherapy along with hospital

rest. Her pain did not abate and spinal destruction gradually

advanced. She was introduced to our hospital 15 months

after the diagnosis. At that time, she was found to have a

moderate back pain without bladder bowel dysfunction or

neurological deficit of her lower extremities. In her

appearance, there was no apparent spinal deformity. Lab-

oratory findings showed that white blood cell count was

7,000/lL, C-reactive protein was 2.3 mg/dL, and erythro-

cyte sedimentation rate was 64 mm/h. Radiographs of her

chest showed no apparent sign of pulmonary tuberculosis,

but there were abnormal shadows on both sides of the

thoracic spine. Computed tomography (CT) and magnetic

S. Kato (&) � N. Kawahara � H. Murakami � S. Demura �K. Yoshioka � Y. Okamoto � K. Tomita � H. Tsuchiya

Department of Orthopaedic Surgery,

Kanazawa University School of Medicine,

13-1 Takara-machi, Kanazawa 920-8641, Japan

e-mail: skato323@gmail.com

123

Eur J Orthop Surg Traumatol (2011) 21:407–409

DOI 10.1007/s00590-010-0723-4

resonance imaging (MRI) of the thoracolumbar spine

revealed destructive changes from T7 to L2 vertebral

bodies; these are surrounded with paravertebral abscess

expanding down to L3 level (Fig. 1). The smear exami-

nation of the specimen harvested by CT-guided puncture of

the paravertebral abscess showed that acid-fast bacilli were

positive (Gaffky 2).

The patient was treated with rifampin, ethambutol, iso-

niazid and pyrazinamide for 3 months after admission to

our hospital. However, her pain and inflammatory signs in

laboratory examination did not improve. We planned a

two-stage surgical procedure (first procedure: anterior

debridement and bone graft, second procedure: posterior

instrumentation) for her extensive thoracolumbar spinal

tuberculosis.

At the first surgery, the patient was placed left side down

on the operation table. We planned the right thoracotomies

at two sites for adequate debridement of the extensive

lesion. The first thoracotomy was made through a wide

resection of the right sixth rib to debride the main spinal

lesion from T8 to T11. The spinal lesion was revealed as a

mixture of destructive and sclerotic lesions: there was no

large defect in the spinal lesion after debridement. By this

approach, the infected lesions from T7 to T11 levels were

debrided adequately. Next, the second thoracotomy was

made through a small resection of the right ninth rib. The

debridement through this approach covered the T12 to L2

levels, with a minimal cutting the diaphragma. Since there

was no large defect, it was not necessary to apply long struts

for bone graft to the spinal lesions. Therefore, short strut

bones and bone chips, made from resected ribs, were packed

into the defect of the spinal lesions after debridement.

Two weeks after the anterior surgery, posterior instru-

mentation was applied. The patient was placed in prone

position on the operation table. Small midline incisions were

made at T5–6 and L3–4 spinal levels, where we planned to

insert pedicle screws. Pedicle screws were inserted using a

paraspinal approach [3] with minimum invasion. Rods were

bent to accommodate her thoracolumbar curve. The rods

were inserted from the T5–6 levels to the L3–4 levels through

her back muscles under her skin without any difficulties, and

then the rods were fixed to the pedicle screws (Fig. 2). A hard

brace was applied for 3 months after surgery.

Antituberculous chemotherapy was continued for

3 months after surgery. Laboratory findings at 3 months

after surgery showed no evidence of inflammatory signs;

Fig. 1 Pre-operative computed tomography showing the destructive changes from T7 to L2 vertebral bodies surrounded with paravertebral

abscess. a Sagittal view. b Coronal view (enhanced). c Axial view at T10 level (enhanced)

Fig. 2 Post-operative radiograph showing posterior instrumentation

using pedicle screws in T5,6 and L3,4. a Anteroposterior view.

b Lateral view

408 Eur J Orthop Surg Traumatol (2011) 21:407–409

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white blood cell count was 5,000/lL, C-reactive protein

was 0.1 mg/dL, and erythrocyte sedimentation rate was

4 mm/h. Three years after surgery, the infected anterior site

healed and bony fusion was achieved (Fig. 3). Progression

of the kyphosis angle from T7 to L2 was 0.2 degree during

the follow-up period. The patient is now completely

asymptomatic without a brace and has not had a recur-

rence. No evidence of inflammatory signs has been

apparent in laboratory examination, since the antitubercu-

lous chemotherapy was finished.

Discussion

Spinal tuberculosis is not common in developed countries, so

much so that medical awareness of spinal tuberculosis has

lessened [4]. This situation can cause initial misdiagnosis or

delayed diagnosis [5], with resulting in severe destructive

changes. In the case presented here, the spinal tuberculosis

expanded due to the delayed diagnosis, and this resulted in

resistance to antituberculous chemotherapy which was the

mainstay of treatment of spinal tuberculosis [6, 7].

Some surgeons advocate a two-stage approach with an

instrumented posterior arthrodesis either preceded or fol-

lowed by anterior debridement and bone grafting [8–10].

Korovessis et al. [11] reported that radical debridement of

spinal infection and anterior insertion of titanium cage

secured with pedicle screw instrumentation had a beneficial

influence on the healing of infection, spinal reconstruction

and fusion. However, there is still a controversy with

regard to the treatment using metallic implants inside the

infectious lesion.

We use only posterior instrumentation outside the

infectious lesion, using pedicle screws in healthy vertebrae.

Posterior instrumentation was mostly used with posterior

arthrodesis in the literature [8–10]. In the case presented

here (a patient with a large infectious lesion involving eight

consecutive vertebrae), we performed supplementary pos-

terior instrumentation without arthrodesis after the anterior

debridement and bone graft to prevent aggressive thora-

columbar kyphotic progression. It was a minimally inva-

sive procedure which did not necessitate a large incision

from T5 to L4 level like a traditional instrumented pos-

terior arthrodesis, and the result proved satisfactory.

Conflict of interest No funds were received in support of this study.

No benefits in any form have been or will be received from a com-

mercial party related directly or indirectly to the subject of this

manuscript.

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Fig. 3 Radiograph and computed tomography 3 years after the

surgeries showing that the infected anterior site had healed, and bony

fusion was achieved. a Lateral view of radiograph. b Sagittal view of

computed tomography

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