Case report of tubercular spondylodiscitis with paraplegia managed by posterior transpedicular decompression and pedicle screw fixation

doi:10.4236/crcm.2013.25076

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Vol.2, No.5, 281-284 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.25076

Case report of tubercular spondylodiscitis with

paraplegia managed by posterior transpedicular

decompression and pedicle screw fixation*

Paragjyoti Gogoi1#, Anshuman Dutta1, Vikash Agarwala1, Prasant a Sonowal2

1Department of Orthopaedics & Trauma , Silchar Medic al College, Silchar, India; #Corresponding Author: [email protected]

2Department of Anaesthesiology, Silchar Medical College, Silchar, India

Received 20 May 2013; revised 21 June 2013; accepted 25 July 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Pott’s paraplegia is still prevalent in this part of

the world. Early onset paraplegia can be im-

proved by timely surgical intervention under

ATT cover. The disease mostly affects the tho-

raco-lumbar spine. Classically, the diseased area

is addressed by anterior thoracic or thoraco-

lumbar approach and after curettage of the dis-

eased and necrotic material the anterior column

is reconstructed by rib or fibular strut graft or

metallic cage and supplemented by posterior

instrumentation and fusion. Laminectomy, as a

method of decompression, was greatly discour-

aged in spinal tuberculosis with compressive

myelopath y except in posterior element involve-

ment. We present a case of a 35 years old lady

with Pott’s paraplegia treated by hemilaminec-

tomy and transpedicular limited anterior decom-

pression of the cord and pedicle screw fixation

with fusion who improved vastly in terms of

motor power.

Keywords: Spinal TB; Pott’s Paraplegia; Adult;

Hemi-Laminectomy; Pedicle Screw; Fusion

1. INTRODUCTION

Spinal tuberculosis is still a cause of major morbidity.

Millions of people are still affected by this ailment. Be-

cause of the improved chemotherapy the mortality is

now reduced to a great extent. Many cases got improve-

ment by chemotherapy alone. Only some selected cases

require surgical treatment. Spinal tuberculosis is notori-

ous for producing spinal deformities and neurological

involvement like paraplegia. In such cases immediate

surgical intervention becomes necessary to regain normal

or useful motor function [1].

Pott’s paraplegia can occur due to compression of the

spinal cord by soft material like tubercular abscess, cas-

eous mass or granulation tissue or by hard material like

internal gibbus, bony sequestrum or a sequestrated disc.

We report a case of Spinal tubercu losis at D12 and L1

level presenting with paraplegia with bowel and bladder

involvement who regained completely normal motor

function and bowel and bladder control after posterior

decompression and stabilization with pedicle screw rod

system.

2. THE CASE REPORT

A lady of 35 years old presented to us with complete

loss of all motor function of her both lower limbs with

retention of urine and pain over the lower dorsal spine.

She had a history of back pain for one month associated

with fever off and on. She did not sustain any trauma

over the area nor was there any history of cough for

prolonged duration or significant weight loss.

On examination both the lower limbs were flaccid

with grade 0 motor power according to MRC grading.

She did not feel the sensation of bladder fullness. Her

sensation was diminished from L1 dermatome.

The spine examination revealed a kyphus deformity at

D12 and L1 level with mild tenderness. Wasting of para-

spinal muscles were also noted. Plain X-ray showed obli-

teration of D12, L1 disc space along with destruction of

inferior part of body of D12 and superior part of body of

L1 as well as wedging at that level. No obvious para-

spinal soft tissue shadow was noted.

MRI scan of the Dorso-lumbar Spine confirmed the

X-ray findings (Figures 1 and 2). There was destruction

of the vertebrae with compression of the spinal cord at

*Consent: Informed consent obtained from the patient regarding pre-

sentation and publication of t h i s c a s e .

P. Gogoi et al. / Case Reports in Clinical Medicine 2 (2013) 281-284

282

D12 and L1 level. Mild abscess noted in and around the

destructed vertebrae. Pedi cles were normal at all levels.

Blood examination showed increase ESR level and

lymphocytosis. Her liver and renal function tests were

within normal limits.

From the clinical history, physical examination and

relevant investigation findings the diagnosis of Pott’s

paraplegia was made and four drugs combination che-

motherapy started. Early surgical intervention was planned

to decompress the cord and stabilize the spine.

The spine was exposed from the posterior aspect. It

was then stabilized with four pedicle screws, two at D11

level and two at L2 level. Hemilaminectomy done at D12

vertebra on right side and the right pedicle was gradually

removed with rongeours and nibblers. The cord was de-

compressed anteriorly by an angulated rongeour remov-

ing the diseased material partly from the D12 body. Col-

lectively the cord was decompressed anteriorly, laterally

and partly posteriorly. Posterolateral fusion with bone

graft was undertaken and the surgical wound was closed

in layers.

Figure 1. MRI scan of the affected spine.

Figure 2. MRI scan of the affected spine.

Post-operatively the patient was continued with che-

motherapy along with assisted physiotherapy. Her motor

power gradually improved after the surgery and she re-

gained motor power of grade 3 after four weeks and

grade 4 after eight weeks. Her bladder control came back

after four weeks and she started walking with walker

from eight weeks with a Taylor brace. Her back pain

resolved and no episode of fever was noted after the op-

eration (Figure 3).

After about eight months following the surgery her

pedicle screws started to back out with pseudoarthosis at

the fused level (Figure 4). However there was no dete-

rioration in her neurological status. The pedicle screws

were revised incorporating one more level below (Figure

5). Six months down the line, the patient is doing well.

There is no pain at the back; no sign of screw back out.

Fusion is still doubtful, but the anterior column structures

healed completely and there is no progression of the ky-

photic angle (Figure 6).

3. DISCUSSION

Surgical treatment for spinal tuberculosis with para-

plegia is constantly evolving. Neurological involvement

warrant early surgical intervention. In earlier days the

spinal canal was decompressed by simple laminectomy

Figure 3. Post-operative X-ray after

the first surgery.

Figure 4. Development of pseudo-ar-

throsis and Screw backout at 8 months.

P. Gogoi et al. / Case Reports in Clinical Medicine 2 (2013) 281-284 283

Figure 5. After revision surgery.

Figure 6. Six months follow up X-ray after the

revision surgery.

via posterior approach. Patients used to recover from the

neural compression but the spine became unstable. As

majority of spinal tuberculosis involve and destruct the

anterior column, the only stabilizin g structure preven ting

the kyphosis remained the posterior elements. So, lami-

nectomy further destabilizes the spinal column. For this

reason and lack of proper instrumentation from the pos-

terior aspect laminectomy was disfavored later on. Sed-

don even condemned laminectomy as a surgical proce-

dure for spinal tuberculosis [2].

Hemilaminectomy or removal of half of the lamina to

decompress the spinal canal was used for easy posterior

approach as well as lesser destabilizing effect on the spi-

nal column.

Costo-transversectomy and antero-lateral decompres-

sion were two procedures slowly gaining popularity [3].

Costo-transversectomy is a simple procedure for drain-

age of the abscess in thoracic region. In the antero-lateral

decompression procedure the spinal canal is decom-

pressed by sacrificing the pedicle as well as the anterior

diseased material. They do not address the radical re-

moval of diseased vertebrae or reconstruction of anterior

column; hence nothing to do with spinal stability or pro-

gression of the deformity.

Hodgeson et al. during their Hong kong experience de-

vised the radical excision of the diseased area by anterior

thoracic or thoraco-lumbar approach and reconstructing

the anterior column by rib graft. They noted significant

improvement in terms of mortality, spinal stability and

cure from the infection [4].

Rajasekaran and Soundarapandian noted failure of rib

graft and progression of kyphosis following the Hong-

kong procedure [5]. They reported fibular graft as better

alternative. In another study they proposed a formula for

expected progression of the kyphotic angle from the ini-

tial radiographic measurement of destruction [6].

Anterior column is reconstructed by rib grafts, fibular

strut graft, metallic cage along with anterior instrumenta-

tion like locking plates. They can be supplemented by

posterior instrumentation and fusion.

Posterior stabilization was earlier done by closed rec-

tangles with sublaminar wires; rod and laminar hook

constructs like Herrington’s, Luque rod system [7]. Pre-

sently these are mostly replaced by pedicle screw-rod

system. All of them act as a tension band in stabilizing

the spine; so the anterior column continuity is a prereq-

uisite for them.

Anterior column reconstruction from the posterior

transpedicular approach has slowly gained popularity.

The diseased material is curetted from the posterior as-

pect, the cord got decompressed from both anterior and

lateral aspect and expandable cage fills the anterior col-

umn defect. Posterior instrumentation then stabilizes the

spine. This procedure obviates the morbidity associated

with anterior thoracotomy approach. This approach is

utilized in vertebral osteomyelitis [8], osteoporotic com-

pression fractures [9], metastatic spinal tumours [10].

Mehta and Bhojraj proposed a MRI dependent classi-

fication system of spinal tuberculosis where they catego-

rized them into four groups. They advocated posterior

transpedicular decompression in the group who cannot

tolerate the thoracotomy [11]. Guven et al. also showed

good result in their cases treated by this approach [12].

Posterior instrumentation was chosen in our patient as

they are familiar to us as a routine procedure in trau matic

spine stabilizations. Pedicle screws offer sufficient stabi-

lizing power and hemilaminectomy along with transpedi-

cular limited anterior decompression ensures spinal cord

relief.

Good chemotherapy helps in rapid healing of the ante-

rior column and gives anterior support. Kyphosis pro-

gression usually stops after healing of the anterior col-

umn and posterior fusion. In our case kyphosis pro-

gressed and fusion failed resulting in pseudoarthrosis as

there was no adequate anterior support during the healing

P. Gogoi et al. / Case Reports in Clinical Medicine 2 (2013) 281-284

284

period. Revised posterior instrumentation along with fu-

sion is doing well because of anterior support provided

by the healed anterior structures which were clinically

confirmed during revision surgery.

OPEN ACCESS

4. CONCLUSION

Posterior transpedicular limited anterior decompres-

sion is a viable option in Pott’s paraplegia. However, an-

terior column reconstruction is important in preventing

kyphosis progression. Pseudoarthrosis may be present in

infective spinal conditions also.

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