Post Tubercular Healed Severe Kyphotic Deformity with Altered Gait Treated Surgically
Pott's Spine accounts for about 2% of all cases of tuberculosis (TB), 15% of extrapulmonary cases and 50% of skeletal TB cases. Clinically, it presents with constitutional symptoms, including back pain, tenderness, paraplegia/ paraparesis, and kyphotic / scoliotic deformities. Most of the time, the disease is restricted to the disc space with the collapse of vertebral body, but it can span to multiple levels causing widespread bone destruction and consequently an unstable spine with deformity, mainly kyphosis. It is not very uncommon to see such patients with advanced disease, especially in rural areas where patients do not have access to timely intervention, initiation of anti-tubercular therapy and surgical correction of the deformity. Such healed deformities of the spine present with surgical challenges and might be associated with paraplegia, both in the pre-operative period and also, unfortunately, post-surgical correction.
Case Study
A 24-year-old female presented at Medanta-Lucknow with stooped forward gait and a sharp deformity over lower lumbar for the last six months. She had a history of lower back pain, which was insidious in nature and gradually progressive for the last nine months. Initially, she responded to local treatment and analgesics, but the pain started to worsen with prominence during the night, causing disturbed sleep. There were multiple episodes of rise in body temperature towards the evening, associated with sweating and loss of appetite. She also reported a history of significant weight loss – about 8kgs in three months.
At the time of presentation, the patient was significantly cachectic and weighed only 38kgs. There was generalized muscle wasting; she walked with her hands rested on the knees and had a stooped forward posture. There was a prominent knuckle deformity around dorso-lumbar spine; all the movements of the spine were painful. Neurologically, her sensory and motor assessment was normal. Her bowel and bladder functions were also normal.
At another centre she had undergone a series of investigations, including a magnetic resonance imaging (MRI) of the spine. Her initial radiographs of the spine showed spondylodiscitis at L3-L4 with a kyphosis of 25 degrees. Her radiographs of lumbosacral spine were repeated at Medanta-Lucknow. It was found that the kyphosis had progressed to 40 degrees, which did not correct on extension. The CT scans showed extensive bone destruction with a kyphoscoliotic deformity around L3-L4. The MRI scans showed extensive soft tissue component in the epidural space with pre- and para-vertebral collections around L4.
She was diagnosed with post-tubercular sequelae at L3-L4 with severe kyphoscoliotic deformity. We planned to do a thorough debridement of the dead and necrotic tissue and bone, collect biopsy samples and attempt to correct the deformity without jeopardizing the neurological status.
Intraoperatively, as the epidural space was opened, around 40ml of abscess was found, which was collected for culture and drug sensitivity, and all the dead bone was removed. L4 was found almost fully collapsed and a corpectomy was done. We got fixation points, both above and below the involved level, by inserting pedicle screws. A major challenge was to restore the height of L4. The L4 and L5 nerve roots were too close to each other, which hindered putting a mesh cage inside. The nerve roots could not have been sacrificed and hence, it was decided to do further bone resection circumferentially to get that space in front of L4. Finally, the mesh cage was successfully positioned in place of L4 vertebra, jacking it up to restore the height and correcting the kyphotic deformity.
The surgery was uneventful with good clinical outcome. Postoperatively, the patient had normal neurological status and maintained all vital parameters. She was restricted to bed for two weeks and was mobilized after her wounds had healed with the help of a walker.
Her postoperative radiograph showed correction of deformity to 10 degrees from the earlier 40 degrees at the time of presentation. The abscess culture and genetic experts confirmed the TB as sensitive to first-line of drugs.
At her two-month follow up, the patient showed clinical improvement, had gained weight and was walking pain-free.
The case highlights the importance of prompt diagnosis of spinal TB and alertness towards development of any spinal deformity.
While Pott’s Spine is primarily a disease requiring proper and monitored treatment for at least one year, any deformity that is developing needs to be addressed promptly to prevent further morbidity. Surgical treatment options significantly improve patient outcomes, and are now well accepted.
