A case report - iKnow

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Singkat Dohar Apul Lumban Tobing

^a

, Dody Kurniawan

^b,∗

aDepartmentofOrthopaedicandTraumatology,FacultyofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoHospital,Jakarta,Indonesia

bResidentofDepartmentofOrthopaedicandTraumatology,FacultyofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoHospital,Jakarta, Indonesia

a r t i c l e i n f o

Articlehistory:

Received25December2019

Receivedinrevisedform30March2020 Accepted16April2020

Availableonline19May2020

Keywords:

Lumbosacraltuberculosis Minimallyinvasivesurgery Arthroscopy

Debridement Abscessevacuation

a b s t r a c t

INTRODUCTION:Spinaltuberculosisusuallyaffectsthethoracolumbarspine,withonly2–3%involving thelumbosacralregion.Lumbosacraltuberculosiscanleadtotheformationofapresacralabscess.For drainageofthespinalabscess,thepresacralregionisoneoftheproblematicregionstoperform.Minimally invasivesurgery(MIS)isanessentialclinicaltechniqueforthedebridementofthespinalabscessinorder todecreasethemorbidityacquiredbythepatient.Wepresentedacaseoflumbosacraltuberculosis treatedwithabscessevacuationusingtheMIStechnique.

PRESENTATIONOFCASE:A28-year-oldmalecamewiththechiefcomplaintofbackpainandalumpin therightgroinareaforfourmonthsbeforeadmission.Physicalexaminationshowedalumpandbilateral positivestraightlegraising.PreoperativeOswestryDisabilityIndex(ODI)andtheJapaneseOrthopaedic Association(JOA)scoresshowedmoderatedisabilityandnormalfunction,respectively.Radiologicexam- inationsshowedsignsoflumbosacraltuberculosis.ThepatientunderwentabscessevacuationusingMIS ofpresacralapproachasdescribedforaxiallumbarinterbodyfusion(AxiaLIF),andimprovementinODI scorewasnoted.

DISCUSSION:Apresacralapproach,aswhatweperformed,isasimpleapproachthatcanreachthelocation oftheabscessbyusingfluoroscopicguidance.Abscessevacuationwasconfirmedbythepresenceofclear fluid,whichindicatedthatthecaseousmaterialhadbeenremovedthoroughly,andalso,astheclearfluid wasnolongernoticed.

CONCLUSION:Thesuccessofthisapproachdependsonthetimeofsurgery.Whensurgeryisdelayed,the granulationtissuehasbeenformed,makingminimallyinvasivetechniquesforsurgicalevacuationmuch moredifﬁcult.

1. Introduction

TheestimatedprevalenceofTBinfectioninIndonesiareached morethan300newcasesperyear[1].Thisnumberispredictedto stayhighespeciallyinpopulationwhohaveco-infectionwithHIV anddiabetes[2].Tuberculosis(TB)ofthespine,alsoknownasPott’s disease,isoneofthemostcommonextrapulmonaryTBinfection aftertuberculosisofthelymphnodes,comprising50%ofallskeletal TB[3].Thelesionusuallyaffectsthethoracolumbarspine,withonly 2–3%involvingthelumbosacralregion[4].Infectioninthisregion carriesspeciﬁccharacteristicsincludinglessriskofkyphosisdue tothelordoticnatureofthelumbosacralspine[5].However,the patientsusuallyendupwithhypolordosisorstraighteningofthe

∗Correspondingauthorat:DepartmentofOrthopaedicandTraumatology,Faculty ofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoHospital,Jl.Dipone- gorono.71,Jakarta,10430,Indonesia.

E-mailaddress:[email protected](D.Kurniawan).

spine.Thisconditionhasbeenshowedtocausepostoperativeback painandcomplicationduringtheupcomingpregnancy[6].

The management of spinal TB has been primarily involved chemotherapyandsurgicaldrainage[7].Conservativetreatmentis appropriateinmostcaseswherethereisnoevidenceofprogressive bonydestruction,improperhealing,persistentpain,deteriorating neurological condition,orprofound deformityof instability[8].

Lumbosacraltuberculosiscanleadtotheformationofapresacral abscess.Theindicationofthedrainageofsuchabscessispresence ofpressuresymptomoriftheabscessdoesnotregresswithanti- tuberculoustreatment.For drainageof spinalabscess,presacral regionisoneoftheproblematicregionstoperform[9].

If lumbosacral tuberculosis has signs of abscesses, cavities, sequestra, and sinus formation, routine treatmentby thorough debridementisrecommended,alongwithbonegraftand/orinter- nalﬁxation.Thedevelopmentofsurgicaltechniqueshasbroughta minimallyinvasivesurgery(MIS)asanessentialclinicaltechnique.

Inthedebridementofthislumbosacralabscess,weusedMISto

https://doi.org/10.1016/j.ijscr.2020.04.007

by/4.0/).

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CASE REPORT – OPEN ACCESS

272 S.D.A.L.Tobing,D.Kurniawan/InternationalJournalofSurgeryCaseReports72(2020)271–276

Fig.1.PhysicalExaminationoftheBack.

Fig.2.PelvisandLumbosacralPlainRadiographofthePatient.

reducethemorbidityacquiredbythepatient[10].Thiscasereport hadbeenwrittenaccordingtotheSCAREguideline[11].

2. Patientinformation

A28-year-oldmalewasseenbythedigestivesurgeryforalump ontherightgroinareawithabackpain(VAS5)forthepastfour months.Becausetherewasnoabnormalityinabdomenarea,the patientwasconsultedtoOrthopaedicDepartment.Thepaindidnot radiateandwasrelievedwhenthepatientliesdownonhisback.

Therewasnonumbnessortinglingsensation.Hehadnotrouble withmicturitionanddefecation.Thepatientdidnothaveahis- toryof lung tuberculosis.However,thepatientwassenttothe pulmonarydivisionbeforeourdepartmentandwasdiagnosedwith tuberculousspondylitisandwasgivenanti-tuberculousdrugssince then.Theclinicaloutcomeswereassessedpreoperativelyandatthe ﬁnalfollow-upbyOswestryDisability Index(ODI)and Japanese OrthopaedicAssociation(JOA)scores.ThepreoperativeODIscore forthispatientwascategorizedasmoderatedisability,whereasthe JOAscoreforthispatientisinnormalfunctionstate.

3. Clinicalﬁndings

Examination of the back showed no apparent deformities (Fig.1);however,therangeofmotionofthebackwasdecreased duetopain.Ontherightgroinarea,a7×4×1cmmasswithcys- ticconsistencywasvisible(Fig.2).Itwaspainfulonpalpation.The examinationoftheabdomenshowednootherpathologies.Sin- glelegraisetestofbothlegselicitedpainat20degreesROM.The neurologicalexaminationwasotherwisenormal.

4. Diagnosticassessment

AstandardAPandlateralplainradiographofthepelvisandlum- bosacralrevealederosionoftheanterioraspectofL4–L5,whichwas accompaniedbypsoashaziness(Fig.3).CTscanoftheabdomen

showedspondylodiscitisofL3-S5withparavertebralabscessfor- mationextendingtotherightpsoasmuscleandinguinalregion (Fig.4).Evidenceofparavertebralabscesswasfurtherconﬁrmed bycontrast-enhancedMRI(Fig.5).Bloodworksshowedelevation ofCompleteBloodCountandESR.MolecularGeneXperttestproved theinfectionofMycobacteriumtuberculosis.

5. Therapeuticintervention

ThepatientwasdiagnosedwithspondylitisTBofL3-S5withpar- avertebralabscess.Thepatientwasputon1stlineTBmedication (RHZE)andunderwentanteriordebridementandabscessevacu- ation.Thetuberculousmedicationsconsistedof4-FDC(Rifampin 150mg,Isoniazid75mg,Pyrazinamide400mg,andEthambutol HCL275mg,whichwasstartedthreeweeksbeforesurgeryand continuedaftersurgery.

Surgeryperformedtothepatientwasanteriordebridementand abscessevacuationthroughminimallyinvasivesurgery(MIS)of usingarthroscopysheathwithablunttrocar.Theapproachusedin thisMISistheapproachusedtoapplyAxiaLIFsystem,asdescribed byRappetal.[12](Fig.6).Thepatientreceivedendotrachealintu- bationundergeneralanesthesiainaproneposition.

Thisprocedurewasperformedentirelyundertheguidanceof theﬂuoroscopywithoutdirectvisualizationoftheoperativeﬁeld.

Thesurgerywasstartedbycreatinga2cmlongitudinalincision attheleveloftheparacoccygealnotchortipofthecoccyx(pre- sacralapproach).Subsequently,thearthroscopysheathwithblunt trocarwasadvancedthroughthepresacralspaceandstayaimed atthemidline,whichisavascular,andwaspushedintothesacrum inthelocationoftheabscess.Theentrypointofthisarthroscopy sheathislateraltothecoccyxandinferiortotheattachmentof thesacrospinousandsacrotuberousligament.Then,alarge-sized bluntarthroscopictrocharof4.0×175mmwasinsertedalongthe samepathway,climbinguptotheanteriorsacralcortexandthen progressed0.5cm anteriortoanteriorsacralbody andintothe

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Fig.3. LumbosacralCTandMRIofthePatient.

Fig.4.TheIllustrationoftheAxiaLIFApproachasDescribed.

abscess(Fig.7).Afterthetrocharachievestheabscess,theabscess wasdrained.Around1Lofpusmixedwithcaseousmaterialswas evacuatedfromtheabscess.Warmnormalsalinewasusedtoirri- gateanddraintheabscessthoroughlyuntilthewithdrawnfluid becameclear.Thisclearfluidcomingoutfromthedrainagesys- temconfirmedthecompletenessofthedrainage.Finally,aroutine drainagetubewasplacedaftersurgery.A14Fdrainwasplaced insidethewoundforthreedays.

6. Followupandoutcomes

Postoperative examination showed signiﬁcant decrease in inguinallumpsizeto2×0.5×0.5cm(Fig. 8).Thebackpainwas immediatelyrelieved (VAS1).The patientwasdischarged after threedays.Intheﬁrstfollow-upvisit(7daysaftersurgery),there wasnodischargefromthewound,andthemassonthegroindis- appear.Thebackpainwasalleviated,andthepatienthadreturned tohisnormal activitywithoutanycomplaint.MRIexamination showed that the size of the abscess wasmarkedly diminished comparedtithepreoperativeMRI(Fig.9).ThepostoperativeODI scoreshowedthatthepatienthasminimaldisabilityandnormal functionintheJOAscore.Thepatientcontinuestoconsumethe anti-tuberculosisdrugfor6months.

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CASE REPORT – OPEN ACCESS

Fig.5.IntraoperativeProcedures.

Fig.6.PostoperativePatientPhysicalExamination.

7. Discussion

As mentioned, the indication of surgical decompression of tuberculousspinalabscessisthefailureofimprovementordeteri- orationinneurologicalstatusduringanti-tuberculoustherapy,as mosttuberculousabscessresolveswithanti-tuberculoustherapy.

Inourpatient,surgicaldecompressionwasindicated duetothe presenceofpositivelegraisetestsinbothlegs,indicatingpresence ofabscesscompressionintheiliopsoasmuscle.

TheOswestryDisabilityIndexisacommondisabilityindexto measuresadultwithspinaldisorders.It’sconsideredasagoldstan- dardformeasuringdisabilityandqualityoflifeforadultwithalow backpain.TheODIcanbeusedtoassessbothchronicandacute conditions.

Therearesomeapproaches in performingsurgery for sacral mass,includinganterior,posterior,andpresacralapproaches.Ante- riorapproach hasthe threatofvascular orneural damage.The presacralroute, byusing anavascular axialcorridor toachieve

vertebralaccess,hastheadvantageofsparingtheposteriormuscu- lature,ligaments,andneuralelementsthatareencounteredduring posteriorapproaches,aswellasavoidingdissectionandretraction ofmajorvesselsandtheintra-abdominalvisceraaswithanterior approaches[12].

Weconﬁrmedthecompletenessofthedrainagebythepresence ofclearﬂuidafterirrigationofabscess,anditscaseousmaterialhad beenremovedthoroughly.Thesuccessofthisapproachdependson thetimeofsurgery.Whensurgeryisdelayed,thegranulationtissue hasformed,andinthiscondition,theanteriorabdominalapproach isrequired[13].

ResearchbyZhangetal.[10]suggestedthatMISissuitablefor mostlumbosacraltuberculosis.However,itisnotabletocorrect spinaldeformityandrelievecanalcompression.Nevertheless,for- tunately,thespinalcanalhasarelativelylargevolume,andthe peripheralnervesinthecanalhavearelativelygoodtolerancefor compression.Therefore,nervecompressionrarelyoccursinlum- bosacraltuberculosis,makingtheMISasanappropriatechoicefor mostcases.TheMIShasdualrolesin bothpatientswithnerve symptomswithandwithoutkyphoticdeformity.Inpatientswith- outkyphosisdeformityandseverenervesymptoms,MISwillmake futureopensurgerysafer.In patientswithkyphosisandsevere nervesymptoms,MIScanbeperformedtoobservehowthepatient responds,inwhichwhenthere isimprovementduringMIS,the non-opentechniquecanberetainedandthatopensurgeryshould beperformedwhenthedeteriorationoccurs.AlthoughMIScan- notcorrectthekyphosisdeformity,itcanquicklyimprovepatient’s generalcondition,removetheabscessandcreaterightconditions forsecondstageofopencorrectivesurgerywhenindicated[10].

Lumbosacraltuberculosisisadjacenttotherectum,iliacvessel, andureter,wheretheabscessisoftenformed.Therefore,thorough removalofthediseasedtissueisahighlydemandingtaskduring surgery.Thetissuefragility,riskofvascularinjury,andtheinci- denceofretrogradeejaculationareincreasedbytheinﬂammation inthesurroundingtissue.Thisaddingtheconsiderationnottoper-

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Fig.7.PatientMRIFollowingtheProcedure.

formathorougheliminationofgranulationtissueinfrontofand bilateralthevertebratoavoidtheincidenceofthevertebralinjury.

However,theabscessﬂuidmustbeevacuatedaspossible,andthe necrotictissuebetweenthevertebraeandinvadingintothever- tebralcanalshouldbeeliminatedinordertoenhancebonefusion andacceleratefunctionalrecovery[14].

TheindicationsofMISareunstablespinecausedbyvertebral destructionand deformity, nerve function injury, or paraspinal abscess[15].TheindicationofMISinourpatientisthepresence ofparavertebral abscessformationextendingtotherightpsoas muscleandinguinalregion.WhenMISisused,anatomicalstud- iesandradiologicalimagingisusedinsteadofneurophysiological monitoringtoavoidtheearlycomplicationrelatedtoMIS[15].This waswhatweperformedtothepatientinourcasereport,inwhich weusedintraoperativeﬂuoroscopicguidancewheninsertingthe arthroscopictrocharintotheabscess.

SomeprerequisitesofMISmustbefulﬁlledbeforetheprocedure isperformed.These preoperativeprerequisitesare thefactthat thepreoperativeanti-tuberculosis reactionwaswell,thepreop-

erativeimagingshowedthattheabscessformedcanbeevacuated althoughnotentirelythroughaminimallyinvasivechannel,and stableinternalﬁxationforspinalreconstruction.Thisindicatesthat apreoperativeregularanti-tuberculosistreatmentiscrucialbefore thesurgicaldebridementisperformed.

MISusingthepresacralapproachasdescribedinAxiaLIFsys- tem is safeand effective. However,there are somelimitations totheAxiaLIFprocedurethatmustbeconsidered.Thisapproach requires surgeons to become familiar with presacral anatomy becausetheentireprocedureisvisualizedunderﬂuoroscopywith nodirectobservationofthevertebrae.Thepossiblecomplication of this approachis bowel perforation,althoughrare. Thiscom- plication can beavoided withappropriate preoperative patient preparationandmeticuloussurgicaltechnique.Preoperativeimag- ingshouldbethoroughlyevaluated,withemphasisonperirectalfat padthickness,identiﬁcationoftherectum/sacruminterface,aber- rantvasculature,andanticipatedtrajectory.Preoperativepatient preparationincludesmechanicalbowelcleansingtoenhancerec- talpliabilityduringbluntdissectionandtolowercontamination

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CASE REPORT – OPEN ACCESS

riskintheeventofbowelinjury.Administrationofbroad-spectrum intravenous antibioticsbefore theprocedurewill furtherlower thecontaminationrisk.Apreciseinitialincisionfollowedbygen- tlebluntdissectionwiththeﬁngerallowsforsafeentryintothe presacralarea.Specialattentiontopotentialbowelcomplications shouldbegiventowomenbecausethepresacralwidthisnarrower comparedwithmales[12].

TheOswestryDisabilityIndexisconsideredasagoldstandard formeasuringdisabilityandqualityoflifeforimpairmentadult withalowbackpain.Itconsistof10-pointpatient-reportedques- tionnaire.The10-pointarepainintensity,easeofpersonalcare, lifting,working,sitting,standing,sleeping,sexlife,sociallifeand travelling[16].JapaneseOrthopaedicAssociation(JOA)scoreisa scorethatusedinpatientswithcervicalcompressivemyelopathy toassesstheseverityofitsclinicalsymptoms[17].

Oneofthegoalsofspinaltuberculosistreatmentistoimprove thepatient’s quality of life. The advantages of MIS are a more favorablepostoperativerecoverywithoutextensivesofttissuedis- sectionandless estimatedblood loss,andshorter hospital stay andoperativetime.Ourpatientstayedforthreedaysinthehos- pitaland dischargedafterthewounddrainwithdrew[15].Case seriesbyAroraetal.[18]showedthatminimallyinvasivetechnique forabscessevacuationoflumbosacralabscesswasasafeoption, andcomparedtootherapproachesthistranspedicularapproach appearstobesafer.Thekeytosuccessofthisapproachisearly diagnosisandearlytreatmenttoavoidthealterationoftheliquid abscessintothegranulomatoustissue[17,18].Wangetal.[15]also notedintheirstudythatMISappearedtobeapromisingnewtreat- mentforlumbartuberculosis.WeconcludedthatMISwasasafe proceduralandcanbeachoiceforsurgicalevacuationofparaspinal abscessformedinlumbosacraltuberculosis.Preoperativeprerequi- sitesmustbefulﬁlledbeforetheprocedurewasperformedinorder toachievethesuccessofthismethodofsurgery.

8. Patientperspective

Aftersurgicaldebridementandabscessevacuation,antituber- culoustreatmentwascontinuedpost-operatively.Thepatienthad recoveryofallbackpainbytwoweekspostoperatively.AcidFast Bacillusstainingfortuberculousbacteriawasdecisiveinthepus evacuated during surgery. At 3-months follow-up, patient was asymptomaticandcanreturntohisnormalactivities.

DeclarationofCompetingInterest

Theauthorsdeclarenoconﬂictsofinterest.

Funding

Theauthorsreportnoexternalsourceoffundingduringthe writingofthisarticle.

Ethicalapproval

Ethicalapprovalwasnotrequiredinthetreatmentofthepatient inthisreport.

Consent

Writtenconsenthasbeenreceivedfromthesubject.

Authorcontribution

SingkatDoharApulLumbanTobing contributestothestudy conceptordesignanddataanalysisorinterpretation.

DodyKurniawancontributesinthedatacollection,analysisand interpretation,andwritingthepaper.

Registrationofresearchstudies NA.

Guarantor

SingkatDoharApulLumbanTobingisthesoleguarantorofthis submittedarticle.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

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