CASE REPORT – OPEN ACCESS

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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports77(2020)191–197

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Anterior debridement and fusion using expandable mesh cage only for the treatment of paraparese due to spondylitis tuberculosis: A case report

Fahmi Anshori

^a^,∗

, Heka Priyamurti

^b

, Ahmad Jabir Rahyussalim

^c

aDepartmentofOrthopaedicsandTraumatology,FacultyofMedicine,UniversitasIndonesia-CiptoMangunkusumoHospital,Jakarta,Indonesia

bDepartmentofOrthopaedicsandTraumatologyFKUI-RSCM,DepartmentofOrthopaedicsandTraumatologyKojaCountyHospital,NorthJakarta, Indonesia

cDivisionofSpine,DepartmentofOrthopaedicsandTraumatology,FacultyofMedicine,UniversitasIndonesia-CiptoMangunkusumoHospital,Jakarta, Indonesia

a rt i c l e i nf o

Articlehistory:

Received28September2020

Receivedinrevisedform26October2020 Accepted27October2020

Availableonline2November2020

Keywords:

Expendablecage Spondylitistuberculosis Anteriordebridement Fusion

Casereport

a b s t ra c t

INTRODUCTION:Thereisacontroversyintherecentliteratureregardingthemostappropriateapproach totreatspondylitistuberculosis,whethertochooseanterior,posterior,andcombinedapproachaswellas one-stageversustwo-stageapproach.Meshcagehaspotentialadvantages,includinginhibitionofinfec- tionbyfusionandreconstructiontechniquecombinedwithcorpectomy.Anteriorsurgeryhasadvantage asitallowsdirectaccesstothediseasedvertebralbodiesandintervertebraldisc.

CASEILLUSTRATION:Wepresentacaseofspondylitistuberculosisoflowerlumbarvertebrae(L5)andL4- L5intervertebraldisccausingparaparesetreatedwithanteriordebridementandfusionwithexpendable meshcage.Patientpresentedwithweaknessoflowerlimbandbackpain,withhistoryofanti-tuberculosis drugs.PatientwasdiagnosedwithparaparesisduetospondylitisTbofL4-S1withparavertebralabscess atL4-S1FrankleD.

DISCUSSION:Thepatientwastreatedwithanteriordebridementandfusionusingexpendablemesh cage.Immediatepostoperativeradiographshowedrestorationofvertebralheight.Thiscaseshowedthat paraparesiscanoccurinlowerlumbarvertebraewithdistinctclinicalappearancetothatoflowertho- racalorupperlumbarspondylitistuberculosis,andthatanteriorapproachfordebridementandfusion usingexpendablemeshisalogicalanddirectmeansofaddressingatuberculousspinelesion,which predominantlyaffectsanteriorelements.

CONCLUSION:Theanteriorapproachhastheadvantageofleadingthesurgeondirectlyintothelesion andallowingagoodvisualization.Instrumentationafterdebridementandbonegraftcanprovideinstant stabilityforthespinalcolumn,whichcanleadpatientstoresumeactivities.

1. Introduction

Tuberculous spondylitis or Pott’s diseaseis one of themost prevalent spinalinfection, especially indeveloping countries. It affectsaround1,7%ofworldpopulationandaccountsforupto50%

ofallboneandjointtuberculosis[1].MostofspinalTBarelocatedin lumbarregion,withthoracalandcervicalsegmentsasthesecond andthirdmostfrequentinfectionsite[2].Theincidenceofbone andjointtuberculosishasincreasedinthepasttwodecades,thisis mainlyduetotheoccurrenceofimmunocompromisedconditions.

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

E-mailaddresses:fhmanshori@gmail.com(F.Anshori),hekaortho@yahoo.com (H.Priyamurti),rahyussalim71@ui.ac.id(A.J.Rahyussalim).

Inspiteofadvancesintreatment,onepersondiesoftuberculosis inevery15s,andapersonisnewlyinfectedwithM.tuberculo- siseverysecond.Spondylitistuberculosisisanimportantcauseof non-traumaticspinalcordinjuryandinendemiccountries,itmay bethemostcommoncauseof non-traumaticspinalcordinjury [3]. Incidenceofneurologicalcomplicationamongpatientswith spondylitistuberculosisrangesfrom10to20%and20–41%inin developedanddevelopingcountries,respectively.Paraplegiausu- allyoccursintuberculousinfectionabovelumbartwo(L2)where thespinalcanalisnarrowerduetobonystructureandphysiologi- calthoracickyphosiswhichdrivesnecrotictissueinsidethespinal canal.Atdorsal spinesegment,abscessformedtendstoremain belowanteriorlongitudinalligamentandentersthespinalcanal throughintervertebralforaminacausingcordcompression.Incon- trast, theabscess leaks downin psoas muscleat lumbar spine segment[4].

https://doi.org/10.1016/j.ijscr.2020.10.126

creativecommons.org/licenses/by-nc-nd/4.0/).

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CASE REPORT – OPEN ACCESS

F.Anshorietal. InternationalJournalofSurgeryCaseReports77(2020)191–197

Fig.1.LateralandAnteroposterior(AP)LumbosacralRadiographofthePatient.Therewaslossoflumbarlordosis,decreaseofbodyheightatL5,burstfractureofL5,end platesclerosisatlevelL4-L5andL5-S1,decreaseintervertebralbodyheightatL4-L5andL5-S1,andfusiformsofttissueopacityaroundvertebraeL4-S.

Table1

TimelineofPatient’sClinicalCourse.

Dates RelevantPastMedicalHistoryandIntervention

April262018 Complaintsofweaknessonbothlowerlimbsandbackpain,andhistoryofnightsweatingandlossofbodyweight.

Dates SummariesfromInitialsandfollow-upVisits DiagnosticTesting Interventions

April262018 Complaintsofweaknessonbothlowerlimbs andbackpain.PatientwenttoRSPELNI

X-rayexaminationofthe spine

Anti-tuberculosisdrugsfor 2months

June152018 Complaintsofweaknessonbothlowerlimbs andbackpain.PatientwenttoRSCM

X-rayandMRI

examinationsofthespine

Preoperativepreparation October26

2018

Complaintsofweaknessonbothlowerlimbs andbackpain.PatientwenttoRSCM

Anteriordebridementand fusionusingexpendable meshcage.

ManagementofspinalTBischallenging,particularlybecause ofunspecificandmyriadclinicalmanifestationthatresultinlate diagnosisandriskofmorbidityandmortalityduetoseveralcom- plications.Earlydiagnosisandtreatmentisthekeytoavoidingthis long-termdisability[4].ThegoalsofspinalTBtreatmentaretocon- firmdiagnosis,achievebacteriologicalcure,alleviatecompression ofthespineandcorrectspinaldeformityanditssequelae.Paraple- giain activediseaseneedsactivetreatmentofanti-tuberculosis drug withor without surgical decompression. Direct observed treatment(DOT)isauniversallyacceptedpolicytoensuretreat- mentadherence.Corticosteroiddrugsisnotusuallygivenunless thereismeningealinvolvement.Surgicalmethodisusuallyper- formedinpatientswithneurologicaldeficitscausedbyspinalcord compression,severeorprogressivekyphosis,spinaldeformitywith instability,substantialamountofparaspinalabscesses,andpoor responseorfailureofanti-tuberculosisdrug[5].Surgicalstrategy isbasedonseveralaspects,includingneurologicalcomplication, locationoftheinfection,andseverityofbonedestruction.Radical

debridementandstrutgrafting(theHongKongmethod)withor withoutsupplementalinstrumentationarethemainstayforspinal TBsurgery [6]. Posteriordecompressionandfusion couldbean optionincaseofepiduralinfectionwithminimaldestructionofthe vertebralbody.Inthoracicspinespondylitis,posteriorapproach isrecommended.Forthosecases,anteriorapproachisnecessary onlyformonosegmentallesionwithoutinvolvementofposterior elements. Generally, it is acceptable that anterior approach for debridement,decompressionandfusionwithbonegraftisrecom- mendedinadvancedanteriorbonedestructionandcollapse[7].

Thereisacontroversyintherecentliteratureregardingthemost appropriate approachto treatspondylitis tuberculosis,whether tochooseanterior,posterior,andcombinedapproachaswellas one-stage versus two-stage approach. Mesh cage haspotential advantages,includinginhibitionofinfectionbyfusionandrecon- structiontechniquecombinedwithcorpectomy.Anteriorsurgery hasadvantageasitallowsdirectaccesstothediseasedvertebral bodiesandintervertebraldisc,throughwhichradicaldebridement

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Fig.2. LumbosacralMRI.Theﬁndingswerelossoflumbarlordosis,corpusdestructionofL5,decreaseintervertebralbodyheightatL4-L5andL5-S1,protrusionofL4-L5 intervertebraldiscintothespinalcord,andparaspinalabscess.

oftheinfectedtissuesandplacementofastrutgraftareperformed.

Anteriordecompression,debridement,andinterbodyfusionwith theuseofautologoustricorticaliliaccrestautograft,withoutaddi- tionofmetallicdevicesanteriorly,arethemostcommonlyused techniques for operative treatment of spondylitis because it is incorporatedeveninthepresenceofsepsis[8].However,long-term resultshaveshownthattricorticalbonegraftonlypartiallyrestored segmentalvertebralstabilitybecauseitsusewasassociatedwith pseudarthrosis,graftcollapse,andextrusioneveninthepresence ofrigidposteriorinstrumentation.Incontrast,theuseofmeshcage possessesthreesignificantadvantages.Firstistheidealshapetobe positionedbetweenadjacentoftenseverelydestructedvertebral endplates,thesecondistheloaddistributionbetweencageand vertebraisappliedclosetotheperipheryoftheendplatewherethe boneisstronger,andthethirdisthesignificantinterfacestrength betweenthecageandosteoporoticvertebralbone[8].Despitethe factthatthetechnicalexpertiseandpreference ofeachsurgeon arethefinaldeterminantofwhichapproachshouldbeused,itis largelyagreedthatanteriorapproachisthemostlogicalanddirect meansofaddressingaTBspinelesion,whichpredominantlyaffects anteriorelements.Posteriorstabilizationshouldbeperformedin patientwithpan-vertebraldisease,orwiththeneedforkypho- sisreductionthroughposteriorcolumnshortening,ormulti-level disease[9].

Wepresentacasereportofapatientwithspondylitistubercu- losistreatedbyanteriorapproachusingsingleexpendablemesh

Fig.3. LocalandRegionalKyphoticAnglebasedonLateralRadiograph.Thelocal kyphoticangleis21.1^◦andregionalkyphoticangleis15.7^◦.

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Fig.4. SurgicalProcedureofAnteriorDebridementandFusion.(A)Patientpreparationanddraping.(B)Exposureofperitoneumbyanteriorapproach.(C)Exposureof thecorpusofvertebraeL4andL5.(D)CorpectomyofL5anddiscectomyofL4-L5intervertebraldisc.(E)Expendablemeshinsertion.(F)Finalconstruct.

cageonly.Thepresentcasereportisuniqueinwhichthecommon techniqueusedisusingposteriorpediclescrewandrodoranterior meshcagecombinewithpediclescrewfromposterior,whereas thetechniqueusedinthiscasewassingleanteriormeshcage.Our manuscripthasbeenreportedinlinewiththeSCAREcriteria[10].

2. Caseillustration

A22-years-oldMalepresentedwithchiefcomplaintofweak- ness onboth lowerlimbsfor 6monthspriortoadmission. The weaknessalsocame alongwithbackpain.Therewasnoprevi- oushistoryoftraumaorfever.Therewashistoryofnightsweat anddecreaseofbodyheight.Patientthenwenttonearesthospi- tal,underwentx-rayexamination,andwastoldthattherewasa spondylitisTB.PatientgotantiTBdrugsfor2months,andafter thattheweaknessimproved.Patientwasabletowalk,buttheback painpersisted.Patientwasthenreferredtoourhospitalforfurther treatment.Therewasnodisturbanceinmicturitionanddefecation.

Therewerenootherfamilieswiththesameconditionasthepatient.

Fromphysicalexaminationwecouldnotﬁndanyabnormal- ity.Musclepowerforbothlowerlimbswere+4.Thetimelineof patient’sclinicalcourseisshowninTable1.

TheresultsofX-rayexaminationwerelossoflumbarlordosis, decreaseofbodyheightatL5,burstfractureofL5,endplatesclerosis atlevelL4-L5andL5-S1,decreaseintervertebralbodyheightatL4- L5andL5-S1,andfusiformsofttissueopacityaroundvertebraeL4- S1(Fig.1).TheﬁndingsofMRIexaminationofthelowervertebrae werelossoflumbarlordosis,decreaseofbodyheightatL5,decrease intervertebralbodyheightatL4-L5andL5-S1,protrusionofL4-L5 intervertebraldiscintothespinalcord,andparaspinalabscess(Figs.

2and3).Thelocalkyphoticangleis21.1^◦ andregionalkyphotic angleis15.7^◦.

Thepatientwasdiagnosed byparaparesisduetospondylitis TbofL4-S1 withparavertebralabscessatL4-S1 FrankleDthen underwentanteriordebridementandfusion(Fig.4).Patientwas giventwomonthsofintensivefour-drugtherapy,includingiso- niazid(H),rifampicin(R),ethambutol(E),andpyrazinamide(Z), followedbytwodrugs(RH)therapyforacontinuationphaseof4 months.

Patientwasfollowedupphysicallyandradiographicallyatone, three, six months, and one year after the surgery. Postopera- tiveradiographshowedrestorationofvertebralheightandvisible expendablemesh(Fig.5).

Threemonthsandsixmonthsandoneyearpostoperativefol- lowupshowedgoodfunctionaloutcomeandsignoffusionfromx

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Fig.5. SixmonthsPostoperativeRadiograph.Expendablemeshwasvisiblethroughx-rayexamination.Thelocalkyphoticangleis15.5^◦andregionalkyphoticangleis3.9^◦.

ray(Fig.6)andCT(Fig.7).Thiskindofprocedureiscurrentlyrare procedurewithoutclearcomparisonbetweenconventionalpedicle screwandrodsystemforcorpusdestructionoflumbalspondylitis tuberculosiswithanteriordebridementandfusionusingexpend- ablemeshcage.However,wehopethiscasereportwillprovide furtherevaluationandlong-termlargerfollowupstudy(cohort study)foranotherkindofspondylitistbprocedureasanalternative treatmentdespitebetterorworseforselectivepatient.

3. Discussion

Spinaltuberculosisisacommonextrapulmonaryformofthe disease.In developed nations,mostcases ofspinal tuberculosis areseenprimarilyinimmigrantsfromendemiccountries.Because theepidemicofhumanimmunodeﬁciencyvirus(HIV)infectionor otherimmunocompromisedconditions causedresurgencein all formsoftuberculosis,increasedawarenessaboutspinaltuberculo- sisisnecessary[11].Despiteitscommonoccurrenceandthehigh frequency of long-termmorbidity,there are nostraightforward guidelinesforthediagnosisandtreatmentofspinaltuberculosis.

Earlydiagnosisandprompttreatmentisessentialforpreventing permanentneurologicaldisabilityandtominimizespinaldefor- mity[11].

SpinalTBaccountsforapproximatelyhalfofallcasesofmuscu- loskeletalTB,andismorecommoninchildrenandyoungadults.

The incidence of spinal TB is increasing in developing nations, especiallyinChina[12].Chemotherapyisaveryeffectivewayof controllingandtreating TBandmostindividualswithspinalTB canbecuredbyconservativetreatment.However,patientswhose diseaseisnotsensitivetoanti-TBchemotherapyandwhodevelop

progressivekyphosis,bonedestructionorneurologicalimpairment usuallyrequiresurgicaltreatment[12].

Spinaltuberculosisinitiallyappearsintheanteriorinferiorpor- tionofthevertebralbody.Subsequently,itspreadsintothecentral partofthebodyordisk[11]. Vertebraplanaindicatescomplete compressionofthevertebralbody.Inyoungerpatients,thediskis primarilyinvolvedbecauseitismorevascularized.Inoldage,the diskisnotprimarilyinvolvedbecauseofitsage-relatedavascularity [11].

Thecharacteristicclinicalmanifestationofspinaltuberculosis include localpain, local tenderness, stiffness and spasm of the muscles,acoldabscess,gibbus,andaprominentspinaldeformity [11].Thecold abscessslowlydevelopswhen tuberculousinfec- tionextendstoadjacentligamentsandsofttissues.Coldabscess ischaracterizedbylackofpainandothersignsofinﬂammation [11].

Thispatientwas unique.Patientpresented withearly onset parapareseduetospondylitisTBinL5vertebraandL4-L5interver- tebraldisc,asweknowthatparapareseismostcommonlyoccursin infectionaboveL2vertebrawherethespinalcanalisnarrowerdue tobonystructureandphysiologicalthoracickyphosiswhichdrives necrotictissueinsidethespinalcanal.Fromhistorytakingpatient saidherlowermotorstrenghtissevereuntilpatientcantwalkbut aftertakingantituberculosisdrugfor1monthshermotoricfunc- tionisincreased.Physicalexaminationshowednogibbusbutwe founddecreasedlowermotoricstrength+4.Thediagnosiswasthen establishedthroughradiographandMRIexaminationoftheback, supportedbyhistoryofanti-tuberculosismedication.

ThepurposeofsurgicaltreatmentisdebridementoffocalTB, reconstructionofsegmentalstability,neuraldecompressionand

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Fig.6.OneYearPostoperativeRadiograph.Expendablemeshwithsignoffusionwasvisiblethroughx-rayexamination.

Fig.7.ThreeMonthsPostoperativeCT-Scan.Expendablemeshwasvisiblethrough2D/3DCT-scanexamination.ShowngoodossiﬁcationandfusionaroundL4-S1and expendablemeshcagecorpusreplacedshowedinternalossiﬁcation.

correctionofkyphoticdeformity.Forthelesionsmainlyinvolved anterior and middle column of the spine, Hodgson et al. ﬁrst reported their“Hong Kong operation” for treating spinal TB in 1960[12].Withthedevelopmentofinstrumentationtechniques, aonestageanteriorprocedurecomprisingdebridementandfusion withinternalﬁxationhasbecomethemostfrequentlyperformed surgical treatment for spinal TB. An anterior approach allows directdebridement,whichfacilitatesfocaldebridementandnerve decompression, withoutdestroyingthespinal posterior column structure [12]. However,theanatomicalstructuresencountered withananteriorapproacharemorecomplex,includingmajorblood andlymphaticvessels,nervesandotherimportantorganssuchas

thelungs,heart,kidney,ureterandbowel.Thereisthereforeahigh riskofstructuraldamageassociatedwithsuchsurgery[12].

In thoracic spine spondylitis, posterior approach is recom- mended.Forthosecases,anteriorapproachisnecessaryonlyfor mono segmental lesion without involvement of posterior elements.Theanteriorapproachfordebridement,decompressionand fusionwithbonegraftisrecommendedinadvancedanteriorbone destructionandcollapse [7].Despite thefactthat thetechnical expertiseandpreferenceofeachsurgeonaretheﬁnaldeterminant ofwhichapproachshouldbeused,itislargelyagreedthatante- riorapproachisthemostlogicalanddirectmeansofaddressing aTBspinelesion,whichpredominantlyaffectsanteriorelements

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CASE REPORT – OPEN ACCESS

[9].Theposteriorapproachaloneisrarelyperformed.Itisusually indicatedincaseswithisolatedposteriordiseaseorincaseswith multi-levelnon-contiguousspinalTBinfection.

Radical debridement is the mainstayof operationfor spinal tuberculosis.Inspinaltuberculosis,manystudiesshowedthatthe involvementofthevertebralbodyishighlyfrequent,andfewcases have beenfoundinvolvingtheposteriorcolumn. In aseries by Ramachandranetal.[12],theyconcludedthatwhenoperatingon spinal tuberculosis, anterior debridementand autogenous bone graftwithone-stageinstrumentationanteriorlyorposteriorlyis preferred[12].

Asmentioned,thecommonprocedureperformedforspondyli- tistuberculosisisposteriorapproachusingpediclescrewandrod, oracombinationofmeshcageandpediclescrew.Singlestageoper- ationthroughanteriorapproachusingexpendablemeshcagecan besuccessfullyperformed,withthebetterresultcomparedtothe posterior approach. Authormake surestand-alonemeshwould not displacebypreventingpatientformmoderate-heavy physi- calactivityandweightlifting/weight bearing.Moreover,patient usedthoracolumbalorthosisbraceforspineprotection.Sixmonths andoneyearafteroperation,wefoundsignoffusionsoweconﬁ- dentthatthestand-alonemeshdidnotdisplace.Thepostoperative rehabilitationafteranteriorapproachisalsobetterthanthecon- ventional posterior approach becauseof less dissected muscles performed.Themajordrawbackofanteriorapproachisthedemand oftheskilloftheoperator.Moreover,theholderofthemeshcage isonlyinitssharpedge,whichcancauseittobedislodgedinthe future.

The anteriorapproachhastheadvantageofleading thesur- geon directlyintothelesion andallowinga good visualization.

Furthermore,decompressionofthespinalcordanteriorlycanbe obtaineddirectlyandcompletely.Inconclusion,instrumentation afterdebridementandbonegraftcanprovideinstantstabilityfor thespinalcolumn,whichcanleadpatientstoresumeactivities[13].

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Funding

The authorsreportnoexternal sourceoffundingduringthe writingofthisarticle.

Ethicalapproval

Ethicalapprovalwasnotrequiredinthiscasereport.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

FahmiAnshoricontributestothestudyconceptordesign,data collectionandwritingthepaper.

HekaPriyamurticontributes tothestudyconcept or design, supervisingandcriticallyreviewthemanuscript.

RahyussalimAJcontributesinthestudyconceptordesign,data collection,analysisand interpretation,oversightand leadership responsibility for the researchactivity planningand execution, includingmentorshipexternaltothecoreteam.

Registrationofresearchstudies

Thisisacasereportandnotaﬁrstinmantrial,thusregistryis notneeded.

Guarantor

RahyussalimAJisthesoleguarantorofthissubmittedarticle.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

Acknowledgement

Noconﬂictofinterestregardingforthepublicationofthispaper.

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