Manajemen Kifosis Pasca Infeksi

Tuberkulosis Vertebra

Dr S Dohar A L Tobing
Div Spine, Dep Orthopaedi-Traumatologi

FKUI/RS Ciptomangunkusumo
 TB spine problems
• Active infection :
– Lung
• Neurological involvement
– Local
• Drug resistance
– Both
– Systemic
• HIV/AIDS

• Health deterioration • Social

• Pain • Environment

• Pus formation • Finance

• Deformity
 Problems in healed TB spine

• Deformity

• Instability

• Late deformity (children)

• Late neurological deterioration

• Recurrence of infection
 Deformity in healed TB spine

• Bony fusion on several level

• Fibrous fusion

• Acute kyphotic deformity

• Failed deformity correction

 Surgical solutions

• Decompression

• Correction of deformity

• Stabilization
 Decompression
• Wide :
– open vs. minimal invasive ?
– laminectomy or corpectomy

• Adhesions to dura :
– fibrotic tissue
– bony prominences
 Deformity

• Mostly kyphosis, scolio or kyphoscoliosis

 Kyphosis correction

• Smith-Petersen Osteotomy (SPO)

• Ponte Osteotomy

• Pedicle Substraction Osteotomy (PSO)

• Vertebral Collumn Resection (VCR)

Smith-Petersen Osteotomy (SPO)
• Monosegmental post closing wedge osteotomy
• Anterior osteoclasis
• Angular correction : 300-400
• Complications :
– aortic rupture
– cauda equina syndrome
– paraplegia
– Sup mesenteric artery syndrome
SPO
 Ponte Osteotomy
• Multisegmental post closing wedge resection osteotomy
• V-shaped or chevron osteotomy
• Facetectomies to pedicle resection !
• Correction thru disk
• Angular corr : 100 / level
• Harmonious correction
• Effective in long, rounded, flexible thoracic kyphosis
Ponte osteotomy
 Pedicle Substraction Osteotomy
• Monosegmental post closing wedge resection
osteotomy
• Correction thru VB (apex)
• All collumns shortened
• Preferred in : AS at L2 or L3, sharp kyphosis, sagittal
imbalance 12-15 cm, in fused spine
• Angular corr : 300-400
PSO
 Vertebral Collumn Resection
(VCR)
• Complete resection 1 or more VB

• Ant and Post resection

• Ant and post approach

• in severe, rigid deformity

• Beware of cord kinking !

Important  correction of sagittal balance !!

 Healed TB, late deformity in children
• Difficult task in bony fusion, acute kyphosis
• Problems :
– correction deformity
– ‘soft’ bone for applying instrumentation
– Growing bone
– instrumentation techniques
 Preparing Team and Positioning
• Patient name and levels/extent of procedure
• Foley / lines/ neuromonitoring
• Anesthesia expectations
• Use of antifibrinolytics/blood management
• Positioning and OR table
• Expected duration of surgery
• What target mean arterial pressure for what part of case
 Preparing Team and Positioning
• Implant use
• Intra-op imaging plan
• Bone graft, bone substitute
• Intra-wound antibiotics
• Special pain management plans (intra-thecal
morphine etc)
• Disposition (regular ward or ICU)
 Table and Positioning
• Jackson table and 4-poster bolster

• Rolled bath towels for shoulder

• Kambin bolster
 Avoiding Complications

• Watch out for pressure sores and eye

complications

• Duration of surgery !!

• Reverse Trendelenburg to decrease pressure

on face
 EF, male 28yo

• Severe LBP since 4 mo

• Gradual LBP since 1 year, but seek no med tx

since still able to do daily work

• At 4 mo seek medical help to rural hospital

and was diagnosed having TB spine
• Look
No deformity/curve, gibbus (+),
no redness, no draining sinus, no
wound

• Feel
Tenderness VAS 5 on midline and
paravertebrae Th10-11 , muscle
spasm (-), step off (-)

• Move
Limited due to pain
 Reflexes Right Left

Patellar tendon (L4) ++ ++

Achilles tendon (S1) ++ ++

Babinsky group - -

Clonus - -

Right Left Right Left

L2 5 5 Th11 2 2
L3 5 5 Th12 2 2
L4 5 5 L1 2 2
L5 5 5 L2 2 2
S1 5 5
L3 2 2

L4 2 2

L5 2 2

S1 2 2
Autonom
Urinary incontinence (-)
Fecal incontinence (-)
•
 Pre Op X Ray
• Kifotic deformity
• Bony destruction L1-
L2,
• End plate destruction
T11-12,
 MRI Sagital
Sagital
MRI Axial
 Laboratory
CBC : 10,4/33,1/419.000/6.710
PT : 9,9 (10,9)
aPTT : 37,6 (33,1)
AST / ALT : 47/26
Ur / Cr : 19/1,0
Electrolyte : 142/3,42/103,6
GDS : 89
ESR : 105
LDH : 503
CRP : 26,3
 Diagnosis Planning
Back Pain due to Spondylitis TB L2-3

List of Problems
•Surgical: Post app
Infection
Pain – Decompression + biopsy
Cold Abcess
Deformity
– Debridement
– Posterior Correction
Date of Thursday
operation 03.05.16 (PSO, corpec)
Implant Pedicle screw,
Rod, Cross link – Stabilization
Vendor XXXXXX – Fusion
Time of surgery 4 hours
 INTRAOPERATIVE
PEDICLE SCREW INSERTION LAMINECTOMY

Caudal Cranial
 INTRAOPERATIVE
FINAL RESULT FINAL RESULT

Post laminectomy, PSO and posterior stabiization Post bonegraft application

POST OPERATIVE X RAY
PRE OPERATIVE X RAY POST OPERATIVE X RAY
 Girl, 2 y.0.
• Able to walk, with mild complains
• Slight gibbus
Solution ?
Female, 10 y.o.
 Post op Complications

• Neurologic compl :
– During surgery

– Several hours post op

 Conclusions
• Healed TB spine with deformity is still a very
difficult issue to solve
• Correction of deformity is high risk of
neurologic complications
• Various technique of osteotomy may be
applied
Terimakasih