Closing–opening wedge osteotomy for severe, rigid, thoracolumbar post-tubercular kyphosis

Abstract

Childhood spinal tuberculosis, especially when associated with severe vertebral destruction of more than two vertebral bodies can end up in severe deformity. These children show progressive deformity throughout the period of growth and can develop severe kyphosis of [100°. Such kyphosis is severely disabling with significant risk of neurological deficit and respiratory compromise. Surgical correction of these deformities by both anterior and posterior approaches has been described but each have serious limitations of approach, correctability and safety. We describe here a technique of posterior closing-anterior opening osteotomy, which allowed us to correct a rigid post-tubercular deformity of 118°in a 13-year-old boy with neglected spinal tuberculosis. The patient was a 13-yearold boy, who had contracted spinal tuberculosis at the age of 6 years. Although the disease was cured by anti-tubercular chemotherapy, he continued to deteriorate in deformity and presented to us with severe thoracolumbar kyphosis (118°). He was neurologically intact but was beginning to show shortness of breath on exertion. Patient also had fore shortening of the trunk with impingement of the rib cage on the iliac crest. Radiographs revealed complete destruction of T12, L1 and L2 vertebral bodies with the T11 vertebra fusing with L3 anteriorly. CT scans and MRI revealed severe collapse of the vertebral column and the spinal cord being stretched over the 'internal gibbus', which was formed by the remnants of the destroyed vertebrae. A single stage closing-opening osteotomy was done by a midline posterior approach with continuous intraoperative spinal cord monitoring. The procedure involved extensive laminectomy of T11-L2, pedicle screw fixation of three levels above and three levels below the apex, a wedge osteotomy at the apex of the deformity from both sides, anterior column reconstruction by appropriate-sized titanium cage and gradual correction of deformity by closing the posterior column using the cage as a fulcrum. This allowed us to achieve a correction to 38°(68% correction). There was no intraoperative or perioperative adverse event and patient had good functional and Electronic supplementary material The online version of this article

Spinal Tuberculosis: Diagnosis and Management

“…In severe kyphosis following spinal TB in children, Rajasekaran et al [98] introduced a new surgical approach. They described a technique of posterior closing-anterior opening osteotomy, which allowed them to correct a rigid post-tubercular deformity as high as 118°.…”

“…They described a technique of posterior closing-anterior opening osteotomy, which allowed them to correct a rigid post-tubercular deformity as high as 118°. The procedure involved extensive laminectomy, pedicle screw fixation of three levels above and three levels below the apex, a wedge osteotomy at the apex of the deformity from both sides, anterior column reconstruction by appropriate-sized titanium cage and gradual correction of deformity by closing the posterior column using the cage as a hinge [98]. The same approaches were employed in adult patients with good results.…”

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS-GOP site

“…The incidence of tuberculosis is on the rise in both the developed and the developing world [1][2][3]. More than 30 million people suffer from overt tuberculosis and more than 2 million have the active spinal form of the disease [4]. The high success of disease cure achieved with antituberculous drugs has made spinal tuberculosis a 'medical disease' [5], nevertheless, despite similar results in longterm outcome and neurologic recovery for surgically and medically treated patients, surgery results in a significantly shorter hospital stay, superior rehabilitation, and spine deformity arrest [6,7].…”

Tuberculosis of the spine

“…In contrast the spinal deformity remain stationary once it heals in adults. TB spine in children requires a different management algorithm than that in adults 3–5. The children at risk for deformity should be identified early by the presence of ‘spine at risk’ radiological signs seen in the plain radiographs and must be selectively advised surgery 6.…”

“…The articles by Gokce et al .,7 is a report of a series of patients, where the author presents his results on TB spine with kyphotic deformity, with emphasis on sagittal balance and correction of spinal deformity. The surgical correction of healed kyphosis is difficult, and guiding principles have been suggested, such as closing–opening osteotomy of the spine 5. The broad principles of kyphotic deformity correction are, anterior corpectomy/osteotomy, posterior column shortening, posterior instrumentation, anterior cages/bone grafting, and posterior bone grafting.…”