Tuberculosis of the Spine in Children: OPERATIVE FINDINGS AND RESULTS IN ONE HUNDRED CONSECUTIVE PATIENTS TREATED BY REMOVAL OF THE LESION AND ANTERIOR GRAFTING

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Abstract

The results in the first 100 consecutive children, eighteen months to ten years old, who had débridement and anterior spine fusion for Pott's disease at the Ruttonjee Sanatorium, Hong Kong, between December 1955 and June 1959 were reviewed retrospectively after follow-ups ranging from one to fifteen years. The duration of symptoms prior to admission ranged from two months to five years. Forty-three of the 100 children had paraplegia and were first seen one month to thirty-six months after the onset of their neural symptoms.

The clinical roentgenographic and operative findings, the methods of treatment, and the results at follow-up are described.

In the forty-three patients with paraplegia, the causes of neural compression were: bone sequestrum, caseous material, pus, a sequestrated disc, a protruding ridge of bone produced by the kyphoscoliosis, pachymeningitis, and frank pus within the dura. All forty-three patients survived; thirty-seven made a complete recovery and six, a partial recovery.

Twelve patients had penetration of a lung by the paravertebral abscess. All did well after débridement, insufflation of streptomycin, closure of the visceral pleura, and the insertion of strut grafts in the spinal defect.

In seventy-four patients, solid fusion and healing of the tuberculous lesion occurred. In sixteen there was a stable non-union and apparent healing of the disease. The remaining ten were classified as having unstable non-unions requiring further treatment. Fifteen patients had an apparent decrease in their kyphos as determined roentgenographically, ten had no increase, and seventy-five had increases ranging from 2 to 106 degrees, or an average increase of 22.2 degrees. The causes of increasing kyphosis were slippage of the grafts, protrusion of the grafts into osteoporotic vertebral bodies, fracture or shortening of the grafts (in two instances combined with suspected reactivation of the disease process), and overgrowth of the posterior part of the fusion mass.

Assessment of these children's working capacity at follow-up revealed that in ninety-four it was complete and in six, partial.

The postoperative complications were: four superficial infections and one deep wound infection, all of which responded to appropriate therapy; pneumothorax in two patients: persistent pleural effusion in one; fracture of the graft in ten; slippage of the graft in five; a Horner's syndrome in two; convulsions in two; postoperative ileus in one; and bed sores in two. The findings and results in these 100 children are compared with those reported in the literature. The following conclusions are offered:

1. In the surgical treatment of Pott's disease in children, the anterior approach gives direct, wide access to the diseased area, which is always more extensive than the preoperative roentgenograms lead one to suppose. Through this approach, it is possible to remove all pathological foci and to make an accurate diagnosis.

2. In children, particularly those with a thoracic lesion, we believe that early decompression of the abscess is essential to avoid further destruction which may result in severe kyphosis, paraplegia, and impairment of cardiopulmonary function.

3. When there is penetration of a lung, the anterior approach to the spine is the only method of dealing with the spinal and the pulmonary lesion in one procedure.

4. Only surgical exposure permits a definite and accurate diagnosis of the cause of paraplegia.

5. The prognosis for recovery from a pure pressure type of paraplegia is remarkably good if the cause of the pressure is removed soon after the onset of symptoms.

6. Based on experiences with the treatment of both adults and children with Pott's paraplegia, it is our impression that the prognosis for recovery is far better in children than in adults.

7. An anterior interbody fusion between more than two vertebral segments can be made more stable, if need be, by a posterior fusion of the same segments.

8. In the treatment of tuberculosis of the spine in children, evacuation of the contents of the abscess, combined with removal of all avascular bone and anterior fusion using strut grafts has given results superior to those obtained by other methods.

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