B.

Surgical Treatment Actually, majority of spinal tuberculosis patients has improved with chemotherapy only (Medical Research Council 1993). Surgical interventions are beneficial for patients whom radiologically compressive lesion causes neurological abnormalities. After surgery, patients usually stay in bed for 3-6 weeks2,10. Surgery is also performed if after 3-4 weeks administration of antituberculotic drug therapy and bed rest (conservative therapy), there were still no improvement, so that the most effective treatment for spinal lesion are direct and blunt surgery to evacuate "purulent" tuberculosis, remove tuberculosis sequester and infected bone and fuse spinal segments involved9,13. Pott's paraplegia itself is always an indication for a surgery (Hodgson), however, Griffiths and Seddon classified indication of surgery as bellow11: A. Absolute indication 1. Paraplegia with onset during conservative therapy; surgery is not performed if there were any signs of pyramidal tract involvement, it was postponed until there was motoric weakness. 2. Paraplegia that became deteriorating or static although has been in conservative therapy. 3. Complete loss of motoric strength for 1 month though has been in conservative therapy 4. Paraplegia accompanied by uncontrolled spasticity so that bedrest and immobilization were not possible or there was a risk for necrosis due to pressure to the skin. 5. Severe paraplegia with rapid onset, indicating tremendous pressure that is not common from abscess or mechanical accident; may also be caused by vascular thrombosis that can not be diagnosed. 6. Severe paraplegia; flaccid paraplegia, paraplegia in flexion position, a complete loss of sensibility, or loss of motoric power for more than 6 months (indication for immediate operation without administration trial of conservative therapy) B. Relative indication

1. Recurrent paraplegia with history of mild paralysis. 2. Paraplegia at older age, indication for surgery was strengthened due to the possibility of adverse effects of immobilization. 3. Paraplegia accompanied by pain, pain can be caused by spasm or nerve compression. 4. Complications such as urinary tract infection or stones. C. Rare indications 1. Posterior spinal disease 2. Spinal tumor syndrome 3. Severe paralysis secondary to cervical disease 4. Severe paralysis due to cauda equina syndrome Choice of operation approach is based on location of the lesion, either anterior or posterior. Generally, if the primary lesion is in the anterior, surgery is performed through the anterior and anterolateral approach, whereas if the lesion is in the posterior, surgery is performed with posterior approach. Current surgery therapy using the anterior approach (HongKong procedure) is a procedure that is done in almost every center9,13. Although surgery was chosen, antituberculosis chemotherapy is still important. Administration of additional chemotherapy 10 days prior to surgery has been recommended. Another opinion stated that the chemotherapy was administered 4-6 weeks before eradicating tuberculosis focus directly with the anterior approach. Necrotic area with cacceaseousa containing dead bone and granulation tissue was then evacuated and the cavity was filled by autogenous bone graft from the rib cage. This radically direct approach encourages rapid recovery and achieves early stabilization of the spine with fusion of the vertebrae affected. Posterior spinal fusion is performed only if there are two or more vertebral bodies destruction, intability due to the posterior elements destruction or delayed bone consolidation and those that can not be approached from anterior.3,9 In cases of severe kyphosis or neurological deficits, additional chemotherapy and bracing is still selected, especially in the centers where equipment for anterior spinal surgery is not available.6 Surgery treatment is

usually accompanied by the administration of chemotherapy as an addition, combined with 6-12 months of bedrest and followed by 18-24 months of spinal bracing.9 For patients with spinal lesions involving more than two vertebrae, a period of bedrest followed by external support in TLSO recommended so that fusion can be consolidated7. Surgery in radiculomyelitis tuberculous conditions does not help much. For patients with intramedullary tuberculoma, surgery is only indicated if the lesion size was not reduced with the administration of chemotherapy and the lesions are solitary. Hodgson and colleagues avoided laminectomy as the main therapeutic procedure for Pott's paraplegia on the grounds that the excision of lamina and posterior neural elements will left the only remaining support structure that runs from the disease in the anterior. Laminectomy is indicated only in patients with paraplegia due to laminar disease or involvement of the spinal corda or when paraplegia remains after anterior decompression and fusion, and also myelography showed blockage8. VIII. Prognosis7-10,14-17 Prognosis of patients with tuberculous spondylitis depends on patients age and general health condition, severity and duration of neurological deficits as well as therapy given. a. Mortality The rate of mortality in tuberculous spondylitis has decreased along with finding of chemotherapy (to less than 5%, if patients were diagnosed early and comply to the treatment regimens and strict monitoring). b. Relapse The rate of trend to the recurrence of patients treated with antibiotics and current medical regiments and strict monitoring was nearly 0%. c. Kyphosis Progressive kyphosis is not only a deformity that affects appearance significantly, but also can cause neurological deficits and heart or respiratory failure because of limited pulmonary function.

Rajasekaran and Soundarapandian in their research concluded that there is a real association between the end of the deformity angle and the amount of vertebral body loss. To predict possible deformity angle, researchers use the formula: Y = a + bX with the caption: Y = final angle of deformity X = number of corpus vertebrae loss a and b are constants with a = 5.5 and b = 30, 5. Thus the final gibbus angle can be predicted, with an accuracy of 90% in patients who did not undergo surgery. If the prediction of this angle is exaggerated, then surgery should be considered as early as possible. d. Neurological deficits Neurologic deficits in patients with tuberculous spondylitis can improve spontaneously without surgery or chemotherapy. But in general, prognosis improves with early surgery. e. Age In children, prognosis is better than adults. f. Fusion Fusion of solid bone is essential for permanent restoration of tuberculous spondylitis. The case was an 8-year-old girl, weighted 17.7 kg, body length 11 cm, arm span 111 cm, with inferior paraparesis ec spondylitis tuberculosis, good nutrition. 2 months before admission, patient complains stiffness on the back, pain (-), a lump on the back with 1-1.5 cm, no pain, no redness, no bleeding, then patient was taken to a handyman until the lump disappear. 1 months, the patient complained his leg weakened, was unable to walk and had to hold on. Fever but with temperature that was not too high (+), history of trauma (-). Her legs were felt more and more heavier, but could still feel pain. Bowel and bladder was normal. Patient felt more and more weaker. Currently she had difficulty moving her leg. Tingling feet (+), could still feel a touch. Then the girl was brought to the regional general hospital of Bekasi and was diagnosed by spondylitis TB, treated

1 month 1 week and only given 2 kinds of drug. On physical examination there was no lump on the vertebrae but there was spastic in the lower extremities, signs of UMN involvement, as well as the good sensibility. TB scoring was 4. Radiographic examination showed no thickening of the hilum, the lumbosacral rontgen showed destruction of the corpus V Th 9 and opacity at the level of right paravertebral Vth 9-11, suspected paravertebra mass that impressed a lumbar spondylitis tended to a tuberculosis. MRI examination found severe spondylolisthesis Th 2-3 with spinal cord supression at the level Th 2-3. Lesion on the Th 9 corpus with compression fracture of Th 9 was accompanied by paravertebral mass which was suspected spondylitis TB. Based on the examinations above, the patient was diagnosed with tuberculosis spondylitis. ATD (antituberculotic drugs) were delayed until 2 weeks because level of AST and ALT increased >5 times. After 2 weeks, laboratory result of AST and ALT were normal, then patient was administered ATD and medical rehabilitation with physiotherapy, also orthotic and prosthetic TLSO. Patient would also undergo PSSW operations performed by neurosurgeons. Because of difficulties in establishing diagnosis of TB in children, then the scoring system was made. Based on the Guidelines for Children's National Tuberculosis scoring system, it is established TB if the score was 6. In this patient, the total score is 4 (positive tuberculin test, and fever >2 weeks). On lavage examination, there was no BTA obtained. Diagnosis must be established with the discovery of Mycobacterium tuberculosis, which is difficult to found in children due to fewer number of bacteria and the difficulty to obtain the specimen (sputum).1,2 TB in children is at risk of developing into TB bones/ joints because of the possibility of hematogenous spread from increasing bones vasculature during growth.1 Spinal tuberculosis (TB spondylitis) infection is the most common skeletal TB infection, followed by coccitis and gonitis TB. 1,2 Infeksi has the nature slow progressive and destructive in one or more vertebra. 1 In this case there were no lump on the back, no pain, no history of trauma, the color were the same as the surrounding skin, but the child was not able to walk.

Kumar divided the course of the disease into 5 stages: 1) the implantation stage: 6-8 weeks, 2) initial destruction: 3-6 weeks, in the form of corpus destruction and mild narrowing of the discs, and 3) advanced destruction: 2-3 months, in the form of massive destruction, collapse, caseaseous mass and pus in the form of cold abscess, wedging that cause kyphosis, 4) neurological disorders: determined by abscess pressure into the spinal canal, and 5) residual deformity: 35 years after implantation stage, kyphosis or gibbus which is permanent . Konstam divided neurological disorders in TB spondylitis into 4 degrees: I) Spastic but still able to walk, II) Could not walk but there is still voluntary movement, III) There is no voluntary movement, paraplegia in extension movement, and IV) Flaccid paraplegia. In this case, the disease process was until stage 3, given by the mass, spastic neurological deficits (children could not walk), so that neurological disorders can be classified to the third degree. Based on history, physical examination, and investigations then it could be established spondylitis tuberculosis in this patient. Management of spondylitis TB in children is inseparable unity between medicine administration, nutrient management, and treatment of comorbidities. Respirology Coordination Unit from Indonesian Pediatric Association determined management of bone and joint TB with antituberculosis rifampicin, isoniazid, pyrazinamide, and ethambutol or streptomycin. RIF and INH were given for 12 months, PZA and EMB/ STREP during the first 2 months. In these patients, the treatments are given in accordance with national tuberculosis guidelines for Indonesian children (UKK IDAI) that is, the first 2 months with INH administration of 5-10 mg/kg/day (1 x 100 mg), RIF 10-20 mg/kg/day (1 x 180 mg), PZA 15-40 mg/kg/day (1 x 300 mg), and streptomycin injection 15-40 /kg/day up to 1 g/day (1 x 300 mg IM), and for the next 10 months 2 ATD: INH and RIF; ATD dose should always be adjusted to the weight. Surgical intervention was substantial in advanced cases with extensive bone destruction, abscesses or neurological disorders. The aim of surgery is to prevent neurological deficits and spinal deformity. Surgery also helps the success of chemotherapy if abscess space causes avascular environment that protects the

bacteria from systemic antibiotics. Surgery with best results are obtained at the beginning of the process before it progresses to fibrosis and scars. Clinical response to surgery is also much faster and better at the baseline of the disease compared to patients with diseases that are chronic and deformity.15-17 General considerations for surgery are: 1) neurological deficit, 2) instability of the spine or kyphosis >30, 3) no respond with ATD, 4) non diagnostic biopsy, 5) big paraspinal abscess that requires drainage, 6) debridement of the infected tissue.1,2,3 Overall, surgery is recommended for about 5% cases without complications, and 60% accompanied by neurological deficit.3,7 The prognosis of spondylitis TB depends on the degree of damage to the joints or bones. Minimal abnormality usually could generally return to normal, but for advanced disorders it could lead to sequelae (defects) that disrupts patients mobility. The research from the British Medical Research Council showed further changes in the radiographs even after ATD therapy is ceased, but kyphosis could still deteriorate. The risks of worsening kyphosis is mostly for: 1) children under 15 years old, in which 3 thoracic vertebrae exposed, 2) in patients whose disease extends from 1-2 vertebra to 3-4 vertebrae, and 3) patients with kyphosis angle >30 .13 In this case, the prognosis is ad bonam because post operative and after routine physiotherapy management, the child can walk and do activities as before the illness.