Laporan Kasus

Comparation Between Operative and Conservative Therapy in Spondylitis Tuberculosis in Hasan Sadikin Hospital Bandung
Heda Melinda Nataprawira,* Agus Hadian Rahim,** Mia Milanti Dewi,* Yulia Ismail*
*Pediatric Department, **Orthopaedic and Traumatology Department Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung-Indonesia

Abstract: Spondylitis tuberculosis (TB) most commonly affects thoracal and lumbal vertebrae. Clinical manifestations are insidious and not specific so that the patient usually presents in advanced disease. Destruction in the corpus results in gibbus formation. Anti tuberculous drugs and conservative treatment remain the cornerstone therapy for spondylitis TB. However, operative treatment must be considered if the child presents with severe deformity or developing and deterioration of neurological deficit. We reported two children diagnosed as spondylitis TB with different management in each cases in addition to antituberculosis treatment. In the first case, a nine-year-old girl came to the hospital with chief complaint of painless lump at the lumbar region and weakness of the limbs. There was no neurological deficit so we performed spinal orthoses. While surgery was performed in the second case with posterior approach, a sixyear-old boy who came to the hospital with chief complaint of painless lump and neurological deficit. With appropriate procedure, both cases showed good results in follow-up. Keywords: Spondylitis tuberculosis, surgery, spinal orthoses

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Comparation Between Operative and Conservative Therapy in Spondylitis Tuberculosis

Perbandingan Tindakan Operasi dan Konservatif pada Anak Spondilitis Tuberkulosa di Rumah Sakit Hasan Sadikin, Bandung Heda Melinda Nataprawira,**Agus Hadian Rahim,** Mia Milanti Dewi,* Yulia Ismail*
*Bagian Ilmu Kesehatan Anak,**Bagian Ortopedi dan Traumatologi Fakultas Kedokteran, Universitas Padjadjaran/ Rumah Sakit Hasan Sadikin, Bandung-Indonesia

Abstrak: Spondilitis Tuberkulosis (TB) sering mengenai tulang belakang daerah torakal dan lumbal. Terdapat berbagai macam manifestasi klinisnya mulai dari yang ringan hingga berat, biasanya pasien akan datang dalam keadaan yang berat. Kerusakan pada korpus akan menyebabkan pembentukan gibbus. Penanganan secara kemoterapi dan terapi konservatif sangat penting dalam terapi spondilitis TB. Namun terapi secara operatif dapat dipertimbangkan pada pasien dengan deformitas yang berat disertai dengan gangguan neurologis. Dilaporkan 2 anak yang didiagnosis sebagai spondilitis TB di Rumah Sakit Hasan Sadikin yang mendapatkan 2 macam penanganan yang berbeda selain pemberian antituberkulosis. Seorang anak perempuan berusia 9 tahun datang dengan keluhan benjolan di punggung tanpa adanya kelainan neurologi sehingga dipasang spinal orthoses. Sedangkan pasien kedua, seorang anak laki-laki, 6 tahun datang dengan keluhan benjolan di pungung disertai deformitas dan kelainan neurologi. Pada pasien kedua dilakukan terapi secara operatif. Meskipun terdapat perbedaan penanganan namun kedua kasus spondilitis TB menunjukkan hasil yang baik selama pemantauan. Kata kunci: Spondilitis tuberkulosa, operasi, spinal orthoses

Introduction Vertebral tuberculosis (TB) is the commonest form of skeletal TB and constitutes about 50 percent of all cases of skeletal TB.1-5 Anatomically, the thoracic spine is the most common site of involvement followed by the lumbar spine.1,4,5 This kind of TB become a dissappearing problem in many Western countries, however, in developing countries this continued to pose one of the major public health problems.1,35 In Hasan Sadikin Hospital, 2.5% of pediatric spondylitis was reported during the previous year (1995-2000).2 Symptoms of spondylitis TB are commonly insidious, so that the majority of the patients reached the hospital late when the disease was fairly advanced.1-3 In our hospital, most of the children (41.2%) had visible lump or angulation of the spine (gibbus) as primary symptom, where as 29.4% had weakness of the lower limbs or paralysis, and 23.5% complained backpain.2 Antituberculous drugs remains the mainstay in the treatment of spondylitis TB, but surgical procedure also plays an important rule.1-3 This conservative approach, however, cannot prevent the possible progression of a kyphotic deformity. Surgery is indicated if there are presence of spinal deformity, significant neurological dysfunction at presentation, failure of conservative management for 6-8 weeks, persistent severe pain, and neurological dysfunction.1,3-6 The aim of this report was to compare between conservative and operative management of spondylitis TB. Conservative apMaj Kedokt Indon, Volum: 60, Nomor: 7, Juli 2010

proach are the choice for patient with no neurological deficit while surgery is for patient with severe deformity and neurological deficit. Report of the Cases Case 1 A nine-year-old girl presented to our hospital with weakness of the limbs since the last two months, however, she still could walk. The parents noted a painless lump at her lumbar region, but initially they did not seek any medical care. Her grandmother who lived in the same household with her was later known to have positive sputum acid fast bacilli, and suggested as source of TB infection. There were no history of night sweat, chronic cough, fever, or poor weight gain on this child. On physical examination, she showed malnutrition, kyphoscoliosis, gibbus at vertebra L4-5 region. Tuberculin skin testing (Mantoux test) was positive and plain chest X-ray appearance was suggestive TB, while vertebral X-ray revealed destruction at vertebral body without paravertebral abscess. Gastric aspirate lavage within 3 consecutive days showed negative acid fast bacilli, and Mycobacterium tuberculosis from culture was not detected. Radionuclear imaging procedure with single photon emission tomography/computed tomography (SPET/CT) using Tc-99methambutol showed hot spot meaning increased uptake in both lungs and lumbal region. The patient was diagnosed as
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Comparation Between Operative and Conservative Therapy in Spondylitis Tuberculosis spondylitis TB on V.L4-5 with the kyphotic deformity measured at initial presentation was 30 and lung TB. Treatment modalities given including bed rest, antituberculosis chemotherapy, and spinal orthoses (Thoracolumbosacralorthose (TLSO)). Follow-up examination at 3 months interval showed reduction of kyphotic deformity which was 22. ray was suggestive TB. Lumbosacral X-rays showed destruction of the vertebral bodies at Vertebra Th12 -L1 with paravertebral abscess. From gastric aspirate lavage there was no acid fast bacilli and Mycobacterium tuberculosis culture was negative. Radionuclear imaging procedure with single photon emission tomography/computed tomography (SPET/ CT) using radiopharmaceutical Tc-99methambutol showed hot spot meaning increased uptake at both parahiler lungs and Vertebra Th12-L1. The patient was diagnosed as spondylitis TB at vertebra Th12-L1 with kyphotic deformity 55 and lung TB. The patient received therapy that included antituberculosis drugs and operative treatment. Histopathologic biopsy was performed and it was consistent with TB. During observation, after two months, marked improvement on kyphotic deformity was noted which as much as 10.

A Figure 1.

A. Clinical Appearance of Case 1 Before Using Thoracolumbosacralorthose (TLSO) B . Gibbus Presented in the Vertebra L 4-5

A Figure 3.

A. Clinical Appearance of Case 2 at Admission (Before Surgery) B . Clinical Appearance of Case 2 After Surgery

A Figure 2 .

A. Clinical Appearance of Case 1 after Three Months Using TLSO B . Vertebral X-ray Showed Destruction at Verte bral Body

Case 2 A 6-year-old boy was admitted with painless lumps which excreted white fluids on the back since 1 year before admission. He experienced difficulty to stand or walk. His grandfather had positive acid fast bacilli on sputum examination. There were no history of night sweat, chronic fever nor cough. On physical examination, he had kyphosis, deformities on the back, moderate malnutrition, and paraplegia. He had positive tuberculin skin testing. Plain chest X 320

A Figure 4.

Vertebral Radiography Shown Kyphotic Defor mity in Case 2 A. Before Surgery 55, B. After surgery 10

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Comparation Between Operative and Conservative Therapy in Spondylitis Tuberculosis Discussions Tuberculosis (TB) of the spine is an uncommon form of TB occurring in fewer than 1 percent of TB patients.1,3-5,10 Spondylitis TB in children is diagnosed based on: (1) History of adults TB with positive acid fast bacilli (AFB), (2) Positive tuberculin skin testing, (3) The presence of gibbus, and (4) vertebral X-rays. However, it is not easy to determine the source of adult TB, and it is difficult to detect the involvement of TB in the spine in early stage as well, so the children commonly admitted to the hospital in advanced disease that showing gibbus and/or weakness of the lower limbs or paralysis.1 To support in diagnosing TB, a recent radionuclear imaging may plays an important role, especially in early detection and localization of the disease.13 The present cases are based on the use of the new radiopharmaceutical Tc-99m ethambutol to detect and locate TB at an early stage in any anatomical site. The main advantage of this radio pharmaceutical is the ability to differentiate tuberculous lesions from other infectious lesions. It is proven to be a stable, reproducible, and safe preparation with high labeling efficiency, having specific concentration in Mycobacterium tuberculosis.13 This procedure are performed to our cases supporting the diagnosis of TB. Even though AFB from gastric aspirate yielded negative, we diagnosed that these cases were most likely TB. Only fewer than 10% of children diagnosed with pulmonary TB had positive AFB.8 Symptoms of spondylitis TB are vary, starting with pain on the back to paraplegy or severe deformities of the spine. Neurological manifestations can be caused by extradural abscess, intradural tuberculoma, sequestrae of corpus vertebrae, and dislocation or pathologic subluxation from the bone.1,4 The progressive severity of neural deficit due to cord compression is staged by some workers essentially depending upon the degree of motor involvement (Table 1 and Table 2).1,12
Table 1. Classification of Tuberculous Paraplegia 1 Stadium Clinical Features Table 2 Neurological Deficit Degree 12 Degree A B C D E Classification Motoric and sensoric not function Only sensoric function Motoric weakness Motoric grade 4-5 Normal

Source: Solomon L, 2001.12 Table 3. Clinico-Radiological Classification of Typical Tuber cular Spondylitis 1 Stage I Clinico-radiological features Duration <3 Mo

Pre-destruc- Straightening of curvaturas, spasm of tive perivertebral muscles, scinti-scan would show hyperemia. MRI shows marrow edema II Early des- Diminished disc-space + paradiscal tructive erosion (Knuckle <10o). MRI shows edema and break of osseous margins, CT scan shows marginal erosions or cavitations III Mild angu- 2-3 vertebrae involved (K: 10o -30o) lar kyphos IV Moderate >3 vertebra involved (K: 30o-60o) angular kyphos V Severe >3 vertebra involved (K>60o) kyphos (hunchback)

2-4 Mo

3-9 Mo 6-24 Mo

>2 Yr

*Stage III, IV, and V all have vertebral bodies destruction and collapse + appreciable kyphos Source: Tuli SM, 20041

I. Negligible Patient unaware of neural dficit, physician detects plantar extensor and/ or ankle clonus II. Mild Patient aware of dficit but manages to walk with support III. Moderate Non-ambulatory because of paralysis (in extension) sensory deficit less than 50% IV. Severe III + flexor spasm/paralysis in flexion/flaccid/sensory deficit more than 50% sphincters involved Source : Tuli SM, 20041

Depending upon the degree of destruction of bone and the angular deformity, Kumar (1988) suggested classification of typical tuberculous spondylitis based on clinicoradiological appearance (Table 3).1

In the first case, the child showed mild neurology deficits and according to paraplegy TB classification included stage II1 and grade D according to Frankel cited from Solomon et al.11 According to clinico-radiological,1 this patient was in stage III because there was kyphosis 30 and 2 vertebraes involved. Case 2 showed mild neurology deficits and according to paraplegy TB classification included stage II and grade C according to Frankel. According to clinico-radiological, this patient include stage IV because there was kyphosis 55. Both children received antituberculosis regimen consisted of standard four-drug therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. This therapy was administered as first line treatment for 2 months, followed by rifampicin and isoniazid for 7-10 months or until symptoms regressed and laboratory and neuroimaging/radiological signs of resolution were not apparent.3-7 Even though the duration of treatment is somewhat controversial, but, some studies favor a 69 months course. Traditional courses range from 9 months to longer than 1 year. Duration of therapy should be individualized and based on the resolution of active symptoms and the clinical stability of the patient. Studies performed by the British Medical Research Council indicated that spondylitis TB
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Comparation Between Operative and Conservative Therapy in Spondylitis Tuberculosis should be treated with combination chemotherapy for 6-9 months.5 Although chemotherapy remains the mainstay in the treatment of spondylitis TB, surgical procedures play an important role. Antituberculosis therapy has not been shown to satisfactorily prevent associated kyphotic deformity.6 In case 1, we found a mild neurological deficit and from vertebral x-ray revealed destruction of corpus vertebrae without paravertebral abscess. Bracing is therefore recommended, and careful radiographic surveillance is necessary to assess response to treatment.6,10 Spinal braces are mostly used for ambulation of cases of spondylitis TB. The nature of the brace depends on the level of the lesion, and it is continued for about 18 months to 2 years when it is gradually discarded.1 Gradual mobilization of the patient is encouraged in the absence of neural deficit with the help of suitable spinal braces as soon the comfort at the diseased site permits. Kyphotic deformity reduced from 30 to 20 after 3 months wearing thoracolumbosacral orthoses (TLSO). On the contrary, in case 2 the severe kyphotic deformity and severe neurologic deficit, herein, the surgical approach is indicated. It is prefered to administer antituberculosis for a minimum of 1 to 2 weeks before surgery to help control of infection and make surgical tissue planes easier to dissect.4 Various surgical methods have been used to treat spondylitis TB. One of the alternative surgical approach is posterior costotransversectomy, posterior fusion combined with rigid instrumentation, which has been reported good results in patients with neurological impairment due to spondylitis TB.4,10 This procedure offers the advantage of an easy access to the spinal canal for neural decompression, prevents loss of correction of the vertebral alignment in the long term, and facilitates early mobilization of the patients.46 In Indonesia, Sapardan11 advocated the ten comprehensive treatment alternative procedures with anterior, posterior and anterior-posterior approach. This patient underwent alternative treatment VI with posterior decompression, laminectomy, costotransversectomy, debridement and paravertebral abscess evacuation, and then was stabilized by placing pedicle screw and rod.11 We advised the patient to follow-up at 1-month intervals in the first year, a 3-months intervals in the second year, and then annually thereafter for 5 years.4 The kyphotic deformity measured preoperatively was 55, and this reduced to 10 in 2 months follow-up after surgery. Conclusion Decisions regarding the treatment of choice for spondylitis TB whether it should be conservative chemotherapy with spinal braces or combination of chemotherapy and surgery, should be individualized for each patient. References
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