Elsevier

World Neurosurgery

Volume 73, Issue 5, May 2010, Pages 560-564
World Neurosurgery

Peer-Review Report
Technique
Chemotherapy in Anterior Instrumentation for Spinal Tuberculosis: Highlighting a 9-Month Three-Drug Regimen

https://doi.org/10.1016/j.wneu.2010.02.023Get rights and content

Background

Anterior instrumentation has been used for surgical treatment of spinal tuberculosis, but there are different regimens of antituberculous chemotherapy used in combination with surgical intervention. The objective of this prospective study was to determine the efficacy of an antituberculous chemotherapy regimen by following a series of patients with spinal tuberculosis, for a minimum of 3 years, who underwent single-stage anterior radical debridement, autogenous bone grafting, and instrumentation.

Methods

The clinical and radiographic outcomes of these patients were analyzed with special reference to postoperative chemotherapy with a 9-month three-drug regimen. A total of 57 consecutive patients were treated surgically with single-stage anterior radical debridement, autogenous bone grafting, and instrumentation between 1999 and 2004. These patients received postoperative antituberculous chemotherapy with a 9-month three-drug regimen of isoniazid, rifampicin, and ethambutol. They were followed for 3-8 years (average = 5.5 years) with clinical and radiologic outcomes examined at each follow-up visit.

Results

All patients received postoperative chemotherapy for 9 months except two for whom postoperative chemotherapy was discontinued 4 and 6 months after surgery because of noncompliance. All patients experienced complete or significant relief of cervical or back pain, rapid improvement of neurologic function, and kyphotic correction. Bony fusion and eradication of the infection were achieved in all patients, with no recurrence of the tuberculosis.

Conclusions

In conclusion, postoperative chemotherapy with the 9-month three-drug regimen of isoniazid, rifampicin, and ethambutol is effective when combined with surgical treatment of spinal tuberculosis using single-stage anterior autogenous bone grafting and instrumentation.

Introduction

As the most important achievement in the treatment of tuberculosis, chemotherapy has been the mainstay of management of spinal tuberculosis (20, 23, 29). Since surgical intervention was recommended for patients with unresponsiveness or noncompliance with antituberculous chemotherapy, anterior radical debridement with autologous grafting of the defect has been popularized in the treatment of spinal tuberculosis. In response to the success in surgical treatment of spinal tuberculosis, a variety of short-course chemotherapy regimens have been employed in combination with radical surgery (1, 5, 15, 17, 26, 30). However, there remains controversy on the duration of chemotherapy regardless of whether surgical intervention is warranted.

Recently, anterior instrumentation has been used following radical debridement and bone grafting in the single stage. The use of anterior instrumentation can effectively correct kyphotic deformity and provide stable alignment and solid fusion on the basis of proper decompression and bone grafting. It has been shown that this procedure is not associated with an increase in the perioperative complications and postoperative persistence or recurrence of spinal tuberculous infection; thus, it may eliminate the concern of placing the implant in the center of infection as a foreign body for bacterial attachment (2, 3, 6, 8, 10, 11, 13, 25, 33).

The purpose of the study was to determine the efficacy of an antituberculous chemotherapy regimen by following prospectively a series of patients with spinal tuberculosis for a minimum of 3 years who underwent single-stage anterior radical debridement, autogenous bone grafting, and instrumentation. The clinical and radiographic outcomes of these patients were analyzed with special reference to postoperative chemotherapy with a 9-month three-drug regimen.

Section snippets

Materials and Methods

This study included 57 consecutive patients who were treated surgically with single-stage anterior radical debridement, autogenous bone grafting, and instrumentation at the authors' institution from 1999 to 2004. There were 33 men and 24 women with an average age of 52 years (range = 23-81 years) at the time of surgery. The indications for surgical intervention included severe cervical or back pain and/or radicular pain resistant to conservative treatment, neurologic deficits with associated

Results

All patients experienced immediate relief of their cervical or back pain on the first postoperative day. Twenty-two patients had mild pain at the final follow-up examination, but none of them needed analgesic drugs. Thirty-five patients with neurologic deficit as defined by Frankel scale as grade B to D on admission showed improvement in different degrees at the final follow-up visit. Thirty of them recovered completely to normal (Grade E). No one had neurologic deterioration. All five patients

Discussion

With regard to the efficacy of antituberculous chemotherapy regimens for spinal tuberculosis, there have been at least, to the best of our knowledge, two randomized controlled trials comparing chemotherapy alone with surgical debridement plus chemotherapy. In one study, all participants received para-aminosalicylic acid and isoniazid for 18 months with or without streptomycin for the first 3 months (16, 19), whereas a 6-month regimen of isoniazid and rifampicin was undertaken in the other study

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