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NSJ-Spine 10/99.

live 9/7/99 5:57 AM Page 163

J Neurosurg (Spine 2) 91:163–169, 1999

Transpedicular instrumentation as an adjunct in the


treatment of thoracolumbar and lumbar spine
tuberculosis with early stage bone destruction

TAO-CHEN LEE, M.D., KANG LU, M.D., LIN-CHENG YANG, M.D.,


HSUAN-YING HUANG, M.D., AND CHENG-LOONG LIANG, M.D.
Departments of Neurosurgery, Anesthesiology and Pathology, Chang Gung Medical College,
and Chang Gung Memorial Hospital, Kaohsiung, Taiwan; and Department of Medical Research,
Ta Jen College of Technology and Medicine, Ping Tung, Taiwan

Object. Because modern imaging techniques now allow for early diagnosis of spinal tuberculosis, more conservative
management options are possible. The authors evaluated the effectiveness of transpedicular instrumentation for treatment
of thoracolumbar and lumbar spinal tuberculosis in patients with mild bone destruction and the main symptom of “insta-
bility catch” (a sudden painful “snap” that occurs when one extends from a forward bent to an upright position).
Methods. Eighteen patients (nine men and nine women, age range 49–71 years) with spinal tuberculosis were treated
with transpedicular instrumentation that was supplemented with posterolateral fusion and chemotherapy. All patients
were wheelchair dependent or bed-ridden due to severe instability catch, with a mean symptom duration of 2.5 months
(range 1–6 months). Two contiguous vertebrae were involved in 17 patients, and a single vertebrae was involved in one.
In five patients mild neurological deficits (Frankel Grade D) were present. During surgery, the screws were implanted
into the two nonaffected pedicles nearest the lesion to stabilize the involved segments. No attempt at radical debridement
or neural decompression was undertaken. The follow-up period ranged from 21 to 40 months. Postoperatively the insta-
bility catch was relieved within 10 days (excellent outcome) and within 1 month (good outcome) in seven and eight
patients, respectively, and within 3 months (fair outcome) in two; in the remaining patient, the symptom did not resolve
(poor outcome). A short duration of symptoms (generally  3 months) and bone destruction of less than 50% in the
involved vertebral bodies were observed in patients who made a good or excellent outcome. During the follow-up peri-
od, good maintenance of spinal alignment, stabilization of the involved segment, and resolution of the inflammatory
process were shown; however, there was no strong evidence that fusion had occurred at the bony defect. Patients in whom
a fair outcome was achieved experienced a longer duration of symptoms, and in each, one vertebral body with greater
than 50% bone destruction was demonstrated. However, good maintenance of spinal alignment was also shown during
the follow-up period. The patient whose outcome was poor had the longest history (6 months) of symptoms and the most
extensive involvement of the spine ( 50% destruction of two adjacent lumbar vertebral bodies). Postoperatively, implant
failure occurred and the patient developed a wound infection.
Conclusions. Transpedicular instrumentation provides rapid relief of instability catch and prevents late angular
deformity in patients with thoracolumbar and lumbar spinal tuberculosis in whom limited ( 50%) bone destruction
of the involved vertebral bodies has been shown and whose main symptom is instability catch.

KEY WORDS • transpedicular instrumentation • spinal tuberculosis • instability catch

tuberculosis is not an uncommon disease enti- sis of spinal tuberculosis has become possible.4,7,12,28 In
S
PINAL
ty in underdeveloped and developing countries.3,6 In addition, more effective regimens of antituberculous che-
the United States, the incidence of spinal tuberculo- motherapy have become available.20,24 Therefore, the treat-
sis has been increasing in the past 10 years.22,26 ment strategy for this disease entity has been revised and
The “Hong Kong operation,” which involves radical re- has become more conservative in recent years.1,6,8,11,20,22–24,26
section of the tuberculous-infected focus and bone grafting, Modern transpedicular instrumentation can provide rigid
was developed prior to the advent of modern imaging stabilization of the thoracolumbar and lumbar spine with
modalities.9,10 At that time, early diagnosis of spinal tuber- only short segments required. It has been proven effective
culosis was difficult, and many patients with this disease for the treatment of many thoracolumbar and lumbar spinal
had already developed severe neurological deficits and disorders that result in segmental instability.2,5,13–19,27,29 This
advanced bone destruction by the time of diagnosis. Conse- operation, which is performed via a posterior approach, is
quently, radical debridement, neural decompression, and re- especially feasible for treatment of spinal tuberculosis,
construction of the vertebral column were often warranted. because the tuberculous infection usually involves the ante-
With the advent of computerized tomography (CT) scan- rior column.4,7,12,26,28,30 Its main shortcomings are that it does
ning and magnetic resonance (MR) imaging, early diagno- not allow for radical resection of the infectious focus and

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T. C. Lee, et al.

does not enable satisfactory interbody fusion. However, in a Guérin vaccine is still administered in this country, the tuber-
recent study by the Medical Research Council Working culin skin test is not diagnostic and was therefore not used in
Party, the authors showed that medical treatment alone can this series for preoperative diagnosis of tuberculosis.
achieve complete or partial fusion at the bone defect in more During the operations, the screws were inserted into the
than 80% of the patients with spinal tuberculosis.20 This two nonaffected cranial and caudal pedicles nearest to the
result encouraged us to introduce transpedicular instrumen- bone destruction. That is, the screws could be inserted into
tation for the treatment of spinal tuberculosis in patients the infected vertebra if the infectious focus did not involve
whose bone defect is too mild to warrant more radical inter- the pedicles. The instrumentation was routinely supple-
ventions but in whom chemotherapy might be inadequate. mented with posterolateral arthrodesis in which autogenous
bone harvested from posterior iliac crest was used. A biop-
Clinical Material and Methods sy sample of the granulation tissue was obtained via a
Between January 1993 and February 1996, 24 patients transpedicular route or by a limited laminectomy, depend-
with severe instability catch, whose imaging findings sug- ing on the location of the infectious focus. When accessi-
gested thoracolumbar or lumbar spinal tuberculosis under- ble, the abscess was drained during the operation. How-
went surgery in which transpedicular instrumentation was ever, extensive laminectomy or radical debridement was
placed and a tissue biopsy sample was obtained. Of these, not attempted because neurological function worse than
18 patients in whom there was histological proof of tuber- Frankel Grade D was not demonstrated in any of the pa-
culous granulomatous inflammation were included in this tients in this series. The biopsy specimens were sent for
retrospective study. The other six patients (including one pathological examination, and the pus obtained from the
in whom a final diagnosis of Salmonella infection was abscesses was sent for culture for mycobacterium tubercu-
made) with pathological findings of only acute or chronic losis. As the polymerase chain reaction technique did not
inflammation were excluded. become available in our hospital until 1997, none of the
The following imaging features were considered patho- specimens obtained in this series was examined using this
gnomonic of spinal tuberculosis: 1) plain x-ray film evi- new technique. The patients, who wore Taylor braces, were
dence of focal erosion in the anterior corner of the vertebral encouraged to move around on the 2nd postoperative day.
body adjacent to the end plate; 2) CT evidence of anterior Antituberculous chemotherapy (rifampin 450 mg daily,
vertebral body destruction with paraspinal soft-tissue in- isoniazid 300 mg daily, and ethambutol 1200 mg daily) was
volvement; and 3) MR imaging findings indicative of ver- instituted the day on which radiological diagnosis of spinal
tebral body and paraspinal soft-tissue mass with decreased tuberculosis was made and it was continued for 12 months.
signal intensity on T1-weighted sequence, increased signal Results
intensity on T2-weighted sequence, and rims of enhance-
ment on gadolinium-DTPA–enhanced sequences.4,7,12,28 The treatment results were shown in Table 1. The duration
Preoperatively, all patients had undergone plain radiogra- of surgery ranged from 3 to 4.5 hours (mean of 3.5 hours).
phy and MR studies, and two patients had undergone an The blood loss ranged from 100 to 300 ml (mean of 220 ml).
additional CT study. No patient required intraoperative blood replacement.
The indications for placement of transpedicular instru- During the operation, the granulation tissue was found in
mentation were radiologically visible bone destruction in the the vertebral bodies in 10 patients and in the epidural space
thoracolumbar or lumbar spine and the clinical symptom in eight. Histological examination of the granulation tissues
of instability catch severe enough to render the patients ful- invariably showed features typical of tuberculous granulo-
ly wheelchair dependent or bedridden. “Instability catch,” matous inflammation: infiltration of lymphocytes and epi-
which implies an unstable spine, was defined by Nachem- theloid cells with areas of caseating necrosis and sporadic
son21 as “a sudden painful snap when someone extends from Langhans’-type giant cells (Fig. 1). Acid-fast bacilli were
a forward bent position into the upright position.” not found in any of the biopsy specimens. Epidural or intra-
There were nine men and nine women, with a mean age osseous abscesses were found and drained during surgery
of 58.8 years (range 49–71 years). The spinal lesions were in six patients. However, mycobacterium tuberculosis grew
located in the thoracolumbar (five cases) or lumbar (13 in only one of the cultures from the abscess specimens. The
cases) spine, from T-9 to L-5. Two contiguous vertebrae erythrocyte sedimentation rate returned to normal in all
were involved in 17 patients and a single vertebra in one. patients after completion of chemotherapy.
Prominent ( 15˚) angular deformity was found only in one The assessment of operative results was based mainly on
patient. The extent of bone involvement was determined the relief of instability catch because patients in this series
using MR imaging, which is sensitive in detecting early experienced no, or only mild, neurological deficits. The
stage inflammatory process.4,7 All patients experienced an results were categorized as follows: excellent, complete re-
intractable instability catch, fulfilling the criteria by which lief of instability catch within 10 days postoperatively; good,
we determined the need for surgical stabilization. In addi- complete relief of instability between 10 days and 1 month
tion to the back pain, five patients had sustained a mild neu- postoperatively; fair, complete relief of instability between 1
rological deficit (Frankel Grade D) that resulted from gran- and 3 months postoperatively; and poor, persistent instabili-
ulation tissue or abscesses that caused neural compression. ty catch throughout the follow-up period. The follow-up
The duration of clinical symptoms ranged from 1 to 6 periods ranged from 21 to 40 months (mean of 28 months).
months, with a mean of 2.5 months. In all patients a moder-
Excellent/Good Treatment Results
ate elevation of erythrocyte sedimentation rate was dem-
onstrated (range 35–70 mm/hour; mean 50 mm/hour). According to this categorization, excellent and good
Because tuberculosis remains endemic and bacillus Calmette– treatment results were achieved in seven and eight patients,

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Transpedicular instrumentation for spinal tuberculosis

TABLE 1
Clinical characteristics in 18 patients with spinal tuberculosis treated with transpedicular instrumentation placement and chemotherapy*
Preop Characteristics

Dur- Site No. of Postop Characteristics


ation of of In- Verte-
Age Symp- volved brae W/ Fusion Spinal Follow
Case (yrs) Frankel tom Verte-  50% Relief Frankel at Align- Compli- Up
No. Sex IC Grade (mos) brae VBD of IC Grade Defect ment cations (mos) Outcome

1 49, F + E 2 L2–3 0 10 days E – yes – 30 excellent


2 55, M + E 2 L4–5 0 10 days E – yes – 24 excellent
3 58, M + E 1 L-4 0 10 days E – yes – 25 excellent
4 51, F + E 3 L3–4 0 10 days E – yes – 36 excellent
5 54, F + E 2 T9–10 0 10 days E – yes – 25 excellent
6 59, M + E 3 L3–4 0 10 days E – yes – 30 excellent
7 58, F + E 1 L2–3 0 10 days E – yes – 23 excellent
8 59, F + E 1 T10–11 0 10 days to 1 mo E – yes – 21 good
9 71, F + E 3 L3–4 0 10 days to 1 mo E – yes – 24 good
10 56, M + D 2 L4–5 0 10 days to 1 mo E – yes – 29 good
11 54, F + E 3 L4–5 0 10 days to 1 mo E – yes – 40 good
12 62, M + E 3 L3–4 0 10 days to 1 mo E – yes – 30 good
13 53, M + E 1 T10–11 0 10 days to 1 mo E – yes – 30 good
14 64, M + D 2 L3–4 0 10 days to 1 mo E – yes – 25 good
15 60, M + E 2 L1–2 0 10 days to 1 mo E – yes – 23 good
16 62, F + D 3 T12– L1 1 1 mo to 3 mos E – yes infection 28 fair
17 65, F + D 5 L3–4 1 1 mo to 3 mos E – yes – 30 fair
18 68, M + D 6 L4–5† 2 ‡ D – no|| infection 36 poor
& implant
failure
*Abbreviations: IC = instability catch; VBD = vertebral body destruction; + = present; – = absent.
† There was a skip lesion at cervical spine.
‡ Instability catch was not relieved during the follow-up period.
|| The implant was removed due to complication.

respectively. These 15 patients (83%, Cases 1–15; Table 1) and they underwent MR imaging during the follow-up ex-
had satisfactory treatment results with similar clinical pic- aminations. These MR studies invariably demonstrated reso-
tures and imaging findings and will be discussed as one lution of the inflammatory process with marked shrinkage of
group hereafter. These patients had a short history of clini- the preexisting paraspinal soft-tissue mass, normalization of
cal symptoms prior to admission—less than 3 months in all the signal intensities of the involved vertebrae, and filling of
of them. Most (13 of 15) patients had not experienced neu- the bone defect with a solid mass (Fig. 2 lower right). How-
rological deficits and in only two was a mild (Frankel Grade ever, absence of trabeculae within the solid masses implied
D) neurological deficit demonstrated. The bone involve- that there was no strong evidence of fusion at the defects.
ment in this group was shown to have the following charac-
teristics: 1) only short segments (one or two vertebrae) were Fair Treatment Results
involved; 2) none of the involved vertebrae showed more
Two patients (Case 16 and 17) in this series were cate-
than 50% destruction of the body (Fig. 2 upper left and cen- gorized as having fair outcomes. In one patient there was a
ter); 3) absence of a prominent ( 15˚) angular deformity 5-month history of symptoms. In both patients two verte-
was demonstrated; and 4) there was absence of a skip lesion brae were involved and mild neurological compromise was
elsewhere. All of these 15 patients experienced great im- demonstrated (Frankel Grade D). In both cases, the pre-
provement of the preexisting instability catch, despite the dominantly involved vertebra showed more than 50% de-
superficial wound pain, and they were able to move around struction of the vertebral body on preoperative imaging
on foot or in a wheelchair by the 3rd postoperative day. studies (Fig. 3 upper left and right). Postoperatively, both
Of the patients in this group, the two patients in whom a patients experienced some improvement of the instability
Frankel Grade D neurological deficit was demonstrated im- catch and were able to use a wheelchair within 1 week and
proved slowly, but progressively, and became neurologically to begin ambulating with a walker within 1 month. Return
normal between the 1- and 2-month follow-up examination. to normal neurological function was demonstrated between
In all 15 patients, examination of follow-up plain radi- the 2- and 3-month follow-up visits. One presented with
ographs showed posterolateral fusion masses (Fig. 2 upper postoperative wound infection. We partially opened the
right). Although a small radiolucent zone ( 2 mm) was wound to drain the whitish pus. Culture of the pus did not
shown around the screws in the patients, follow-up radiogra- grow bacteria or tuberculous bacilli. Because the patient’s
phy demonstrated obvious remineralization at the bone general condition was good, we treated her with frequent
defect, maintenance of the spinal alignment, and stabiliza- dressing changes and continued antituberculous medica-
tion of the involved segment in all 15 cases (Fig. 2 lower left tion. Thereafter the wound healed completely within 1
and center). In eight patients titanium implants were used, month. Despite the presence of an obvious ( 2 mm) area

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T. C. Lee, et al.

the bone destruction. This patient experienced persistent


instability catch and neurological deficit and was bedridden
throughout the 36-month follow-up period. Although we
had planned further surgical correction with anterior de-
bridement and fusion, the patient’s general condition re-
mained poor, and he was eventually lost to follow-up study.

Discussion
Despite the general acceptance of the Hong Kong opera-
tion for the treatment of spinal tuberculosis, a recent study
in Korea by the Medical Research Council Working Party
found that chemotherapy alone is efficacious for spinal
tuberculosis, even when myelopathy or obvious bone
destruction is present.20 They reported that good clinical
recovery was attained in 92% of patients and that complete
or partial fusion with a mean increase of kyphosis less than
18˚ by 36 months was obtained in 84% of patients. Their
finding that a tuberculous lesion may heal with spontaneous
FIG. 1. Photomicrograph of the granulation tissue obtained in a fusion indicates that the Hong Kong operation is no longer
patient, demonstrating caseating necrotic debris in the right upper the sole treatment option for patients with spinal tuberculo-
corner surrounded by an admixture of lymphocytes and epitheloid sis. In recently published papers, authors have tended to
histiocytes. A Langhans’-type giant cell can also be seen in the left emphasize the importance of tailoring the management
lower corner (arrow). H & E, original magnification  160. options to the individual needs of the patients with spinal
tuberculosis. Nussbaum, et al.,22 have treated patients with
spinal tuberculosis according to the degree of bone destruc-
of radiolucency around the screws and minimal remineral- tion. In their series, aggressive debridement and fusion were
ization at the bone defect, maintenance of the spinal align- performed only in patients in whom advanced vertebral
ment on follow-up radiographs was demonstrated in both body involvement resulted in kyphosis. Rezai and associ-
patients (Fig. 3 lower left). The long-term (30-month) fol- ates,26 have reported that radical operative management was
low-up MR images revealed shrinkage of the preexisting required only when the extent of vertebral body destruction
paraspinal soft-tissue mass, normalization of the signal exceeds 50%. Boachie-Adjei and Squillante1 have suggest-
intensity of the involved vertebrae, and filling of the bone ed that neurological function as well as bone involvement
defect with a solid mass in both patients, but no evidence of should be carefully evaluated before making surgery-relat-
fusion at the bone defect (Fig. 3 lower right). ed decisions for the treatment of patients with spinal tuber-
culosis. They recommended that patients with Frankel
Grade A or B lesions undergo rapid decompressive surgery,
Poor Treatment Result while those with Grade C or D lesions may be treated
Only one patient (Case 18) was categorized as having a expectantly with chemotherapy alone.
poor result. This patient had the longest history (6 months) Because most of the patients in our series were neurolog-
of clinical symptoms as well as extensive ( 50%) destruc- ically normal and had no severe bone destruction, theoreti-
tion of the vertebral body of the two affected lumbar verte- cally they could be expected to have had good treatment
brae. He also harbored a tuberculous lesion in the cervical outcomes by undergoing antituberculous chemotherapy
spine region that was observed at a previous operation. alone. However, this conservative method cannot prevent
During the instrumentation placement procedure, infectious the possible progression of kyphotic deformity, and it usual-
material was found in the vertebral body while we probed a ly requires long-term rest to achieve relief of severe back
presumed healthy pedicle and into the rostral portion of one pain.24 Based on analysis of the literature, a rigid stabiliza-
involved vertebral body. In the study by Oga and col- tion system provides the best solution, not only to prevent
leagues,23 they reported that mycobacterium tuberculosis kyphosis but also to achieve relief of pain due to spinal
does not adhere well to inert surfaces and that spinal instru- instability.2,5,13–18,27,29 This concept was introduced by Garst,6
mentation does not pose a risk of spreading the infection; who first used the technique of posterior fusion without
therefore, we chose to place the screw in the infectious focus instrumentation to replace drastic anterior interbody fusion
rather than the adjacent noninvolved vertebra. Unfortun- for spinal tuberculosis. He reported that this safer procedure
ately, this resulted in loosening of the screw and spread of can enable the spine to become stable and pain free and that
infectious material from the vertebral body into the subcu- it can be performed in developing countries where facilities
taneous space through the iatrogenic pedicular tunnel. for transthoracic procedures are not available. Guven and
Consequently, the patient developed a wound infection, coworkers8 have used posterior instrumentation (with a
with draining sinuses, and pullout of the implant. A subse- screw and/or hook system) for the treatment of thoracolum-
quent operation was performed to remove the implant and bar spinal tuberculosis in 10 neurologically intact patients,
debride the subcutaneous granulation tissue. The wound and clinical and radiological evidence of stable fusion was
healed approximately 1 month after this subsequent surgery. obtained in all their patients.
The follow-up imaging studies demonstrated progression of In the present study, we used transpedicular instrumen-

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Transpedicular instrumentation for spinal tuberculosis

FIG. 2. Imaging studies obtained in a 62-year-old man whose treatment outcome was good. Upper Left:
Preoperative plain radiograph revealing slight posterior displacement of the L-3 vertebra onto the L-4 vertebra and bone
erosion (arrow) at the anteroinferior aspect of the L-3 body. Upper Center: Preoperative noncontrast T1-weighted MR
image (TR 516 msec, TE 17 msec) of the affected L-3 and L-4 vertebrae and the paravertebral soft-tissue mass (arrow),
demonstrating low signal intensity. Upper Right: Anteroposterior radiograph obtained at 30-month follow-up exami-
nation revealing the intertransverse fusion mass (arrow) and limited laminectomy. Lower Left and Center: Lateral flex-
ion (left) and extension (right) radiographs obtained at 30-month follow-up examination revealing maintenance of the
spinal alignment, presence of minimal radiolucency around the upper screws, and remineralization at the bone defect.
Lower Right: Postoperative T1-weighted MR image (TR 516 msec, TE 17 msec) without contrast enhancement obtained
at 30-month follow up, demonstrating normalization of the signal intensity of the involved vertebrae, shrinkage of the
paravertebral soft-tissue mass, and filling of the bony defect with a solid mass. However, absence of trabeculae inside the
solid mass implies that there is no strong evidence of fusion at the bone defect.

tation because it has been proven to be a good method for none of these patients was a vertebra with greater than 50%
stabilizing the thoracolumbar and lumbar spine and is not vertebral body destruction or a history of symptoms lasting
as drastic an intervention as the anterior radical operation. longer than 3 months demonstrated, and most (13 of 15)
This posterior approach has a special advantage in that it patients were neurologically intact. In addition to providing
avoids contact with the infectious focus, because the rapid relief from instability catch, the instrumentation also
tuberculous infection usually involves the anterior col- preserved spinal alignment and stabilized the involved seg-
umn.26,28,30 The fact that tuberculous lesions may heal in ment in these patients. Although the mass in the quiescent
spontaneous fusion makes this posterior approach feasi- tuberculous lesions in these patients cannot be considered to
ble.20 During the placement of instrumentation, we insert- be as good as a fusion mass, we believe, it may function as
ed the screws into the healthy pedicles adjacent to the a “spacer” to support the anterior column. In experienced
bone destruction. This method has also been used by Rath hands, this operation is not time consuming nor does it
and colleagues25 who suggested that screws can be placed require blood replacement. It can allow early ambulation
into affected vertebrae if the upper part of the vertebral and shorten hospital stay.
body is not destroyed by infection. In the two patients in whom fair operative results were
Analysis of our results shows that transpedicular instru- obtained, relatively extensive involvement of the spine was
mentation is highly effective for quick relief of instability in demonstrated (one vertebra with  50% destruction of the
patients with early stage spinal tuberculosis. Good or excel- vertebral body). Compared with the 15 patients in whom
lent operative results were obtained in 15 patients (83%); in satisfactory operative results were achieved, these two pa-

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T. C. Lee, et al.

recurrence of disease, the use of the conventional radical


surgery (debridement and fusion) is recommended.
In our series, only one patient was categorized as hav-
ing a poor result. The poor outcome in this case was part-
ly related to the relatively late diagnosis, multiple infec-
tious foci, and advanced bone destruction, and it was partly
caused by surgery-related complications. The direct inser-
tion of a screw into the infectious focus resulted in implant
failure, as well as spreading of infectious material to the
subcutaneous space. Our experience in this case further
supports that patients with relatively extensive ( 50%)
vertebral body destruction should be initially treated with
anterior debridement and fusion. In addition, we must
emphasize that direct insertion of a screw into an infected
focus should be avoided during transpedicular instrumenta-
tion placement in patients with spinal tuberculosis.

Conclusions
In the era of modern imaging modalities and effective
antituberculous medication, patients with early diagnosed
spinal tuberculosis may be treated with more conservative
surgical methods or even medical treatment alone. In
patients with a severe instability catch caused by bone
destruction, surgical stabilization may facilitate the reso-
lution of this pain. Transpedicular instrumentation, a pos-
teriorly placed system, and posterolateral fusion are espe-
cially advantageous for thoracolumbar and lumbar spinal
tuberculosis, which frequently involves the anterior por-
FIG. 3. Imaging studies obtained in a 65-year-old woman whose tions of the vertebral bodies. This less drastic modality can
treatment outcome was considered fair. Upper Left: Preoperative achieve rapid relief of instability catch in patients with
plain radiograph demonstrating severe bone destruction (arrow) at limited ( 50% destruction) vertebral body involvement.
the inferior portion of the L-3 and superior portion of L-4 vertebral Although this procedure did not result in obvious bone
bodies. Upper Right: Preoperative T1-weighted, gadolinium-DTPA fusion at the involved site, spinal alignment was main-
contrast–enhanced MR image (TR 716 msec, TE 11 msec) reveal- tained during the follow-up period that ranged from 21 to
ing extensive bone destruction of the L-4 vertebra ( 50% destruc- 40 months. However, further follow-up review is neces-
tion of the vertebral body). Areas of high signal intensity can be sary to monitor for possible disease recurrence or implant
seen at the involved bodies and the paravertebral soft-tissue mass failure. In our experience, the screws can be inserted into
(arrow). The site of bone destruction shows low signal intensity.
Lower Left: Postoperative plain radiograph obtained at 30-month the healthy pedicles immediately adjacent to the area of
follow up demonstrating an area of radiolucency around the upper bony destruction. However, direct insertion of the screws
screws as well as minimal remineralization at the bone defect; into the infectious focus should be avoided.
however, spinal alignment has been maintained. Lower Right:
Postoperative gadolinium-DTPA contrast–enhanced MR image
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in the ambulatory treatment of spinal tuberculosis. Results at Accepted in final form July 23, 1999.
three years of a study in Korea. J Bone Joint Surg (Br) 75: Address reprint requests to: Tao-Chen Lee, M.D., 123, Ta-Pei
240–248, 1993 Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan.

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