Percutaneous pedicle screw fixation in caries spine – Does early MIS fixation has advantage over conservative?

Nishant; Varun Kumar Agarwal

doi:10.4103/joss.joss_12_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 3 | Page : 159-166

Percutaneous pedicle screw fixation in caries spine – Does early MIS fixation has advantage over conservative?

Nishant, Varun Kumar Agarwal
Department of Orthopaedic Surgery, Rohilkhand Medical College, Bareilly, Uttar Pradesh, India

Date of Submission	15-Mar-2022
Date of Acceptance	12-May-2022
Date of Web Publication	13-Sep-2022

Correspondence Address:
Varun Kumar Agarwal
Department of Orthopaedic Surgery, Rohilkhand Medical College, Bareilly, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joss.joss_12_22

Abstract

Objective: We performed this study to investigate the role of fixation by percutaneous pedicle screw fixation (PPSF) in spondylodiscitis secondary to TB origin for pain relief and rapid early mobilization of the patient.
Material and Methods: Thirty-two cases of tuberculous spondylodiscitis were managed from March 2017 to 2019. Clinical assessment, radiological evaluation, and laboratory studies with over a year follow-up after PPSF without decompression. Visual analog scale (VAS score) and Oswestry disability indices (ODI scale, Hindi version) were used for outcome measure.
Results: Female-to-male ratio was 19:13. The average follow-up was 14 months ± 6 days and the duration for fusion was around 6 months. The mean duration of hospital stay was 4.006 ± 1.17 days. The average blood loss was 27.18 ml ± 17.71. The mean surgical time was 121.25 ± 14.59 min. ATT was continued for 12–18 months. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) pain scores (visual analog scale), and ODI were lower at 3 months and at final follow up. No failure of instrumentation or decline in neurological condition was reported after operative intervention.
Conclusion: Primary treatment of TB spine has been chemotherapy with limited indications for surgery. Severe pain in the presence of spondylodiscitis without neurological deficit or deformity projects as an unclear situation and a temporary surgical fixation gives stability to prevent unexpected neurological injury and promote early healing with faster rehabilitation in contrast to strict bed rest and external bracing.

Keywords: Pedicle screw fixation, percutaneous, spondylodiscitis, tuberculous

How to cite this article:
Nishant, Agarwal VK. Percutaneous pedicle screw fixation in caries spine – Does early MIS fixation has advantage over conservative?. J Spinal Surg 2022;9:159-66

How to cite this URL:
Nishant, Agarwal VK. Percutaneous pedicle screw fixation in caries spine – Does early MIS fixation has advantage over conservative?. J Spinal Surg [serial online] 2022 [cited 2023 Apr 2];9:159-66. Available from: http://www.jossworld.org/text.asp?2022/9/3/159/356019

Introduction

Tuberculosis of the spine is the most common form of musculoskeletal tuberculous (TB) accounting for 1% of all TB cases and 50% of osseous involvement.^[1],[2] Popularly known as Pott's disease, usually causes spondylodiscitis with or without affecting the adjoining structures.^[3] Routine radiographs are not sufficient to diagnose early involvement.^[4] The most common presentation is the affliction of the disc space causing spondylodiscitis or involvement of the posterior structures of the spine. In such scenario, higher modalities of investigations such as computed tomography (CT) and magnetic resonance imaging (MRI) aid in picking up the lesions sooner than compared with radiographs alone. The presence of inflammation around the spine like the bony or soft-tissue involvement is the clue to the diagnosis in such advanced investigating modalities. The cornerstone of management is medical management with limited surgical indications. Any advancement of angular deformities like kyphosis or neurological deterioration needs decompression, adequate debridement to halt formation or progression in the deformed spine.^[5],[6],[7] Debridement has its complications like further trauma to soft tissue with more complications. There is inevitable damage even to healthy tissue despite all precautions which delays the recovery period. Pott's is well-known medical disease with excellent treatment with antituberculous medications. A similar response with medication is witnessed in pyogenic causes inflicting the disc space. Bed rest along with antituberculous chemotherapy is the mainstay and pillar against the tubercle bacilli inflicting the spine with disease process at the spinal elements.^[2]

Recently, this practice has been questioned as prolonged immobilization adversely affects lung function, leading to hypostatic pneumonia, osteoporosis, and declining limb strength.

Some authors describe that due to unresponsiveness or inadequate treatment in 5%–11% of Pott's spine patients on treatment has further aggravated the already challenging scenario.^[7] In such cases, early intervention is a necessity to thwart the damages linked like osseous destruction, worsening deformity, and intractable pain during the infective duration.^[5]

Recently developed techniques such as small incision percutaneous technique has provided an alternative approach by providing stability essential for repair process by functioning as an inside splint or brace by assisting patients in early ambulation and rehabilitation by giving a rigid internal support.^[8],[9] It has an additional advantage of having soft-tissue sparing and the least impairment of adjacent healthy tissue by less aggressive modality of treatment. Pott's disease requires a prerequisite of a rigid stabilization for healing tissue. Adequate healing ensures that the deformity does not progress. These parameters have gained approval, but very few published works support the early but limited intervention fixation by pedicular screws, hence the need for this study. This novel procedure has gained attention since it aids in providing adequate pain relief, combating angular deformity, and has improved the outcome by decreasing the disability-adjusted life year.

Methods

This was a prospective case series, conducted in our orthopedic department, with ethical committee acceptance, with written and informed consent from each patient from March 2017 to March 2019. The data collection included clinical and imaging data of 62 cohorts with diagnosed Pott's spine along with complications. Out of 62 patients, 32 cases were evaluated after meeting the criteria of exclusion and percutaneous pedicular screws were placed with existing spondylodiscitis of tubercular origin. Our inclusion criteria were, (1) progressive bone destruction tending toward deformity, (2) unstable spinal elements, and (3) persistent pain. Patients with Neurological deficit and or large abscess were excluded. The same surgeon performed the percutaneous pedicle screw (PPS) fixation in every case.

Perioperative management

Diagnosis as established using a blood picture test, tissue diagnosis (biopsy), and other investigating modalities like (X-ray, CT, and MRI) with minimum of 2 weeks of antituberculous treatment before proceeding with surgery. The chemotherapy drugs were prescribed for the minimum duration of 1 year, till healed lesion was documented on a repeat MRI. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) decreased; was obtained and recovery conditions were measured. The patient was mobilized on the first postoperative day following surgery. Postsurgical bracing was recommended and was discontinued following treatment for 2–3 weeks as tolerated by the patient. Duration chemotherapy was around 36 weeks of following RHZE regimen for 9 months (Intensive Phase), and another 3 months of HRE (isoniazid, rifampicin, and ethambutol) chemotherapy (continuation Phase) was administered.

Operative techniques

All patients were positioned in prone under the influence of general anesthesia, on radiolucent spine frame (Allen spine frame) with free abdomen. Adequate lordosis was maintained, and the bony prominences were well padded, with arms in abduction and legs in extension on an adequately padded board. Antibiotic prophylaxis, Cefuroxime 1.5 gm was given intravenous before skin incision. Under C arm guidance, Anteroposterior (AP) and lateral views were taken, and the vertebral levels were identified and lateral pedicular, medial pedicular and midline lines were marked on skin with marker pen. A slight lateral entry point lateral to the lateral border of pedicle is chosen for transpedicular placement of screw especially in lumbar levels. Through paraspinal approach, the skin incision is made to be large enough to accommodate the extenders of the instrumentation. The entry is made with a Jamshidi needle in both views usually in the upper outer quadrant. A mallet is used to gently tap and advance the jamshidi in the transpedicular channel approximately 30 mm and not to cross the medial border of the pedicle [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. The guidewire is inserted through the needles under C- Arm guidance followed by placement of serial dilators and canulated screw with extenders over the guidewire. This entire step is performed under lateral view. A rod measuring device is used to measure the appropriate rod length with the extenders assembled. Rod bender is used to contour the rods before insertion or pre-bent titanium rods were placed using, a rod passer passage across the screws using Medtronic Longitude Screws System. The rods are placed percutaneously from a small separate proximal incision, followed by compression and tightening and later caps broken off from the screw head [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, [Figure 2]g. Early ambulation was encouraged first postoperative day as tolerated by the patient. [[Case 1], [Case 2], [Case 3] illustration with intraoperative pictures from [Figure 1] and [Figure 2]].

Figure 1: (a) Jamshidi needle inserted AP view. (b) Jamshidi needle inserted lateral view. (c) Guidewire passed through jamshidi needle AP view. (d) Guidewire passed through jamshidi needle lateral view. (e) Cannulated pedicle screw fixation over guidewire AP view. (f) Cannulated pedicle screw fixation over guidewire lateral view. AP-Anteroposterior

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Figure 2: (a) Marking. (b) Incision. (c) Jamshidi Needle. (d) Dilators in situ. (e) Guide wire inserted through jamshidi. (f) Cannulated tap passed over the guide wire. (g) Rod being passed through rod passage. (h) Percutaneous pedicle screw placement. (i) pedicular screw tightening with extenders. (j) Incision closure with staples

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Postoperative assessments

The blood loss with total surgical time was recorded. Conventional radiographs and CT scans were done 4 weeks, 6 weeks, and 24 weeks following spinal fixation to assess stability with spinal instrumentation. VAS and ODI score were taken for all patients immediate post op and on subsequent follow ups at 6 weeks 12 weeks, 3 months and final follow up.

Results

Only 32 out of 62 patients with Pott's spine were reviewed and met our inclusion criteria. Nine had the thoracic level disease and 23 had lumbar involvement. The age of presentation was 38.81 ± 8.19. The male-to-female ratio was 19:13. The age group ranged from 26 to 55 years old. Data included duration of surgery, intraoperative loss of blood, and time of stay in hospital [Table 1]. The detailed follow-up data have been recorded [Table 2]. 14 months ± 6 days over 24 weeks was fusion time for the cohorts. The visual analog scale score improved postoperatively from 7.37 ± 0.48 and 3.37 ± 0.64, respectively. The Oswestry disability indices (ODI) (%; Hindi version) was 70.43 ± 8.30, at 6 weeks postsurgical ODI of 34% improvement with 34.25 ± 6.57 at 12 weeks was14.31 ± 14.06 with 59% improvement at final follow-up.^[10] The average blood loss was 27.18 ml ± 17.71 and the surgical period of 121.25 ± 14.59 min. The presence of comorbidity or immune-compromised status was not reported in any patient. CRP, ESR pain scores (visual analog scale), and ODI were lower at 3 months and at the final review [Graph 1], [Graph 2], [Graph 3], [Graph 4]. No skip lesions, instrumentation loosening, or failure or resurgence of the tubercle bacilli resurfaced at the final review. Following surgery, patients were neurologically sound. The pain at the back region improved in a couple of weeks' time frame including radiculopathy. Two cases had superficial infection involving the lumbar level have undergone culture-sensitively guided appropriate antibiotics treatment. All patients achieved baseline CRP in 12 weeks, with an equal number of the cases having a mild increase in ESR. Fusion was gained by end of 24 weeks to 48 weeks in every cohort all patients.

Table 1: Demographic and operation data of patients

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Table 2: Preoperative and postoperative follow-up C-reactive protein, erythrocyte sedimentation rate, white cell count, Oswestry disability indices, Visual Analog Scale, and American Spinal Injury Association

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Discussion

In developing countries, TB is still widespread despite medically curable entities and progress in diagnosis and treatment. Anti-tuberculous medications have played a pivotal role in curing the ailment and reducing the disease burden among those exposed.^{[11],[12],[13]} The adequacy of treatment was reflected by the return of baseline ESR and CRP as a marker of successful chemotherapy treatment. It is established that even where debridement was performed, anti-Tb drugs were unable to halt the spread. Controversy has been in current literature whether early surgery is required or has any change in treatment outcome. A study summarized that no extra successful outcome was witnessed when cases underwent surgery with concurrent chemotherapy versus anti-tuberculous drugs alone for treating Potts spine with the conclusion that chemotherapy alone was sufficient with immobilization in bed.^[23]

Recent authors have acknowledged the presence of two primary inherent defects in Pott's spine. First, the neurology concomitant osteoporosis, pulmonary embolism, hypostatic pneumonia and even DVT can be aggravated due to the absence of inherent strong stabilization or prolonged immobilization in form of bed rest. Second, even with strict immobilization with bracing there is lack of adequate internal stability essential for the segment which leads to intractable pain at the back, aggravation of deformity can occur. Another study^[14] pointed out certain specific indications like deterioration in neurology, not responding to antituberculous medications for 4–6 weeks, or existing instability (anteroposterior or lateral translation; kyphosis), for intervening by early surgery in those patients without loss of neurological status. Classical strategies were to perform focal debridement, achieve proper stability by spinal instrumentation and perform adequate decompression to prevent progressive deformity. The aggressive approach during surgery for Pott's spine has can have disastrous effects on degree of loss of blood or impairment to the neurovascular structures. Additionally, procedures warrant spinal fixation with healing after debridement. This raises the concern and objection to the controversial intervention of radical procedure in Pott's spine. To address such concerns, we suggest percutaneous stabilization as assistive devices like an internal splint or brace by placing pedicular screws which gives rigid support for such pathological conditions. Magerl introduced this concept by using external fixator in the thoracic and lumbar spine.^[15] A Magerl modification technique,^[16] was incorporated for the perfect entry point for precise placement of PPS. Foley and Gupta^[17] further designed percutaneous pedicle screw treating spinal tumors, spinal trauma, and even spondylolisthesis.^{[18],[19],[20]}

Minimal disruption of soft tissue or para-spinal muscles by mini stab incision procedures has this advantage which prevents worsening of the deformity.^[21] Among our 32 patients, the outcome (imaging and functional) was reflected by achieving pain relief, improving the disability, attaining good spinal curvature, and preventing deformity progression, especially kyphosis. The laboratory parameters like ESR have been established as a more sensitive and specific parameter for Tb than for pyogenic infections because its an inflammatory marker for chronic infection. However if increase in ESR accompanied by normal or moderate leukocytosis, we can suspect secondary infection, as reflected in two of our cases of superficial infection. A highly sensitive marker for inflammation is CRP which is increased in TB. Furthermore, it is compulsory to monitor CRP and ESR to monitor disease spread and to check proper treatment with anti-tubercular treatment. However, these markers are nonspecific and are raised in other conditions with inflammation or autoimmune conditions. On serial monitoring continued rise is indicative of disease progress and fall is indicative of disease resolution. These have been quoted as “early phase reactants,” and currently are the cheapest with good reliability for monitoring the benefit of medications. We observed that preoperatively, all these makers were raised and finally fall and achieve their baseline on continued treatment which further establishes our findings. One of the major causes for the existence of pain over the back is due to the underlying destruction of osseous elements further leading to instability.

Every case reported successful bone healing further substantiates our findings. This supports our hypothesis that a minimally invasive technique like percutaneous spinal instrumentation, does not disturb the fusion process as the TB foci heals by regenerating bony tissue.^[22] In addition, it decreases operative time, bloodless, time of stay as in patient and avoids complications pertaining to prolong immobilization in bed with distinct benefits of quicker rehabilitation.

Conclusion

We ascertain that PPF is a safe, small incision procedure to provide internal rigid stabilization. PPF provides pain relief, improves disability, and attains fusion which prevents the progression of the angular curve in treating Pott's spinal involvement with spondylodiscitis and avoids the requirement of a radical debridement advocated in earlier literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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