Professor Kenneth Cheung Jessie Ho Professor in Spine Surgery Head of Department British Journal of Surgery 1956 Duchess of Kent 1970s Complications of TB Kyphosis Principles of Surgical Management

Introduction 36 y Housewife 36 y Housewife TB Spine age 4 TB Spine age 4 Posterior Spinal procedure Aged 4 Posterior Spinal procedure Aged 4  Complicated with paraplegia? Thoracotomy Anterior Approach Aged 6 Thoracotomy Anterior Approach Aged 6  2 Ribs resected  Paraplegia resolved

History Present complaint Present complaint  Poor mobility with prolonged exercise particularly walking for >1 hour  Short of breath  Food feels trapped when she eats  Nocturnal O2 No Back pain, No Neurological deficit No Back pain, No Neurological deficit

3D CT 2011

MRI Sagittal 2010

What should be done? Observation? Observation? Surgery? Surgery?  Fusion?  Correction?  Decompression? High risk of neurological complications High risk of neurological complications

Tuberculosis of the Spine “Acute” Infection   Treatment of infection   Neurology   Back Pain   Kyphosis Late sequelae of infection   Neurological deficit   Reactivation   Pott’s paraplegia of “healed disease”   Kyphosis

Tuberculosis of the Spine “Acute” Infection  Treatment of infection  Neurology  Back Pain  Kyphosis Late sequelae of infection  Neurological deficit  Reactivation  Pott’s paraplegia of “healed disease”  Kyphosis

Tuberculosis of the Spine “Acute” Infection  Treatment of infection  Neurology  Back Pain  Kyphosis Prevention of progressive kyphosis  Results of MRC trial

Medical Research Council (MRC) Working Party on Tuberculosis of the Spine First report. JBJS - British Volume 1973, 55: 4, Fifth report. JBJS - British Volume 1976, 58-B: 4, Seventh Report. Tubercle 1978, 59: 2, Sixth report. JBJS - British Volume 1978, 60-B: 2, Eighth Report. JBJS - British Volume 1982, 64: 4, Ninth report. JBJS - British Volume 1985, 67: 1, Tenth report. Tubercle 1986, 67: 4, Twelfth report. JBJS - British Volume 1993, 75: 2, Thirteenth Report. JBJS - British Volume 1998, 80: 3, Fourteenth report. International Orthopaedics 1999, 23: 2, 73-81

Surgical vs. Conservative Treatment Drug treatment Debridement surgery Radical debridement and anterior spinal fusion (Hong Kong Operation) TB L2/3

Radical anterior debridement - removal of abscess, sequestrum, and loose disc fragments and bone to healthy bleeding bone Anterior strut interbody fusion Hong Kong Operation

5 years15 years Conservative +21°+25° Debridement +8°+11° Radical surgery -3° Kyphosis progression

5 years15 years Conservative +21°+25° Debridement +8°+11° Radical surgery -3° °° 5% of conservative group had increase of kyphosis 51° to 70°

Indications for surgery Progressive neurology Progressive kyphosis Uncertain diagnosis Failed conservative treatment (severe back pain)

Take home message Progressive severe kyphosis can be prevented by early spinal fusion Progressive severe kyphosis can be prevented by early spinal fusion Hong Kong Operation Hong Kong Operation  anterior debridement and spinal fusion remains an important principle  anterior or posterolateral approach can both achieve the same goals

Late sequelae of infection

Presentation   Kyphosis   Indication for treatment?   Neurological deficit   Reactivation   Paraplegia of healed disease Internal kyphus Degenerative changes Evidence for delayed onset up to 30 years later Late sequelae of infection

 Treatment of  infection  internal kyphus Presentation   Kyphosis   Indication for treatment?   Neurological deficit   Reactivation   Paraplegia of healed disease Internal kyphus Degenerative changes Late sequelae of infection

 Treatment of kyphus Presentation   Kyphosis   Indication for treatment?   Neurological deficit   Reactivation   Paraplegia of healed disease Internal kyphus Degenerative changes Late sequelae of infection

Treatment of kyphus Decompression Fusion +/- Correction

Treatment of kyphus Decompression Fusion +/- Correction Severity of kyphosis  Mild  Anterior decompression  Severe  Internal kyphectomy (costotransversectomy approach )

Direct Internal Kyphectomy for Severe Angular Tuberculous Kyphosis ____________________________________________________________________________ Y. W. Wong, FRCSE, FHKAM (Orth), FHKCOS * ; J. C. Y. Leong, OBE, FRCS, FRCSE, FRACS, FHKAM (Orth) † ; and Keith D. K. Luk, MCh Ortho, FRCSE, FRCSG, FRACS, FHKAM (Orth) * CLIN. ORTH. AND RELATED RESEARCH: 460/ , 2007

Treatment of kyphus Decompression Fusion +/- Correction Anterior column reconstruction by strut grafting Anterior column reconstruction by strut grafting

Treatment of kyphus Decompression Fusion +/- Correction

Treatment of kyphus Decompression Fusion +/- Correction

Treatment of kyphus Decompression Fusion +/- Correction Closing wedge osteotomy  Small to moderate kyphoses  ? indicated

F/20, TB in the age of 7, kyphosis 110° Back pain, no neurological symptom, babinski (+) Case example Spinal osteotomy – Prof ZQ Chen Beijing 3 rd Hospital

110°

Correction of acute angular kyphosis without neurology Risk vs benefit Risk vs benefit  Risk of paraplegia from correction  Long term consequence of severe kyphosis  back pain  “paraplegia of healed disease” Do modern surgical techniques reduce risk? Do modern surgical techniques reduce risk?

Current approach to TB kyphosis Prevention in acute disease   Hong Kong Operation in 1-2 level disease   Instrumentation in multilevel disease Late sequelae   Neurological deficit -high risk surgeries   Decompression – always needed   Fusion – often needed   Correction of deformity – maybe needed

The University of Hong Kong Queen Mary Hospital The Duchess of Kent Children’s HospitalFaculty of Medicine