Patients with neural deficit require more aggressive approach. Classical approach was to put all the patients on chemotherapy and strict bed rest.
Some surgeons suggest radical approach which advocated operating almost every tubercular lesion with [or even without] neural deficit to debride the tissue and relive the pressure on neural structures.
While first approach produced less than desirable results, second one is associated with increased surgical burden and associated mortality.taking best of both approaches.
It puts the patient on chemotherapy and rest and observes for response. The premise of the treatment is that, as the drugs act on the bacteriae, the reduced destruction and pus production leads to lesser pressure on the neural structures which tend to recover once mileu gets better by use of medicine.
This regime advocates surgery for the patients of TB of the Spine who do not get better with the initial treatment or are not candidates for conservative treatment.
Every patient with neural complications will not be cured by antitubercular drugs and rest alone, however, all patients do not need surgical decompression.
An absolutely conservative approach to pott’s paraplegia is considered unjustifiable as one might be damage of the cord may take place if the deterioration progresses to complete loss of motor and sensory function.
Indications for surgery in presence of neural deficit are:
• Neurological complications which do not start showing signs of progressive recovery to a satisfactory level after a fair trial of conservative therapy.
• Patients with spinal caries in whom neurological complications develop during the conservative treatment.
• Patients with neurological complications which become worse while they are undergoing therapy with antituberculous drugs and bedrest.
• Patients who have a recurrence of neurological complication.
• Patients with prevertebral cervical abscesses, neurological signs and difficulty in deglutition and respiration.
• Advanced cases of neurological involvement such as marked sensory and sphincter disturbances, flaccid paralysis or severe flexor spasms.
• In the cases that started showing progressive recovery complications on triple drug therapy between 3 to 4 weeks and progressed to complete recovery surgical decompression was considered unnecessary.
Surgery in Spinal Tuberculosis:
Surgery in the spinal tuberculosis is required mostly for decompression of the neural structures or drainage of abscesses and provides stability to the spine.
Surgery is also done for deformity correction in severe kyphus.
In children, posterior spinal fusion is done so as to correct the deformity with growth.
Operative procedures for decompression of neural tissues
• Decompression and debridement with or without bone grafting
• Cervical spine and cervicodorsal junction – anterior approach.
• Dorsal spine and dosrolumbar junction peritoneal approach or transpleural approach
• Lumber spine and lumbosacral junction – extraperitoneal approach.
• Laminectomy for posterior spinal disease, extradural granuloma or tuberculoma.
• Anterior transpostition of the cord through the anterolateral in severe kyphotic deformity causing paraplegia.
Recovery after Surgery
Recovery after surgery has been observed after 24 hours to 12 weeks after the decompression. Most of the patients showed the first evidence of objective recovery within 3 weeks of the decompression; however, others take a longer time to recover. The time taken for near complete recovery varied between 3 to 6 months, and in few cases more than a year.
Extensor plantar response, a sign of pyramidal tract involvement, lasts for a very long time.
Patients who recover are able to return to their full activity within 6 to 12 months of the treatment. Brace is recommended for about 2 Years