[Surgical Treatment of Tuberculous Spondylodiscitis]. / Operacní lécba tuberkulózní spondylodiscitidy.

PURPOSE OF THE STUDY The paper presents a monocentric retrospective study of patients treated surgically for spinal tuberculosis. Clinical and radiological results are analysed, early and late complications are recorded. The study aims to answer the following questions. 1. Can we use instrumentation to restore the stability and alignment in the infected spinal focus? 2. Should we always perform radical anterior resection of TBC lesions? 3. What is the prognosis of surgical treatment of TBC patients with neurological deficit manifestation? MATERIAL AND METHODS Between 2010 and 2020, a total of 12 patients were treated for spinal tuberculosis at our department, of whom 9 patients (5 men, 4 women) with the mean age of 47.3 years (range 29 to 83 years) underwent a surgery. A total of three patients were operated on before the final confirmation of the TBC and treatment with antituberculosis medication, four patients in the initial therapy phase and two patients in the continuous phase. Two patients only underwent a non-instrumented decompression surgery followed by external support fixation. In the other seven patients, always with spinal deformity, instrumentation was used (3 cases of isolated posterior decompression, transpedicular fixation, posterior fusion, 4 cases of anteroposterior instrumented reconstruction). In 2 cases a structural bone graft and in 2 cases an expandable titanium cage were used for anterior column reconstruction. RESULTS Of the total number of patients, altogether eight patients were assessed at 1 year after surgery (one 83-year-old patient died from heart failure 4 months after surgery). Of the remaining eight patients, three patients exhibited a neurological deficit and postoperative regression of the finding. The McCormick score improved from the preoperative mean score of 3.25 to 1.62 at 1 year after surgery (p < 0.001). The clinical VAS score regressed from 5.75 to 1.63 at 1 year after surgery (p < 0.001). Radiographic healing of the anterior fusion was achieved in all patients, both after decompression and instrumented surgery. The initial mean kyphosis of 20.36 degrees of the operated segment measured by the mCobb angle was corrected to 14.6 degrees postoperatively, with a subsequent slight deterioration to 14.86 degrees (p < 0.05). The greatest correction was achieved in patients who had undergone a two-stage surgery with anterior resection and AP reconstruction. DISCUSSION In our cohort, titanium instrumentation was used in seven of nine patients. One patient only manifested persistent tuberculosis with nonspecific bacterial flora superinfection. Revision surgery with anterior radical debridement and subsequent treatment with antituberculotic drugs healed the patient. There were four patients with major preoperative neurological deficit persisting more than 2 weeks before the final treatment with subsequent improvement in all cases. These patients were treated with anteroposterior reconstruction and anterior radical debridement. CONCLUSIONS No increased risk of recurrent infection associated with the use of spinal instrumentation was found in the study. Anterior radical debridement is performed in patients with manifested kyphotic deformity and spinal canal compression, followed by reconstruction with a structural bone graft or a titanium cage. The other patients are treated based on the principle of "optimal" debridement with or without the use of transpedicular instrumentation. If adequate spinal canal decompression and stability are achieved, neurological improvement can be anticipated even in case of a major neurological deficit. Key words: spine tuberculosis, tuberculous spondylitis, Pott's disease, anterior debridement, spine instrumentation.

[Vertebroplasty and kyphoplasty--treatment of osteoporotic vertebral fractures]. / Vertebroplastika a kyfoplastika - metoda lécby osteoporotických zlomenin pátere.

PURPOSE OF THE STUDY The surgical treatment of osteoporotic vertebral body fractures is associated with many complications. Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive procedures allowing us to strengthen the vertebral body and thus stabilize it. The aim of this non-randomized study is to evaluate a group of patients treated by VP and KP procedures and to discuss related risks. MATERIAL Between September 2005 and October 2007, a total of 32 patients (37 vertebrae) were treated by the VP and KP techniques. Vertebroplasty was used in 21 and kyphoplasty in 11 patients. In this initial group, four patients were excluded from evaluation because of a tumour aetiology of the fracture. The remaining 28 patients who had an osteoporotic vertebral body fracture verified by CT scan findings were followed up and evaluated. METHODS The evaluation was based on modified Oswestry disability index (ODI) and visual analogue scale (VAS) scores recorded at 6 weeks, 3 and 6 months and 1 year postoperatively. Cement leakage detected by X-ray was assessed by means of the classification used by Yeom et al. and, at the same time, the occurrence of adjacent vertebral fracture, if any, was detected by 1 year after surgery. RESULTS Radiographic cement leakage was found in eight patients (21.6%), with clinical manifestation in two (5.4%). One had an incomplete motor lesion due to cement leakage into the spinal column, and the other had pulmonary embolism due to cement leakage into the mediastinum. The whole group showed marked improvement in clinical condition, as assessed by the ODI. When expressed as per cent, the average ODI was 57% pre- and 15.7 % post-operatively. All patients reported pain relief in the affected spine. The average VAS score of 8.1 pre-operatively decreased to an average of 2.6 post-operatively. There were no radiographic findings of adjacent vertebral body fracture. DISCUSSION Vertebroplasty and kyphoplasty are currently used to treat osteoporotic vertebral fracture. Their advantages include an immediate stabilization of the vertebra by cement solidification, possibility of percutaneous application under local anaesthesia, and early patient mobilization without any external fixation. However, when evaluating these techniques, safety of the surgical procedure should be taken into consideration. The most frequent risk is cement leakage. CONCLUSIONS Vertebroplasty and kyphoplasty can, under strict adherence to the operative protocol, be an effective approach to the treatment of osteoporotic vertebral body fracture. It permits early mobilization of the patient without the necessity of external fixation. Key words: vertebroplasty, kyphoplasty, osteoporotic spine fracture, osteoporosis.