We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8 degrees. Loss of correction was maximal in the lumbosacral spine at 13.7 degrees. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.

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Study DesignRetrospective analysis of radiological images.PurposeTo determine the prevalence of lumbosacral transition vertebra (LSTV) and to study its significance with respect to clinically significant spinal symptoms, disc degeneration and herniation.Overview of LiteratureLSTV is the most common congenital anomaly of the lumbosacral spine. The prevalence has been debated to vary between 7% and 30%, and its relationship to back pain, disc degeneration and herniation has also not been established.MethodsThe study involved examining the radiological images of 3 groups of patients. Group A consisted of kidney urinary bladder (KUB) X-rays of patients attending urology outpatient clinic. Group B consisted of X-rays with or without magnetic resonance images (MRIs) of patients at-tending a spine outpatient clinic, and group C consisted of X-rays and MRI of patients who had undergone surgery for lumbar disc herniation. One thousand patients meeting the inclusion criteria were selected to be in each group. LSTV was classified by Castellvi's classification and disc degeneration was assessed by Pfirrmann's grading on MRI scans.ResultsThe prevalence of LSTV among urology outpatients, spine outpatients and discectomy patients was 8.1%, 14%, and 16.9% respectively. LSTV patients showed a higher Pfirrmann's grade of degeneration of the last mobile disc. Results were found to be significant statistically.ConclusionsThe prevalence of LSTV in spinal outpatients and discectomy patients was significantly higher as compared to those attending the urology outpatient clinic. There was a definite causal relationship between the transitional vertebra and the degeneration of the disc immediately cephalad to it.

Study DesignRetrospective clinical series.PurposeTo assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.Overview of LiteratureThe use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.MethodsSeventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.ResultsFinal follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.ConclusionsInspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.