Tuberculous paraplegia, costotransversectomy

If a patient with spinal tuberculosis complains of clumsiness, weakness, or incoordination of his legs, he is becoming paraplegic. Later, the voluntary power of his legs is reduced, their muscle tone is increased, and his plantar responses become extensor. Later still, he has flexor spasms, and finally contractures.

Paraplegia is the major complication of spinal tuberculosis. In early cases it is due to an inflammatory oedema round a paraspinal abscess, and later to compression. Paraplegia may be his presenting symptom, and is usually treatable. In most cases it is motor only (unless it comes on very rapidly), because the abscess presses on the anterior columns of his cord rather than on the posterior ]]ones. Although tuberculous osteitis affects the various regions of the spine in the following order of decreasing frequency: low thoracic, lumbar, upper thoracic, and cervical, you will see tuberculous paraplegia most commonly in the thoracic region, sometimes in the cervical region, and seldom in the lumbar region. This is because the spinal canal is wide there, and the cauda equina running through it is less easily affected than the cord.

There are two types of tuberculous paraplegia: (A) The common early type is due to inflammatory oedema which responds well to chemotherapy, and surgery, if this is necessary. (B) A less common later type, due to pressure and stretching from a bony deformity, when bony union has not occurred. It is the result of no treatment, incomplete treatment, or late treatment. Its prognosis is poor with chemotherapy alone, and even with specialized surgery (not described here), it is not good.

Fig. 29-3a COSTOTRANSVERSECTOMY for a tuberculous or a pyogenic paraspinal abscess. A, the incision. B, the approach to the ribs and transverse processes. After Campbell's Orthopaedics, Fig. 13-10, with kind permission.

TUBERCULOUS PARAPLEGIA THE PROGNOSIS AND MANAGEMENT are different in the two forms of the disese in Section 29.4. The patient's bowels and bladder are sometimes involved in Stage (3) below and always in Stage (4); their improvement mirrors that of his his limb muscles. If his prognosis is good he should be operated on:

(A) If his paralysis is fairly recent ([lt]3 months) and his deformity is [lt]60[de] (common) inflammatory oedema is the likely cause, and if the indications for surgery are followed, his prognosis is good. Even if he has [mt]60[de] of deformity, he is worth managing as if oedema was the cause, but his prognosis will not be so good.

(1) If his weakness is mild ([lt]grade 3, see 27.2), he is almost sure to recover fully.

(2) If his weakness is severe (grade 0[nd]3) without muscle spasms, he will probably recover.

(3) If his weakness is severe with extensor spasms, he has [mt]50% chance of a full recovery, and if not, he will probably have a partial recovery.

(4) If weakness is severe with flexor spasms, he can expect little or no recovery, and he has little chance of walking without special aids.

(B) If his paraplegia is due tp pressure or stretching from a bony deformity of his neural canal (uncommon in most areas and usually of late onset), the clinical picture is the same, except that the onset of paraplegia is late when kyphosis is marked. However, even if he has marked bony deformity with no paraspinal abscess visible on X-ray, his paraplegia may possibly still be due to inflammatory oedema, so refer him for surgery if you can. If you cannot, try chemotherapy alone: but don't operate yourself, the surgery of this kind of paraplegia is too difficult.

TREATMENT [s7]FOR TUBERCULOUS PARAPLEGIA NON-OPERATIVE TREATMENT. Admit him, and put him to bed. There is a very good chance that he will recover. If chemotherapy and bed rest don't cause neurological improvement in 6 weeks (unusual), review him. Your diagnosis is likely to be wrong, but if you are sure that he is tuberculous, consider costotransversectomy.

CHEMOTHERAPY. Give this as in Section 29.1.

NURSING CARE is the same as for traumatic paraplegia, so manage his morale, his skin, his urine, and his bowels as in Section 64.13.

COSTOTRANSVERSECTOMY INDICATIONS. Costotransversectomy is also indicated for osteomyelitis of the spine, as described in Section 7.15. (1) Paraplegia due to osteitis (usually tuberculous), provided a paraspinal abscess (tuberculous or pyogenic) can be demonstrated on X-ray. (2) A large paraspinal abscess (tuberculous or pyogenic) when there is no paraplegia. (3) To obtain tissue for histology, when the cause of an osteitis is still in doubt, after considering the clinical condition and the X-rays.

If possible, refer him, if not proceed as follows.

ANAESTHESIA. (1) General anaesthesia (A 9.1). (2) Ketamine (A 8.1). You must intubate him (A 13.2) and give him a relaxant (A 14.1), because you will have to lay him prone (A 16.12) with his chest supported on pillows, and control his ventilation. A prone patient cannot breathe spontaneously unassisted.

PREPARATION. Have 2 units of blood for him in reserve. Diathermy is useful.

Find the vertebra or vertebrae most markedly involved, by noting the site of any gibbus, and examining his X-rays. Clean his back, and cover it with a laparotomy towel with a central hole, or with 4 surrounding towels.

INCISION. Stand on his left and make a 20 cm incision centred on the affected vertebrae, curved to the left, and reaching his spinous processes at each end. Raise a flap of skin and subcutaneous tissues, and turn this medially, to expose his supraspinous ligament.

CAUTION ! (1) Approach the abscess from the left, so as to avoid his azygous vein (at some levels) and his vena cava. You are unlikely to damage his aorta. (2) Later, gentle dissection near his vertebral bodies will help you to avoid damaging his pleura and entering his pleural cavity.

Use a knife to divide his left trapezius near its origin from his spinous processes, and his latissimus dorsi, as this arises from his lower six thoracic vertebrae. Open the plane between his spinous processes, and his sacrospinalis muscle, by cutting at first, and then by dissecting off the muscle from the bone with a stout periosteal elevator. If he bleeds much, pack the wound tightly with a laparotomy pad, and wait up to five minutes.

Expose the transverse processes and the related ribs of his maximally involved vertebrae, together with one vertebra above and below these. Expose the whole of each transverse process and 5 cm of rib distal to its tip.

Cut the periosteum of a rib longitudinally, and elevate it with a periosteal elevator all round. This will help to separate it from the tissue covering his underlying pleura, and protect his intercostal vessels and nerve.

Cut the rib with rib cutters (or carefully with bone cutters), 3 cm from the tip of its related transverse process. Try to avoid damaging his pleura. Then resect the medial part of the rib and the transverse process at its base. Repeat this for at least one other rib.

Now look for his paraspinal abscess. Insert your index finger along the side of his vertebral bodies, and separate the tissues gently. You may need some sharp dissection with scissors[md]if so keep very close to the bone. This will lead you to the abscess, and not to his pleura!

Tuberculous pus is watery, with debris in it. Pus from osteomyelitis is yellow and creamy. Drain and culture what you find. Pass your finger round the anterior surface of each vertebra, up and down to ensure thorough drainage.

If you find no pus, check the X-ray, you may have chosen the wrong level. If so, remove a further transverse process and its related rib and feel again.

If you still find no abscess, take some tissue from the disc space for histology. The best place to biopsy is felt more easily than seen. Use forceps designed to biopsy the cervix, or use dissecting forceps and a No. 15 blade mounted on a long handle.

CLOSURE. Preferably use suction drainage (''Redivac', 4.10). There is no need for an intercostal drain, unless you damage his pleura. Approximate his muscles to his spine by sewing his trapezius and latissimus dorsi to his supraspinous ligament with 1/0 multifilament, or chromic catgut. Close his skin with continuous 1/0 or 2/0 monofilament. Apply a dressing. Nurse him on his back and sides, changing his position 2-hourly. He should be able to turn the upper part of his body by 48 hours, but he will still need 2-hourly assistance with turning. He may show no improvement for up to 6 weeks. If he has not improved by this time, his outlook is poor. If improvement starts by 6 weeks expect it to continue for 6 months. It will be hastened and improved by the drainage of a significant abscess.

If his paraplegia continues as before, see Section 64.13.

CAUTION ! Avoid an indwelling catheter. If he needs help, use intermittent sterile catheterization[md]see Section 64.16!

DIFFICULTIES [s7]WITH COSTOTRANSVERSECTOMY If you DAMAGE HIS PLEURA, see Section 9.2D.

Fig. 29-4 ABDOMINAL TUBERCULOSIS can present in many ways. Patient A's abdomen is distended with ascitic fluid. You may not diagnose some of the other forms of tuberculous peritonitis until you do a laparotomy. Kindly contributed by Gerald Hankins.