Radical surgical approach to spinal tuberculosis.

In many cases of Pott’s disease conservative measures give satisfactory results, but the long period of treatment necessary causes the patient considerable inconvenience and loss of earnings. The need for more rapid cure has been recognised and many attempts have been made to achieve this. in his work on paraplegia Pott (1779) wrote: “ The remedy for this dreadful disease consists merely in procuring a large discharge of matter, by suppuration from underneath the membrana adiposa on each side of the curvature and in maintaining such discharge until the patient shall have perfectly recovered the use of his legs.” Thus in giving the original description of the disease, Pott also laid the foundation of its surgical treatment. During the period of antiseptic surgery many abortive attempts at radical operation were made. To do this by laminectomy involved resection of many nerve roots. The practice of leaving the wound open with a tampon of iodoform gauze further helped to render the prognosis gloomy, and the mortality was considerable. in 1892 M#{233}nard inadvertently opened a paraspinal abscess while performing thoracic laminectomy for paraplegia. After the operation there was a dramatic return of function, and this led him to perform a series of costo-transversectomies, the successful results of which he reported in 1900. Nevertheless, the procedure soon fell into disfavour, because of the excessive mortality from secondary infection and the dissemination of tuberculosis. Ely (1911) quoted Calot as saying “ to open an abscess from a tuberculous spine or to permit it to burst, is to open a door through which death almost always enters.” Elsberg (1916) suggested that operative treatment should be performed only after conservative treatment had failed. Girdlestone (1931) restored interest in the direct surgical attack by demonstrating that costo-transversectomy was not unduly hazardous if accompanied by meticulous aseptic technique and that it was more effective than conservative or indirect operative treatment for tuberculous paraplegia. The first direct attack upon the solid compressing agent anterior to the theca was made in 1933 by Capener. To relieve a paraplegia of late onset with severe flexor spasms Capener devised the operation of lateral rachotomy. This is a lateral rather than antero-lateral exposure, with excision of ribs and pedicles on the side attacked. Antero-lateral decompression, devised by Alexander in 1946, preserves the lateral stability of the diseased spine by leaving untouched the laminae and posterior intervertebral joints. In 1934 Ito, Tsuchiya and Asami and in 1956 Hodgson and Stock reported their results of treatment of spinal tuberculosis by an anterior transthoracic approach. The advantage of this approach is that it allows decompression of the abscess with removal of pus, caseous material, granulation tissue, intervertebral discs and sequestra. Unless the spine is approached anteriorly the extent of the disease must remain unknown; it has been found almost invariably at operation that the lesion is more extensive than the radiographs suggest. From the mechanical viewpoint the obvious place to fuse the spine is in front where the graft is under compression.