Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 6 of 8 in Advances in Spinal Surgery Technology
Complex Spine Reconstruction: TB Spine, Revisions and Delayed Referral
May 26, 2024
Beyond routine cases, complex spinal reconstructions, from tuberculosis of the spine to failed prior surgeries, show how far correction techniques have advanced.
Tuberculosis of the spine and failed surgery revisions
TB infection of the spine can destroy vertebral bone, sometimes after a prior surgery has already failed; reconstruction with a new cage and correct alignment can still restore a stable, functional spine. Severe deformity cases, including a 90-degree spinal curve from TB spine, have been corrected by removing the affected vertebra and realigning the spine, with patients who arrived unable to walk regaining the ability to walk within about four weeks of surgery.
The cost of delayed referral
A hemivertebra that should have been operated on at age four, if instead only referred at age 16 because it wasn't recognised as urgent, turns a straightforward four-hour surgery into major reconstructive surgery lasting around 16 hours, using techniques like ultrasonic bone cutting to safely remove and realign bone. Correcting long-neglected, severe curves (in some cases close to 100 degrees, including complex kyphoscoliosis and cervical spine deformity) is possible, but the surgery and recovery are far more demanding than if the same deformity had been treated early.
This article is based on a Jivo Masterclass session conducted by Dr. Puneet Girdhar, Principal Director & Head, Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Puneet Girdhar taught doctors across Africa on May 26, 2024.
FROM THE LIVE Q&A
Moderator
Does nutrition play any role in spine health, and is a nutritional deficiency a risk factor for developing spine problems?
Dr. Puneet Girdhar
The spine is made up of three main components, each with its own nutritional needs: bones need calcium, vitamin D and sunlight; muscles and tissues need exercise and good protein in the diet; nerves need exercise and vitamin B12. Altogether, a good lifestyle, diet and exercise are what keep the spine healthy.
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Frequently Asked Questions
At what point can we say scoliosis bracing has failed and surgery is indicated? Also, for the interbody cage, can long plates not be used instead?▼
For idiopathic scoliosis, once the curve goes beyond 40 to 45 degrees, bracing has failed and surgery is indicated. On plates: long plates such as Steffee plating are no longer used - for the last 15 to 20 years, the standard has been transpedicular screws with a titanium or PEEK cage instead.
What are the possible obstacles to performing minimally invasive spine surgery in tropical, resource-limited areas?▼
There is no real obstacle - the obstacle is in the mind. As an example, three minimally invasive spine surgeries (two of them revisions of prior laminectomies) were performed in Abuja, Nigeria over the last two months, and all three patients were walking the next day; this has already led to inquiries from ten different hospitals wanting to start similar programmes. It is a matter of local doctors taking the initiative, supported by training and partnership.
What would be the medical method for the management and support of individuals with discopathy (disc disease)?▼
The first line is medicine and physiotherapy. If that doesn't help, a nerve block injection is the next step. If that also fails, endoscopic surgery is used.
How long will it take with rehabilitation for a patient to regain full mobility after spinal arthrodesis (fusion)?▼
With minimal invasive and robotic techniques, the patient walks the same day, is discharged in one to two days, can return to work within a week, and can return to active sports within three weeks.
Why is spinal arthrodesis still the technique of choice when a majority of patients who benefit from it develop vertebral listhesis (adjacent-level problems) after years?▼
It is by far the best solution science has invented so far. Vertebral listhesis develops in some patients, not the majority - of around a thousand operations a year, only a small subset develop problems at another level. Just because a surgery might cause a problem many years down the line doesn't mean a patient in pain and unable to walk today should be denied its benefit now - the same reasoning applies to a liver transplant, which is offered even knowing it may extend life by only five to ten years.
Can severe spinal deformities from TB or failed prior surgery be corrected?▼
Yes - through vertebral resection and reconstruction with new cages and hardware; patients who arrived unable to walk have regained walking ability within about four weeks.
Why does delayed referral for a hemivertebra matter so much?▼
A hemivertebra ideally operated on at age 4-5 takes about four hours; delaying until the teens can turn it into a 16-hour major reconstruction.
In This Series: Advances in Spinal Surgery Technology
- 1.Advances in Spinal Surgery Technology
- 2.The Technology Behind Modern Spine Surgery
- 3.Robotic Spine Surgery: Accuracy and Outcomes
- 4.Minimally Invasive Surgery for Disc Herniation and Spinal Stenosis
- 5.Scoliosis: Warning Signs and When to Brace or Operate
- 6.Complex Spine Reconstruction: TB Spine, Revisions and Delayed Referral
- 7.Bringing Minimally Invasive Spine Surgery to Resource-Limited Settings
- 8.Spinal Fusion, Symptom-Based Surgery Decisions, and Spine Nutrition