Spinal TB Surgery: Tumours, Scoliosis and Children's Spines

Spinal tuberculosis needs surgery when the infection has destroyed vertebrae, compressed the spinal cord or bent the spine out of shape. Dr. SK Rajan, Chief - Neuro Spine Surgery & Additional Director - Neurosurgery, Artemis Hospitals, Gurugram, India, describes spinal TB as very common in India and in Africa, and has operated on patients weakened or paralysed by it, including a child who could walk and stand straight again after surgery.

Spinal TB belongs to a group of conditions, alongside spinal tumours, scoliosis, traumatic fractures and congenital spine problems in children, that share one feature: they damage the structure of the spine itself rather than simply causing pain. This article covers how each is treated surgically, drawing on the cases Dr. Rajan presented. The complete guide to making spine surgery safe explains the technology and team that make these operations safer.

Spinal tuberculosis: when surgery is needed

Spinal tuberculosis, also called Pott's disease, is infection of the vertebrae by Mycobacterium tuberculosis. The infection typically destroys the front part of the vertebra, the vertebral body, and the disc next to it, and can form a collection of pus. As the bone collapses, two problems follow: the pus and fragments of bone can press on the spinal cord, and the spine can angle forward into a deformity.

The backbone of treatment for spinal TB is a full course of anti-tuberculosis drugs. Surgery is added when there is compression of the spinal cord with neurological deficit, a significant or progressive deformity, instability of the spine, or failure to respond to drug treatment.

Case: paralysis from spinal TB

Dr. Rajan presented a woman whose MRI showed a vertebral body destroyed by tuberculosis and compressing the spinal cord. Before surgery she could not move her legs at all, even when asked to. The operation had three parts:

1. Removing the pus.
2. Removing the diseased bone.
3. Stabilising the spine with screws and rods.

Dr. Rajan showed her after surgery and after some weeks and months of follow-up. The case illustrates the central point about spinal TB surgery: the paralysis is caused by mechanical compression, and removing that compression gives the cord the chance to recover.

Case: spinal TB with deformity in a child

The second TB case was a child in whom the infection had also caused deformity. Set against a normal MRI, the child's scan showed a spine that was completely damaged and angulated, compressing the spinal cord and causing weakness. The child could not straighten the legs.

After surgery, the spine was straight, the legs were improving, and the child could walk and stand straight, which had not been possible before the operation.

Spinal tumour surgery for cord compression

Tumours of the spine cause harm in the same way that TB does, by occupying space in or around the spinal canal and pressing on the spinal cord and nerves. Dr. Rajan placed tumours, infections and spinal deformity together among the conditions that need spine surgery.

His tumour case was a woman whose MRI showed a tumour compressing the spinal cord. She could not move her legs at all. After the tumour was removed, and with a few weeks of physiotherapy, she was able to walk.

Spinal tumours in his series have also been removed by the keyhole method, through small cuts rather than the long incision conventional surgery requires. His separate masterclass on minimally invasive surgery for spinal tumours and other complex spine cases covers the technique in more depth.

Scoliosis correction surgery

Scoliosis is a sideways curvature of the spine, usually accompanied by rotation of the vertebrae. Some curves develop without a known cause during adolescence; others are congenital, caused by a malformed vertebra present from birth.

Hemivertebra: removing the wedge

Dr. Rajan presented a young girl whose scoliosis was caused by a hemivertebra, a vertebra that has formed only on one side and so has the shape of a wedge. The wedge tilts the spine above it, producing a curve that tends to worsen as the child grows.

The operation removed the wedge of bone causing the deformity and fixed the spine with screws. After surgery the spine was straight. The procedure is a form of scoliosis correction aimed directly at the cause: once the malformed segment is gone, the spine above and below can be aligned.

Major curve correction: a 10-hour operation

The second scoliosis case was a patient referred from Africa with severe curvature of the whole spine. The correction, with implants, took over 10 hours of surgery, and the spine was made straight.

Operations of this length and complexity are where the safety system described in the guide to making spine surgery safe matters most: three-dimensional imaging to place many screws accurately, neuromonitoring to watch the spinal cord while the curve is corrected, and a frame that positions the patient safely for many hours. The cost of scoliosis and spinal deformity correction is listed separately.

Spinal fracture surgery after an accident

Accident fractures that narrow the spinal canal are among the cases Dr. Rajan treats surgically, now including keyhole screw placement for dislocated vertebrae. Trauma is the other major cause of structural damage. Dr. Rajan presented a patient injured in an accident, whose CT scan showed a fractured vertebra with bone narrowing the spinal canal and causing weakness of the legs. The fracture was treated surgically, and the post-operative images showed the result.

Where several vertebrae are dislocated, his team now places screws using the keyhole method. In the case he showed, screws were placed through very small incisions and the patient was able to stand and walk the day after surgery. Fractures caused by osteoporosis in older patients are a different problem with a different treatment, covered in the article on when spine surgery is needed.

Paediatric spine surgery from six months to 18 years

Dr. Rajan's team treats children from the age of six months to 18 years. Asked whether the team operates on children with neural tube defects, he answered that he himself performs a large amount of paediatric spine surgery, supported by specialist spine surgeons and paediatric surgeons. The conditions include:

• Neural tube defects such as meningocele, a sac protruding through a gap in the spine, formed when the neural tube does not close completely in early pregnancy.
• Chiari malformation, in which the lowest part of the cerebellum, at the back of the brain, extends down into the spinal canal at the base of the skull.
• Tethered spinal cord, in which the lower end of the cord is abnormally fixed, so that it is stretched as the child grows and can cause weakness of the legs.
• Scoliosis and hemivertebra deformities, including the wedge-shaped vertebra described above.
• Tumours of the spine.

For referring doctors, the point is that a child with a congenital spine problem, a curve that is worsening or new weakness in the legs can be assessed and treated within the same spine service as adults.

Why these spine conditions need prompt assessment

The cases in this article share three features that set them apart from ordinary back pain:

1. A clear structural cause, visible on MRI or CT: destroyed bone, a tumour, a malformed vertebra, a fracture.
2. A neurological threat, with weakness or paralysis in many of the patients before surgery.
3. A recovery that depends on decompression and stabilisation, followed by weeks to months of physiotherapy.

They are also the conditions in which delay costs most. A patient who cannot move the legs because of TB or a tumour has spinal cord compression that needs prompt assessment by a spine surgeon. For international patients, Dr. Rajan's figures for typical hospital stay and cost are set out in the article on when spine surgery is needed, and the questions doctors raised in the session are in the Live Discussion.