Prognostic Factors and Timeline of Neurological Recovery in Surgically Managed Active Dorsal Spine Tuberculosis with Myelopathy
Authors: Tapal Kiran , Basu Saumyajit , Biswas Amitava , Kondety Sri Krishna Chaitanya 
Published: May 2015

Introduction

Surgical outcome, complications, and safety/efficacy of various types of surgery in active dorsal spine tuberculosis with myelopathy have been extensively studied. The objective of this study is to find out the prognostic factors that determine neurological recovery including onset and progression of pain/neurological deficit, spinal cord level involved, type of material compressing the cord, (pus/granulation tissue/caseous material). The time frame required for postoperative recovery in motor, sensory, and bladder functions were also studied.

Patients and Methods

A total of 21 patients, with strict inclusion criteria were recruited from January to December 2010 were studied prospectively. In preoperative assessment, onset and progression of pain and neurological deficits and level of affection were noted. On the basis of ASIA classification, we have classified our patients by considering the predominant MRC grade in more than half of key muscles below the level of lesion as the motor function grade. For sensory assessment, we classified sensory loss into the following four categories: (1) when there is a complete loss, (2) when posterior column sensations were present but anterior column was lost, (3) when both anterior and posterior column sensations were impaired, and (4) when normal. Bladder dysfunction was scored using JOA score for bladder dysfunction. All patients underwent spinal stabilization and transpedicular/extracavitary decompression with posterior spinal fusion. During surgery, the nature of the compressing tissue (pus/granulation tissue/caseous material) was noted. Assessments were done at 48 hours, 7 days, 1 month, 3 months, 6 months, 1 year, and 2 years.

Results

Duration from onset of pain to diagnosis, 4 months; from onset of pain to onset of neurology, 3.7 months; from onset of neurology to surgery, 1.39 months. Nine had acute neurological deterioration. Average preoperative motor grade was 2.05 which improved postoperative 48 hours, 2.90; 7 days, 3.38; 1 month, 3.76; 3 months, 4.33; and 1 year, 4.76. Overall 14 of 18 (77.8%) improved 1 grade within 48 hours. Everyone regained normal sensation by 1 month. At 3 months 7of 8 (87.5%) with preoperative catheter were out of it. The average preoperative power was 1.83, granulation; 1.67, caseous material; and 2.83, pus group, at 48 hours post-op; they improved to 2.5 ( p = 0.0873), 2.55 ( p = 0.101), 3.83 ( p = 0.054), respectively. Lesion above D9 deteriorated from normal power to motor grade of 1.67 (mean) in 1.04 months, whereas, those below D9 took 1.86 months to deteriorate to 2.55 (mean). Postoperatively, above D9 improved to 2.41 in 48 hours, 2.83 in 7 days; and below D9 improved to 3.55 in 48 hours, and 4.11 in 7 days. Those who had sudden onset neurological deterioration showed improvement of 20% ( p = 0.0014) motor and 37% ( p = 0.0002) sensory in 48 hours when compared with slow deterioration, who showed 12.5% ( p = 0.005) in motor and 11.33% ( p = 0.085) sensory.

Conclusion

Sudden onset severe preoperative neurological deterioration is associated with faster postoperative recovery. Lesions above D9 show rapid onset and dense neurology with poorer surgical outcome. Compressing material does not influence recovery. 80% show motor recovery 1 grade,7 days; 2 to 3 grades, 3 months; 4 grades, 1 year. Complete sensory recovery, 1 month and 80% out of catheter, 3 months.