Minimally invasive stabilization of an unstable multi-level thoracic gibbus in multi-level contiguous spinal tuberculosis: a case report

Abstract

Tuberculosis (TB) is a disease of poverty with a global concentration in sub Saharan Africa. While 10% of extrapulmonary tuberculosis is skeletal, 50% of this occurs in the spinal column. Multi-level spinal TB is however a rarity, especially in the HIV negative population. Besides the medical management of this condition which decades ago revolutionized the treatment of these patients, spinal surgeons must today still decide on the best way to manage the challenges of instability, deformity and the often large cold abscesses that accompany this condition. We present an immunocompetent male patient who presented to our unit complaining of mild chronic mid-thoracic axial backache. Despite these minor symptoms our investigations revealed extensive tuberculous destruction of his entire thoracic spine with unstable pathological compression fractures of the T5 and T6 vertebral bodies, and a large pre-vertebral tubercular abscess. To definitively address each problem, we performed minimally invasive transthoracic thoracoscopic drainage of the pre-vertebral tubercular abscess and transthoracic thoracoscopic T5 and T6 corpectomies and cage reconstruction in the same surgery. At a second surgery 3 days later a T2-T8 posterior instrumented surgery was performed to afford a 360-degree stabilization and fusion. Post operatively the patient was braced to assist healing. The patient had immediate improvement in his symptoms and was discharged in a brace, fully ambulant, on anti-tuberculosis treatment, for out-patient follow-up. At his 2-year follow-up he was doing well and follow-up thoracic spine X-rays revealed no progression of his deformity. In conclusion patients with unstable spinal tuberculosis can gain more benefit from a minimally invasive anterior approach which avoids the morbidity of thoracotomy rather than an open surgical approach.

Keywords: Minimally invasive surgery, Spinal tuberculosis, Transthoracic thoracoscopic surgery