Video-assisted thoracoscopic decompression of tubercular spondylitis: Clinical evaluation

Study Design. A prospective, observational study using a novel procedure of video-assisted thoracoscopy and conventional, long spinal instruments for decompression of dorsal tubercular spondylitis. Objectives. To assess the efficacy of video-assisted thoracoscopic decompression of dorsal tubercular spondylitis and compare it with the published data of classic thoracotomy procedures. Summary of Background Data. Surgical decompression of dorsal tubercular spine with the transpleural transthoracic method is a standard procedure. It is a major surgery with significant morbidity in terms of blood loss, intensive care unit (ICU) and hospital stay, postoperative incision pain, and chest tube insertion. A procedure that has the potential to achieve comparable recovery in patients with dorsal tubercular spondylitis but with a surgery of lesser magnitude and morbidity has immense potential. Methods. There were 16 patients with mid-dorsal tubercular spondylitis with paraplegia/paraparesis requiring surgery who were included in the study. Every patient had a recent paradiscal disease at a single level. A soft tissue shadow was visible on plain radiographs of the spine, and conservative treatment for at least 3 weeks had shown no recovery. Patients with obvious respiratory insufficiency and likely to have significant pleural adhesions were excluded from the study. Single lung anesthesia and ipsilateral lung collapse using a double-lumen tube were administered. A 3-portal thoracoscopy approach was used, and conventional but long spinal instruments were used through an open port to decompress the spine. Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of chest tube insertion, ICU and hospital stay, and neurologic recovery. Patients were observed for a minimum of 6 months. Results. Of 16 patients, 14 (88%) had good neurologic recovery. In 1 patient, thoracoscopy was abandoned, and open thoracotomy was performed because of persistent bleeding. Another patient did not recover, and anterolateral decompression was performed 10 weeks after thoracoscopy. She recovered subsequently. Other complications included fracture of the sixth rib in 1 patient and breakage of suction tip in another. Adequate tissue biopsy for histopathologic examination could be obtained in all patients. Duration of surgery was 223 minutes (+/-56), blood loss was 497 ml (+/-302), and blood transfusion was required in 3 patients ( 3 U in 1 and 1 U in 2). Postoperative analgesic (tramadol) was 243 mg (+/-70) for 2-4 days (median 3), median hospital stay was 5.5 days ( range 4-9), chest tube requirement was 3 days (range 2-7), and 2 patients were required to stay in the ICU for 1 day each. Conclusion. Video-assisted thoracoscopic decompression of tubercular dorsal spondylitis is a viable option to achieve significant neurologic recovery with less morbidity, blood requirement, and hospital stay compared to the open thoracotomy procedures.