To The Editor:
I was interested in the article "Anterior Instrumentation
for the Treatment of Spinal Tuberculosis" (81-A: 1261-1267,
Sept. 1999), by Yilmaz et al., as I have seen anterior spinal instrumentation used
for the treatment of tuberculosis of the cervical spine at the Center
for Spinal Study and Surgery in Nottingham. I would appreciate the
authors’ comments on the use of anterior spinal instrumentation
early in the disease process in an attempt to stabilize the spine
following radical débridement and bone-grafting.
Between 1991 and 1993, three young adult Asian immigrants were
referred with acute-onset Frankel level-C quadriparesis as a result
of tuberculosis of the cervical spine. Magnetic resonance imaging
of the cervical spine showed abscess formation, vertebral body destruction,
and disc involvement causing kyphosis of the cervical spine at the
site of the disease. After extensive resection and plate fixation
with insertion of two screws each in the fourth, fifth, and sixth
cervical vertebrae, all three patients had full recovery from the
neurological deficit. After two to six years of follow-up, there
was no recurrence of the disease or the cervical spine deformity.
I agree with Yilmaz et al. and others that the insertion of strut
grafts in the space created after débridement of the affected
vertebral bodies provides some support anteriorly, but I believe
that this is insufficient1,2.
When more than two levels are affected, the grafts frequently either
fail or are resorbed1,2. Perhaps
spinal instrumentation would prevent graft resorption as we observed
in the three cases described above. I would like for Dr. Yilmaz
et al. to comment on the length of the interval between the diagnosis
of the disease and the correction of the kyphotic deformity. I would
also appreciate their comments on the use of early anterior spinal
instrumentation in the presence of tuberculous disease of the spine;
I believe that such treatment would prevent future deformity and the
need for more difficult corrective surgery a few years down the
line. I am aware of the concerns regarding the use of metal implants
in the presence of infection; however, there are enough data in
the literature to indicate that there is no increased risk associated
with the use of such instruments in patients with spinal tuberculosis1.
—Adnan A. Faraj, FRCS(Ed), MCh(Orth)28
Colston Close, Crow Tree Lane
Bradford BD 8 0BN, United Kingdom
E-mail address: adnanfaraj@hotmail.com
C. Yilmaz, H.Y. Selek, I. Gürkan, B. Erdemli,
and Z. Korkusuz reply:
We agree with Mr. Faraj that augmenting strut grafts with anterior
instrumentation is indicated when more than two segments are involved,
as the risk of resorption or failure of the graft is relatively
high. Although the literature indicates that metal may be implanted
in the region of the tuberculous infection, and although our experience
confirms this, we still are reluctant to consider the use of such
an implant in patients with indications other than those described
in our article. We believe that the decision should be made individually
for each patient on the basis of the extent of the disease, the
degree of destruction prior to the time of diagnosis, and the severity
of the kyphosis.
—Cengiz Yilmaz, MD
Hakan Selek, MD
Ilksen Gürkan, MD
Bülent Erdemli, MD
Zeki Korkusuz, MDCorresponding author: Cengiz
Yilmaz, MD
Department of Orthopaedics and Traumatology
University of Ankara Medical School, Ibn-i Sina Hospital
3.Cad. 55/3 Bahçelievler
Ankara 06500, Turkey
E-mail address: cyilmaz@doctor.com