360° spinal fixations through posterior only approach in a child with pott’s disease: a case report

Spondylitis is the most common manifestation of osseoarticular TB, and 1%–3% of patients with TB have skeletal involvement. It is most common in the first 3 decades of life and is a leading cause of paraplegia⁶. Vertebral body involvement usually occurs through the extensive venous plexus of Batson, spreading infection to multiple spinal segments while characteristically sparing the disc space^7,8. Tuberculous spondylitis without any spinal cord compression or neurological deficits can be treated conservatively with anti-TB medications. Surgery is considered for patients with spinal cord compression or neurological compromise, significant spinal deformity, persistent severe axial pain or disease progression on maximal medical therapy^9,10. Multiple surgical approaches are available for treatment of TB spondylitis in the pediatric age group. Outcomes of extensive surgery is similar to debridement alone except better correction of kyphosis and deformity in case of extensive surgery¹¹. In addition, extensive surgery reduces the duration of chemotherapy¹². Although Pott’s disease affecting young children are rare but it’s surgical management is technically challenging¹³. Presentation of vertebral TB in children are often insidious in onset and include back pain, fever and motor, sensory or autonomic dysfunction. Although chemotherapy is the first line of treatment, but surgery may be warranted if spinal cord compression or kyphotic deformity is present. Around 3% of children with pott’s disease develop severe kyphosis (> 60°)¹⁴ .Risk factors for kyphotic deformity includes age <10 years; involvement of ≥ 3 VBs; or involvement of  thoracic spine¹⁵. Severe kyphosis is cosmetically unacceptable and causes spinal cord compression over the apex of the deformity and cardiopulmonary dysfunction from restrictive lung disease. Skeletal immaturity of young children must be taken into account during surgical intervention and number of fused segments should be minimized (particularly in dorsal spine) to avoid complications such as iatrogenic short stature, crankshaft deformity, and restricted growth of the rib cage causing pulmonary hypoplasia. Younger patients exhibit a more aggressive form of TB, with severe extra-pulmonary involvement and progressive VB collapse¹³, placing them at a higher risk for disabling complications in comparison to adults. So we performed surgery which halted progression of kyphotic deformity and improved neurological symptoms in our patient. The surgical technique of choice for spinal TB has been a matter of continuous debate¹⁶. Posterior-only surgical approaches in these cases had unfavorable outcomes because they were usually limited to laminectomy with or without fusion but spinal cord compression is located anteriorly¹⁷.  In our patient, we performed extensive surgery with vertebral column reconstruction with an anterior titanium cage and posterior instrumentation extending from 2 levels above and 2 levels below the lesion, even in the setting of acute infection which resulted in debridement of infectious focus and a reduced and stabilized kyphotic deformity. Our patient represents one of the few young patients treated with a single-stage, 360 vertebral column reconstruction with an anterior titanium cage and posterior pedicle screw fixation through posterior only approach. At follow-up, our patient’s neurological examination and kyphotic deformity were stable. However, she needs to be followed for the next several years, given her young age and skeletal immaturity, to check for development of complications.