Evaluation of Therapeutic Efcacy of Surgical Intervention in Dorsal Spinal Tuberculosis

Tuberculosis (TB) is an infectious disease. The mycobacterium tuberculosis is the causative agent of TB. The prevalence of TB is in�uenced by the economic, sanitary, and medical conditions of the area. Although TB has the worldwide prevalence but it is most common in underdeveloped and developing nations like Pakistan, China, and several African nation. The every 24 to 32 people out of 100,000 in developed countries are suffering from TB. Objective: To analyze the surgical intervention for active dorsal spinal tuberculosis at early stage in patients suffering from paraparesis and paraplegia. Methods: This retrospective study was conducted at the neurosurgery department of the tertiary care hospital for the duration of four years and six months from January 2017 to June 2021. The study was carried out on 138 patients. There were 85 male and 53 female candidates. Written consent was taken from the patients. In order to determine the therapeutic effects of surgery, the neurological status on ASIA grading and NASCIS scores were examined. Results: Majority of the patients healed after single posterior procedure. The average time of surgery was 193 minutes approximately, and the mean blood loss was found to be 874 ml. The average motor improvement in NASCIS score for paraplegia was 78±13.1 and for paraparesis; it was 100 ± 0.0. Conclusions: In this study, it was concluded that early surgical intervention can prove to be bene�cial in case of active dorsal spinal TB patients with cord compression.

affected by MTB is the lung. The symptoms such as thoracalgia, hemoptysis, fatigue, cough, expectoration and fever are indicative of lungs disease. Other organs may be also affected if the lung lesion is not effectively treated [1,2]. One of the most prevalent extrapulmonary kinds of TB, spinal TB results from an initial lung lesion caused by MTB. It spread via the Batson plexus. The patients diagnosed with Tb can be treated with anti-TB medication treatment. The severe kyphotic deformity and an irreparable impairment are the results of pursuit of anti-TB drug treatment while ignoring surgical interventions. The surgical interventions are recommended to the spinal TB patients with compressed spinal cord, spinal instability, Therapeutic E cacy of Surgical Intervention in Dorsal Spinal Tuberculosis

I N T R O D U C T I O N
Tuberculosis (TB) is an infectious disease. The mycobacterium tuberculosis is the causative agent of TB. The prevalence of TB is in uenced by the economic, sanitary, and medical conditions of the area. Although TB has the worldwide prevalence but it is most common in underdeveloped and developing nations like Pakistan, China, and several African nation. The every 24 to 32 people out of 100,000 in developed countries are suffering from TB. Objective: To analyze the surgical intervention for active dorsal spinal tuberculosis at early stage in patients suffering from paraparesis and paraplegia. Methods: This retrospective study was conducted at the neurosurgery department of the tertiary care hospital for the duration of four years and six months from January 2017 to June 2021. The study was carried out on 138 patients. There were 85 male and 53 female candidates. Written consent was taken from the patients. In order to determine the therapeutic effects of surgery, the neurological status on ASIA grading and NASCIS scores were examined. Results: Majority of the patients healed after single posterior procedure. The average time of surgery was 193 minutes approximately, and the mean blood loss was found to be 874 ml. The average motor improvement in NASCIS score for paraplegia was 78±13.1 and for paraparesis; it was 100 ± 0.0. Conclusions: In this study, it was concluded that early surgical intervention can prove to be bene cial in case of active dorsal spinal TB patients with cord compression. included in the study. Both approaches focused on decompression of neural structure and xation of spinal instability according the set guidelines in the department. A l l t h e p a t i e n t s we r e g r a d u a l l y m o b i l i z e d w i t h thoracolumber corset and followed to 12 months at least. The standard four drugs TB chemotherapy was started and followed by the ID team. The patients with impaired hepatic functioning and systematic TB were excluded from the study. The demographic and clinical data of every patient was recorded and the statistical analysis was performed. The data was strati ed. Different statistical test was performed for the analysis. The SPSS tool was used.  [3]. The one of the most prevalent disease among top ten is spinal TB that results in disability in Pakistan. In Pakistan the number of new cases of spinal TB has been consistently high, harming individuals' physical and mental health and putting a tremendous strain on the healthcare system, affecting the patients' families and add to society's overall nancial burden [4,5]. The dorsal spine is more typically damaged in children and teenagers whereas, the lumber spine is the most commonly effected in the adults. The underlying cause is the dorsal spinal canal's narrowness with inadequate dorsal spinal cord blood ow. Patients with dorsal spinal conditions may get paralysis fast. In dorsal spine due to relatively smaller canal space, the presence of excessive abscess causes direct compression on the spinal cord due to which neurological de cit takes place. This is considered as one of the worst complications of TB. There are two distinct stages of neurological de cit; paraparesis and paraplegia [6,7]. Paraplegia is the complete loss of motor strength. Strength impairment distinguishes paraparesis from paraplegia, the loss of strength and both conditions impact the motor function with or without affecting sensory function. This study compares the effects of neurological improvement between paraparesis and paraplegia. The study aimed to analyze the surgical intervention for active dorsal spinal tuberculosis at early stage in patients suffering from paraparesis and paraplegia [8,9].
The study was carried out on 138 patients. There were 85 male and 53 female candidates. Written consent was taken from the patients. The patients were asked to follow-up for 12 months and then data was collected for analysis. The ethical and review board committee of the hospital approved the study. In order to determine the therapeutic effects of surgery, the preoperative and postoperative neurological assessment was analyzed on the basis of ASIA grading and on NASCIS score improvement. The range of neurological decline was from 1 to 21 days on average. To make a diagnosis, tests for erythrocyte sedimentation rate (ESR) were performed. Patients who met the following inclusion criteria were included in the study; (1) Presented with con rmed spinal TB by Infectious Disease (ID) team on radiological and laboratory tests' basis.
(2) They had underwent surgery within twenty-one days of the beginning of paraparesis and paraplegia (3) The 12 months follow-up was done. The choice of surgical approach posterior versus anterolateral was on the radiological ndings of epidural abscess size and number of involved vertebral levels. It was decided by the same surgical team for all the patients

R E S U L T S
The study was carried out to analyze the surgical intervention for active dorsal spinal tuberculosis at early stage in patients suffering from paraparesis and paraplegia. The study was carried out on 138 patients. There were 85 male and 53 female candidates as shown in the table 1. Written consent was taken from the patients. The patients were asked to follow-up for 12 months and then data was collected for analysis.

Male Female
Age (years)  Without any vascular or neural injury, all the surgeries were accomplished. There were ve patients that were reported went through revision surgery, it was needed in four because of the prolonged presence of paravertebral abscess, while in one patient there was misplaced screw. Majority of the patients healed after single posterior procedure. The average time of surgery was 193 minutes approximately, and the blood loss was found to be 874 ml. The thoracostomy tube was inserted in 26 cases due to breech of pleura during surgery and all were removed in 72 to 96 hours after full in ation of lung on post op x-ray chest as shown in table 2. During stay at the hospital after surgery, there were no major complications, except CSF leak in six patients and super cial wound infection in four cases. All of them managed conservatively without any further sequelae. The signs and symptoms that indicated [15,16]. However, the late-onset takes place because of rigid pressure conditions like granulomatous scar, kyphotic bone ridge etc. In our study the all the cases were the patients suffering from early onset paraplegia and paraparesis. The diagnosis was made after radiological analysis and laboratory studies. The main cause that was reported in our study that led to spinal cord compression was soft tissue materials like formation of pus like uids and proliferation of granuloma. Our ndings were consistent with the previous results where similar results were derived. In case of our study the compression on spinal cord was applied to a small amount of time so MRI was unable to nd malacia or spinal cord denaturation. But in this study there were cases where epidural adhesion was found in the patients. According to the literature review it was found that paraparesis and paraplegia are some of the complications produced as a result of TB, that can be improved with by taking right measures. According to studies conducted by different researchers it was concluded that by making use of anti-TB drugs one can manage such complications [17,18]. As only soft pressure is exerted and it can be absorbed by anti-TB drugs. As per studies it was found that delaying decompression and keeping patients on just prolonged usage of anti-TB drugs can also have negative and irreparable loss of neurological function. Therefore, it is important to have surgical procedure involved to avoid long term use of anti-TB drugs.

Location of the lesion
In case of this study, a course of 2 weeks was suggested to the patients, they used drugs for fourteen days, but in certain cases where there is sudden and acute sort of collapse in the neurological function the duration of drugs is reduced to less than 2 weeks because of the emergency surgery. The main aim of surgical intervention is to make patient get rid of excessive neural pressure, as a result there is a decrease in the infectious burden [19,20]. As per studies, it was found that a 2-3-week anti-TB drug treatment is carried before proceeding for operation so that progression in the impairment of neurological can be avoided. As surgery can only be done if there is a signi cant lowering of CRP and ESR values. In this study early operation was considered as the operation that is done within 3 weeks of the occurrence of paraplegia and paraparesis. A combination of streptomycin and levo oxacin is given to the patients before operation. If the hepatic function is severely damaged or there is disturbed CRP and ESR values, then drug treatment is given. In this study there was a signi cant improvement in the neurological function after the early surgery. Thus it was supported that the early surgical intervention is bene cial for the recovery of patients suffering from paraplegia and paraparesis. In our study it was found that MRI is very important to estimate that whether an anterolateral In dorsal spine due to relatively smaller canal space, the presence of excessive abscess causes direct compression on the spinal cord due to which neurological de cit takes place. This is considered as one of the worst complications of TB [10][11][12]. There are some other mechanisms as well like meningitis and infection in the thrombosis of spinal vessels that lead to complications leading to neurological de cit. The instability in the strength of spinal cord function is known as paraparesis in which there is impairment in the motor functioning of spinal cord [13,14]. Here in this study the patients with TB were analyzed for early surgical intervention in case of active dorsal spinal TB. 138 patients were taken and study was carried out after taking written consent from the patients. According to previous the studies, as paraplegia is the complete loss of motor strength so the A and B grade of ASIA scores should be considered as both cases include patients with and without loss of sensory function. Likewise, the patients with grade C and D scores should be considered in category paraparesis. Because in this case there is loss of motor functions ignoring the sensory status. Conditions like pus, tuberculous granuloma becomes the cause of early on-set of paraplegia and paraparesis. The symptoms of these conditions include slow repeated and gradual compression   In this study, it was concluded that early surgical intervention can prove to be bene cial in case of active dorsal spinal TB patients with cord compression. This is true not only for cases of paraparesis but also for even paraplegia; although the outcome is more good for the former than the later.

R E F E R E N C E S
The authors declare no con ict of interest.

C o n  i c t s o f I n t e r e s t
The author(s) received no nancial support for the research, authorship and/or publication of this article