We report a case of tuberculous spondylitis treated with posterior instrumentation surgery. A 42-year-old man complained of severe low back pain and left leg pain. Physical examination disclosed a tenderness to palpation on the spinous process of L5, and muscle weakness with decreased sensation in the left leg. Laboratory tests were unremarkable except for an erythrocyte sedimentation rate (ESR) of 46mm/hr. Roentgenograms of the lumbar spine showed a loss of disc height at L4-L5 and partial collapse at the L5 vertebral body. Magnetic resonance imaging (MRI) studies showed a space occupying lesion in the L5 vertebral body. This lesion was heterogenous and hypointense on T1-weighted images (WI), and hyperintense on T2WI with “rim enhancement” after Gadolinium administration.
The patient underwent an open biopsy of the L5 vertebral body via the pedicular route. In microbiological studies, polymerase chain reaction (PCR) tested positive for Mycobacterium tuberculosis. Pathological examination revealed granulomatous inflammation with caseous necrosis. In spite of treatment with brace immobilization and four combined antituberculosis drugs (isoniazid, rifampicin, streptomycin, pyrazinamide) for 2 months, vertebral destruction had spread and pain worsened. The patient therefore underwent debridement, anterior interbody fusion with iliac crest strut graft at L4-L5, and posterior instrumentation using the double claw hook-and-rod system from L4 to L5. Six weeks after surgery, the patient was discharged from hospital on foot without any support.
We believe that posterior instrumentation using the double claw hook-and-rod system is very useful for the treatment of tuberculous spondylitis. The use of this system can prevent decreasing lordosis in the instrumented segments, and preserve the motion segments of the lumbar spine.
