Use of Hartshill rectangle with sublaminar wiring for posterior stabilization of D7-D9 tubercular spondylodiscitis with paraplegia: a cost effective treatment
DOI:
https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20241522Keywords:
Spinal tuberculosis, Hartshill cage, Hartshill rectangle, Sublaminar wiring, Decompression, TuberculosisAbstract
Tuberculosis presents a significant health challenge, with extrapulmonary cases comprising 15-20%. Spinal tuberculosis often leads to neurological deficits, requiring surgical intervention such as Hartshill system fixation. Various posterior instrumentation methods are employed, with sublaminar wiring pioneered by Luque and enhanced by Dove's Hartshill system for superior biomechanical performance. This case underscores Hartshill system's efficacy in stabilizing the spine post-tubercular destruction, offering a cost-effective alternative to pedicle screws. An 18-year-old presented with 6-month upper back pain, progressing weakness in lower limbs, weight loss, and fever. Radiographs revealed D7-D9 vertebral destruction, leading to kyphosis. MRI showed paradiscal bony destruction and abscess, suggestive of tubercular spondylodiscitis. Surgery with Hartshill rectangle and sublaminar wiring provided kyphosis correction. Post-operative Gene-Xpert confirmed tuberculosis. Mobilization and chemotherapy led to limb power restoration within 3 months, with ongoing rehabilitation and consolidation of affected segments with complete recovery by eight months. Instrumented stabilization in spinal TB prevents kyphosis and graft complications; Hartshill loop rectangle and sublaminar wire fixation, cost-effective and suitable for resource-poor settings, offer comparable outcomes to pedicle screws, enabling hybrid fixation, especially in low-income countries.
References
Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ. 1999;160:1597-603.
Fussey SP, Lindsay JG, Fuller C, Perham RN, Dale S, James OF, et al. Autoantibodies in primary biliary cirrhosis: Analysis of reactivity against eukaryotic and prokaryotic 2‑oxo acid dehydrogenase complexes. Hepatology. 1991;13:467‑7.
Jain AK, Kumar J. Tuberculosis of spine: neurological deficit. Eur Spine J. 2013;22Suppl4:624-33.
Hodgson AR, Stock FE. Anterior spine fusion for the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first 100 cases. Bone Joint J Surg. 1960;42:295-310.
Upadhyay SS, Saji MJ, Yau ACMC. Duration of antituberculosis chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis. Spine. 1996;21:1898-903.
Bostman OM, Myllynen PJ, Riska EB. Unstable fractures of the thoracic and lumbar spine: the audit of an 8-year series with early reduction using Harrington instrumentation. Injury. 1987;18:190-5.
Sullivan JA. Sublaminar wiring of Harrington distraction rods for unstable thoracolumbar spine fractures. Clin Orthop. 1984;189:178-85.
Ferguson RL, Allen BL. A mechanistic classification of thoracolumbar spine fracture. Clin Orthop 1984;189:77-88.
Chang KW. A reduction - fixation system for unstable thoracolumbar burst fractures. Spine 1992;17:879-86.
Luque ER. Segmental spinal instrumentation for correction of scoliosis. Clin Orthop Relat Res. 1982;163:192-8.
Dove J. Internal fixation of lumbar spine: the Hartshill rectangle. Clin Orthop. 1986;203:135–90.
Dove J. Internal fixation of unstable spinal fractures: the Hartshill system. Injury. 1989;20(3):139-44.
Jain AK, Maheshwari AV, Jena S. Kyphus correction in spinal tuberculosis. Clin Orthop Relat Res. 2007;460:117–23.
Wilber RG, Thompson GH, Shaffer JW, Brown RH, Nash CL. Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring. J Bone Joint Surg Am. 1984;66:1178 87.
Coe JD, Warden KE, Herzig MA, McAfee PC. Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine (Phila Pa 1976). 1990;15:902-7.
Mohan AL, Das K. History of surgery for the correction of spinal deformity. Neurosurg Focus 2003;14:e1.
Jain AK, Jain S. Instrumented stabilization in spinal tuberculosis. Int Orthop. 2012;36(2):285-92.
Srivastava SK, Aggarwal RA, Bhosale SK, Roy K, Nemade PS. The Versatile Approach: A Novel Single Incision Combined with Anterior and Posterior Approaches for Decompression and Instrumented Fusion to Treat Tuberculosis of the Thoracic Spine. Asian Spine J. 2017;11(2):294-304.
Srivastava S, Marathe N, Bhosale S, Purohit S, Raj A, Amin A, et al. Golden Wires and Rectangle: A Cost-Effective Treatment for Tuberculosis of the Thoracic Spine. Asian J Neurosurg. 2020;15(2):328-32.
Güzey FK, Emel E, Bas NS, Hacisalihoglu S, Seyithanoglu MH, Karacor SE, et al. Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases. J Neurosurg Spine. 2005;3(6):450-8.
