Tuberculosis of the Spine

Literature has shown studies that aim to determine the timing and reasons for surgery in spinal tuberculosis and to evaluate the efficacy of different surgical approaches in addressing kyphosis and neural outcomes. In instances of spinal tuberculosis, surgery is advised to tackle the difficulties in diagnosis, the neurological effects, and to halt the advancement of kyphosis.

The spinal cord can tolerate a canal’s encroachment of up to 76% in a typical neurologic condition since it can endure compression that increases gradually.

Nonoperative therapy has shown positive results in patients who have edema/myelitis with primarily fluid compression on MRI, but whose cord size remains largely intact.

However, individuals with cord edema/myelitis or myelomalacia, as well as extradural compression caused by granulation tissue with minimal fluid component, require early surgical decompression.

Two common procedures for decompression of the spine are extrapleural anterolateral decompression and transthoracic transpleural anterior decompression, with comparable outcomes in the dorsal spine. When post-debridement deficiencies exceed two disc gaps, instrumented stabilization may be necessary to prevent graft-related problems in short-segment illness.

However, even with instrumented stabilization, progression of kyphosis can still occur, especially in long-segment illness, so it is essential to closely monitor the situation. Correcting severe kyphosis after healing requires multiple surgical steps and is a risky procedure. Therefore, prospective studies are necessary to define the surgical approach, stages, issues, and challenges of kyphosis correction in spinal TB.

Spinal TB affects up to 50% of patients with musculoskeletal TB, with the anterior column being affected in 98% of these cases. Between 10% and 47% of spinal TB patients experience neural complications, and many develop varying degrees of kyphotic deformity.

The primary objectives of treating spinal tuberculosis are to eliminate the infection, prevent further worsening of angular deformities, and recover from any neurological deficits. The approach to treating spinal TB has evolved over the past 50 years, thanks to advancements in imaging, surgical techniques, and implants. The focus now is on healing the lesion while minimizing spinal deformity, as opposed to previous approaches that aimed to heal the lesion with residual deformity.

General Treatment of Spinal TB

The objectives of the treatment include verifying the diagnosis, eradicating the lesion through bacterial means, addressing spinal cord compression and its associated effects, and managing spinal deformity and its potential consequences, such as the onset of paraplegia in later stages.

Clinical and radiographic examination is a dependable approach for identifying spinal tuberculosis. In situations where the clinical or radiological evidence is not conclusive, a surgical decompression should be performed to obtain adequate tissue for histopathological evaluation and to confirm the diagnosis.

The compromised immunity in numerous HIV-positive individuals and the pathogenic organism’s resistance to therapy have resulted in a renewed outlook on the treatment of spinal TB.

Recent progress in spine reconstruction and instrumentation has provided patients with access to advanced treatment alternatives. Patients with severe neurological deficits were limited to radical resection of the tuberculosis-infected focus and bone grafting as the only available treatment options in the past.

Nevertheless, early diagnosis has become possible with the advent of modern imaging modalities such as CT and MRI. Advanced spinal TB patients in developing nations can now receive nonoperative treatment due to the availability of more powerful antituberculosis therapy regimens.

A patient with TB of the spine who receives non-operative treatment should be regarded as a nonresponder and surgery should be strongly considered if they develop a new lesion or do not exhibit an adequate clinical radiographic healing response.

When a patient with a deep-seated vertebral tubercular lesion should be classified as a nonresponder requires agreement among researchers. The surgery is necessary to make the diagnosis, lessen the disease burden, and obtain enough tissue for culture and sensitivity tests.

If a patient with spinal TB undergoes non-operative treatment but does not show adequate clinical radiographic healing or develops a new lesion, surgery should be strongly considered. However, there is a need for agreement among researchers on when to classify a patient with a deep-seated vertebral tubercular lesion as a nonresponder. Surgery is necessary to diagnose the condition, reduce the disease burden, and collect sufficient tissue for culture and sensitivity tests.

For the past 50 years, two surgical treatment strategies for spinal TB have been used: universal extirpation surgery and limited surgery with specific indications. Current antitubercular medications have made it possible to sterilize the lesion, eliminating the need for universal surgery.

A study by the British Medical Research Council found that both the Hong Kong procedure (anterior radical resection and débridement with fusion) and nonoperative treatment produced positive outcomes, but developing nations lack the resources for fusion surgery. Patients with a higher number of affected vertebrae may experience some kyphosis before the lesion heals, and before brace support is needed.

Spinal Instability

Spinal instability occurs when both columns of the spine are compromised, such as in spinal trauma or vertebral fractures. Chronic inflammation like that caused by tuberculosis may not necessarily make the spine unstable due to the healing response of the tissues. However, if an infection process and a mechanical insult occur together, the spine can become unstable.

When tuberculosis damages the facets and posterior complexes, the spine becomes unstable, resulting in a neurological deficit. These lesions should be recognized on AP radiographs, and if imaging shows destruction of both columns of the vertebral bodies, the spine should be stabilized. Patients with significant kyphosis or long-segment disease may also require stabilization.

Neurologic Involvement

Neurologic complications in the spine can be caused by cord compression, instability, intrinsic factors, and infective thrombosis/endarteritis. Pus, granulation tissue, caseous tissue, discs, or bony sequestra can compress the spinal cord, but there may not always be a correlation between cord compression and neural deficits.

Instability can be caused by pathological subluxation or dislocation due to pan vertebral illness. Intrinsic factors such as cord edema, myelomalacia, and direct affectation of the meninges and spinal cord can also lead to neural complications. Infectious thrombosis or endarteritis can also cause neural complications, but a combination of factors may result in less severe canal compromise and neural complications.

Our Goal at Complete Orthopedics

Spinal TB can cause devastating effects such as paralysis and deformity, and its prevalence is increasing worldwide, especially among immunocompromised individuals. Despite advances in understanding and treatment, the incidence of paraplegia and spinal deformity remains around 20%.

Gross kyphosis can lead to pulmonary and cardiac complications, and while chemotherapy may render the disease inactive, vertebral collapse can persist until the bone matures into a bone block indicating healing. However, significant advancements in TB chemotherapy and spinal canal decompression have improved outcomes, and with early diagnosis and treatment, excellent results can be achieved.

The goal of treating kyphosis caused by spinal TB is to achieve as close to a normal kyphosis as possible. However, since the dorsal spine naturally has a kyphosis of 10° to 20°, a correction may not always be necessary. Dorsolumbar kyphosis can cause compensatory lumbar lordosis and may only require minor correction.

In a study of 28 cases, a surgical approach involving posterolateral decompression and anterior interbody fusion was used to correct an average kyphosis of 40.2° from a preoperative mean of 64.3°. More research is needed to determine the best surgical approach, steps, stages, and challenges for correcting kyphosis of 60° or more.

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Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
Dave
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
Eclectic54
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.