TREATMENT OF VERTEBRAL TUBERCULOSIS BY FUSION OPERATION
Journal of the American Medical Association
seven years have elapsed since the earliest and three and one-half years since the latest patient was operated on. This is a sufficient length of time to make possible a fair estimate of the influence of the operation on the course of the disease. The operation was designed and its technic perfected with the single object of eliminating motion of the diseased articulations, experience having proved that the limited motion obtained by various mechanical means, such as braces, corsets, etc., was
... corsets, etc., was beneficial. It was felt that absolute elimination would hasten the cure and perhaps prevent deformity. The absolute elimination of motion in any joint is accomplished only when the bones entering into its formation become fused. This is possible only when all tissue other than osseous is removed or destroyed from between their articular ends and new bone formation fills the gap. This is sometimes accomplished by nature without operative aid. In the case of a verte¬ bral joint affected by tuberculosis, however, nature is too slow. The spinous processes, laminae and lateral articulations are rarely involved. Their easy accessi¬ bility and close approximation make them peculiarly well adapted for operative fusion. OPERATION An incision is made through the skin and sub¬ cutaneous tissue from above downward over the spinous processes of the segment to be fused, exposing the tips. The periosteum over the tips of the first two spines above is split and "the interspinous ligament between. With a periosteal elevator these are bared of periosteum for about one half their length. Small packs of gauze are now inserted to prevent oozing. The periosteum of each tip and the interspinous liga¬ ment between is split in turn, and the periosteum is freed from the bone and treated as described and so on including each vertebra to be fused. Beginning at the upper end again, with a dull perios¬ teal elevator for children, and a sharp one for adults, the operator separates the periosteum farther forward from the spinous processes and laminae to the base of the transverse processes, exposing the lateral articula¬ tion. Each vertebra is treated in this manner from above downward and packings inserted as noted. These packs are very important, as they keep the operative field dry. Beginning at the upper end again with a small curet, the operator curets the lateral articulations and removes the periosteum and ligament from the adja¬ cent edges of the laminae arid bases of the spinous processes. This is done with each vertebra in turn over the entire field, with packs inserted as described. lamina and turns it from above downward, its free end resting on the one next below. Each in turn is so treated with packings inserted afterward. With the operator beginning at the upper end again with a bone forceps, each spinous process is carefully cut and fractured, so that its tip rests on the bare bone next below. The periosteum and ligament which have been split and pushed to either side and lie in prac¬ tically an unbroken sheet, are brought together in the middle and sutured with interrupted sutures of ten-day chromic catgut. The subcutaneous tissue is closed by a continuous suture of plain catgut. The skin wound is closed with a continuous suture of ten-day chromic catgut. Sterile dressings are applied and an immo¬ bilizing brace. Summary : All tissue other than osseous has been removed from between the lateral articulations, the laminae and the spinous processes, and bone contact is secured at the lateral articulations, the laminae and the spinous processes, so that with the perios¬ teum closed, we have practically a tube of periosteum filled with live, healthy bone, lying in continuous con¬ tact and insuring a perfect fusion. Great care should be exercised in the removal of all tissue from the bones, as the area of fusion will be determined absolutely by the thoroughness and extent of the dissection. If the dissection is made subperiosteally, there is absolutely no difficulty from hem¬ orrhage, and the whole operation may be done with practically a dry field. The number of vertebrae to be fused in each case is determined by the extent of the disease. Great care should be exercised that two healthy vertebrae are included at either end. As will be seen later on, in some cases a sufficient number of vertebrae were not included, and it became necessary to perform a second operation. The patient is kept quiet in bed for eight weeks after the operation and continues to wear a brace for from six months to a year. The form of brace used is the Taylor model, because it is accurate, and is the most efficient means of securing immobilization after operation. It is always fitted to the patient before operation, and is, therefore, perfectly comfortable. In this group of cases, there has been no operative mortality and all the wounds have healed by first intention. There has been practically no shock in any case. In dealing with these patients, we have always had in mind the fact that they were suffering from tuberculo¬ sis, and, when possible, every influence, such as good food and good air, has been brought to bear on them. An attempt has been made to keep every patient under constant observation, and in most instances this has been done by the visiting nurses and our dispensary department. The patients all come from among the poorer classes and most of them live in crowded ten¬ ements. No attempt has been made to select cases. Every patient with Pott's disease who would consent to operation and whose general condition warranted the administration of an anesthetic, v*as operated on, regardless of other complications or the extent of the disease. I believed that the operation would hasten the cure of many and for those in whom cure could not be expected, it would at least contribute to their comfort. Most of these patients had had some form of brace or jacket treatment before operation.