October - LRS Institute of Tuberculosis & Respiratory Diseases

TUBERCULOSIS OF SPINE 217
it has established that an initial period of rest
in bed offers little if any benefit”.
The Second Report (Medical Research
Council 1973b) on the study at Pusan, Korea
deals with a series of 150 children on ambulatory
treatment with the standard chemotherapy
with or without Plaster of Paris jacket immobilisation.
At the end of three years, 85 per cent
of children in plaster jacket for nine months
and 82 per cent of children without jacket had
responded favourably. The corresponding figures
for the increase in the gibbus at three years
were 12° and 10° respectively. 80 per cent of
patients on triple regimen and 87 per cent of
patients on isoniazid and PAS had a favourable
response. Therefore the triple regimen was no
more effective than the two-drug regimen.
P.O.P. Jacket offers no benefit.
The Third Report (Medical Research
Council 1974a) concerns a study in Bulawayo.
Rhodesia where a controlled trial of debridement
and ambulatory treatment with a. second
random allocation of triple or two-drug regimen
for eighteen months was done. Unlike the
Korean studies the series included a high
proportion of adult patients. Debridement
consisted of the removal of pus, caseous
material, sloughs and sequestra but not deliberate
removal of unaffected or viable bone.
85 per cent of the debridement series and 86
per cent of ambulatory series had favourable
results at third year. There was significant
mean vertebra] loss in debridement series while
the increase in gibbus was not significant. Bony
fusion had occured in 51 per cent of debridement
series and 67 per cent of ambulatory series
at three years As in Korean series, there was
little difference between SPH and PH series’, 84
per cent and 86 per cent respectively responding
favourable at three years.
Debridement is not a good operation.
83 per cent of biopsy specimens were histologically
and/or bacterologically positive for tuberculosis.
In Bulawayo a clinical diagnosis of
active tuberculosis was nearly always proved
correct.
The Fourth Report (Medical Research
Council 1974b) compares the anterior spinal
fusion (Rad. series) and debridement on patients
(Deb. series) on triple drug regimen for
18 months at Hong Kong. The mean total
vertebral loss on admission was 0.7 in each of
the series; at three years a mean gain of 0.2
of a vertebra in Rad. series and a mean further
loss of 0.2 of a vertebra in Deb. series was seen
(P< 0.001). There was a significant increase
in the gibbus angle of 0.9° for the Rad. series
and 4.5° for Deb. series at three years (P=0.1).
Radiographic evidence of bony fusion of affected
vertebral bodies was 93 per cent and 69
per cent respectively at 36 months (P—0.003).
The favourable response was 87 per cent and
86 per cent respectively at three years.
Eighty five per cent of 149 specimens were
histologically tuberculous and/or yielded positive
cultures for tubercle bacilli. The radical operation
is, therefore, a better procedure.
In all there were 630 patients in four studies.
The favourable status of various series were
nearly identical at third and fifth years excepting
in radical surgery where 89 per cent showed
favourable status by 18 months.
Griffith (1979) states that “on the evidence
of this (first) series of trials (Medical Research
Council (1973a, 1973b, 1974a, 1974b, 1976,
1978), spinal tuberculosis uncomplicated by
paraplegia should be treated by adequate
chemotherapy combined with Hong Kong
radical operation, if, only if, surgical expertise,
adequate anaesthetic facilities and skilled nursing
are readily available. If these facilities and
skills arc not available, the operation should
not be performed, and reliance should be
placed with confidence on ambulant out-patient
chemotherapy. In-patient care and plaster
jackets were not shown to confer any advantage
and advantages that might be claimed for
operative debridement do not appear adequate
to justify that operation as a therapeutic
measure, valuable as it may be as a means of
diagnosis in an otherwise difficult diagnosis
problem”.
The Rationale of Short Course Chemotherapy
for Tuberculosis of Spine
The merits of short course chemotherapy
are that the medication can be supervised and
the case holding is easier. Several reports have
appeared in recent years on short course chemotherapy
in the management of pulmonary
tuberculosis. “Tuberculosis of parenchymatous
organs is characterized by a high bacterial
population; tuberculosis of bone by a low one
(Canetti, Debeyre and De Seze 1957). Debauinout
(1966) showed that the total bacillary
population of tuberculous spine may amount
to fewer than are million organisms. A positive
sputum on the other hand, may contain upto
300,000 bacteria in 1 millilitre (Boquet 1938).
This low bacterial population also implies the
likelihood of a lower incidence of drug resistant
mutants in spinal disease than in pulmonary
tuberculosis (Canetti and Grosset 1961) and it
may be that this makes the spinal involvement
Ind, J. Tub., Vol. XXIX, No. 4