Late-Onset Paraplegia/ Paraplegia of Healed disease occurs due to long-standing kyphosis in the tubercular patient where compression of neural structures happens after a certain period of the active stage of TB.
- Long-standing kyphosis ( With a history of TB Spine > 10 years back)
The patient presents with the sign of Upper motor neuron paraplegia
Causes of Late-Onset Paraplegia/ Paraplegia of Healed disease
Secondary to reactivation of old/ healed lesion at previous kyphosis level
Intrinsic changes in the spinal cord due to stretch on the spinal cord due to kyphosis
Treatment of choice
Extrapleural anterolateral or Costotransversectomy is preferred
Anterior decompression is faster, better, and safe inpatient with the active patient but in the case of healed diseases, anterior decompression is more difficult and gives less satisfying results.
Details on Tuberculosis of the spine
Complications following anterior decompression
- Neural deterioration
- CSF fistula
EXTRAPLEURAL ANTEROLATERAL OR COSTOTRANSVERSECTOMY
Steps for extrapleural anterolateral decompression done in late-onset paraplegia are discussed below:
Direct exposure to the internal structure
Posterior 5 cm of three crowded ribs at the apex is removed along with a transverse process
The surgical plane should remain in extrapleural/ retroperitoneal space
Segmental intercostal nerve serve as a guide to intervertebral foramina
Two/ Three pedicles at the apex are removed and Dura is visualized clearly
One or more intercostal vessels excised
Removal of the posterior half of collapsed vertebral is done with a high-speed burr leaving behind the posterior rim
Avoid forward migration of the dural sac which might further compress neural structure
This allows the spinal cord to be transported anteriorly and an adequate length of anterior dura is exposed
Cortical strut grafting is performed as far anteriorly as possible after exposing the proximal and distal limit of angular kyphosis
Pulmonary function is not affected on already compromised lung
