Spinal tuberculosis, historically known as Pott's disease, remains a significant cause of morbidity globally. Determining the "best" surgical design is not a one-size-fits-all proposition but rather a nuanced decision based on the disease's location, severity, and the patient's neurological status. The primary goals of any surgical intervention are to achieve adequate debridement of the infected tissue, restore spinal stability, and decompress the neural elements.
The cornerstone of surgical management often involves a combination of debridement and fusion. The Anterior Approach is frequently considered the gold standard for lesions primarily located in the vertebral body. It allows direct access to the infected focus, enabling thorough debridement, correction of kyphotic deformity, and anterior column reconstruction using bone grafts or titanium mesh cages. This approach directly addresses the pathology's origin.
For cases with significant posterior column involvement or instability, a Posterior Approach offers excellent stabilization. It involves pedicle screw fixation to provide a rigid construct, indirectly decompressing the cord through ligamentotaxis. While less effective for direct debridement from this approach alone, it is crucial for restoring alignment and stability.
Increasingly, surgeons are adopting a Combined Anterior and Posterior Approach for severe cases. This strategy, though more extensive, provides the benefits of both: anterior debridement and reconstruction followed by posterior instrumentation for unparalleled stability. It is particularly indicated for patients with severe kyphosis, pan-vertebral lesions, or those with neurological deficits requiring 360-degree decompression.
Modern designs also incorporate Minimally Invasive Surgical (MIS) techniques. Utilizing tubular retractors and percutaneous screw fixation, MIS aims to achieve the surgical goals with reduced muscle dissection, less blood loss, and quicker recovery. The choice of implant—static versus expandable cages, the type of bone graft (autograft, allograft, or bioactive substitutes)—also plays a critical role in the long-term success of the construct.
Ultimately, the best spinal TB design is a patient-tailored strategy. Key factors influencing the choice include the number of vertebrae affected, the degree of kyphosis, the presence of an abscess, and the patient's overall bone quality. A multidisciplinary team approach, involving spinal surgeons and infectious disease specialists, is essential for selecting the optimal surgical design to eradicate infection and restore a pain-free, functional life.
