title: Antepartum surgical management of Pott's paraplegia along with maintenance of pregnancy during second trimester.
abstract: BACKGROUND
  The existing literature is limited and inconclusive regarding management of spinal tuberculosis with neurological deficit during advanced pregnancy. None of the previously published case series concerning this problem during the second trimester of pregnancy have explored the option of simultaneous surgical intervention for it along with maintenance of pregnancy.
  
  
  METHODS
  A 22-year-old woman with 26 weeks of pregnancy (2nd trimester) presented with upper back pain for the past 2 months, inability to move both lower limbs for the last 1 week, bladder and bowel dysfunction for the past 5 days (Frankel Grade B). Patient subsequently underwent MRI scan dorsal spine and the image findings were suggestive of spinal tuberculosis T2 level. After obstetric evaluation and opinion of the expectant mother, in view of extensive neurological deficit which progressed rapidly, decision was taken for surgical intervention along with maintenance of pregnancy. Patient was positioned in right lateral position after giving general anesthesia using double lumen endotracheal tube with lung isolation technique. Exposure was done using transthoracic third rib excision approach. Decompression was achieved by radical debridement at T2 vertebrae level followed by multiple rib strut grafts and stabilization with screw and rod construct between T1 and T3 vertebrae. Intra-operative measures including type of anesthesia, prevention of maternal hypotension, hypoxemia and hypothermia, and fetal monitoring by attending obstetrician were undertaken to maintain feto-maternal safety. Postoperative ultrasonography evaluation of the fetus revealed a normal study. Post-surgery histopathological evaluation of the surgical specimen confirmed tuberculosis infection and the patient continued anti-tubercular drug therapy for 9 months. She delivered a healthy girl child at 36 weeks of gestation by cesarean section. After about 14 months of postoperative follow-up, patient has completely recovered motor power with mild persistent sensory symptoms. She is self-voiding with mild constipation requiring occasional intermittent laxative use. Radiological improvements in comparison to the previous reports were also seen at the last follow-up.
  
  
  CONCLUSIONS
  Although this is only a single case but being the first to our knowledge, the good results highlight the point that both surgical management and maintenance of pregnancy during second trimester complicated by Pott's paraplegia are possible, involving a multi-disciplinary team approach for optimal maternal and fetal outcome.
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India. rahulkaul1977@gmail.com.
authors.forename: Rahul
authors.initials: R
authors.lastname: Kaul
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: H S
authors.initials: HS
authors.lastname: Chhabra
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Vijayanth
authors.initials: V
authors.lastname: Kanagaraju
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Rajat
authors.initials: R
authors.lastname: Mahajan
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Vikas
authors.initials: V
authors.lastname: Tandon
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Ankur
authors.initials: A
authors.lastname: Nanda
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Gururaj
authors.initials: G
authors.lastname: Sangondimath
authors.affiliation: Spine Department, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Nishit
authors.initials: N
authors.lastname: Patel
mesh_terms: D001863:Bone Screws; D003646:Debridement; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D011184:Postoperative Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000601:surgery*; D011262:Pregnancy Trimester, Second; D011295:Prenatal Care / Q000379:methods; D013904:Thoracic Vertebrae / Q000601:surgery; D016896:Treatment Outcome; D014399:Tuberculosis, Spinal / Q000175:diagnosis / Q000601:surgery*; D055815:Young Adult
keywords: Anti-tubercular drugs; Pott’s paraplegia; Second trimester pregnancy; Surgical decompression