Pedicle screw sublaminary wiring (PSSW) combined with anti-tuberculosis chemotherapy for treating spinal tuberculosis in adults: A cohort study

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Morales-Mancías, S. Vázquez-Fuentes, A.C. Cantú-Salinas, L. de León-Flores, B.E. Chávez-Luévanos, H. Villarreal-Velázquez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "L.R." "apellidos" => "Morales-Mancías" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Vázquez-Fuentes" ] 2 => array:2 [ "nombre" => "A.C." "apellidos" => "Cantú-Salinas" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "de León-Flores" ] 4 => array:2 [ "nombre" => "B.E." "apellidos" => "Chávez-Luévanos" ] 5 => array:2 [ "nombre" => "H." "apellidos" => "Villarreal-Velázquez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665579616300564?idApp=UINPBA00004N" "url" => "/16655796/0000001800000071/v1_201608180032/S1665579616300564/v1_201608180032/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Pedicle screw sublaminary wiring (PSSW) combined with anti-tuberculosis chemotherapy for treating spinal tuberculosis in adults: A cohort study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "78" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Azharuddin, J.K. Fajar" "autores" => array:2 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Azharuddin" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "J.K." "apellidos" => "Fajar" "email" => array:1 [ 0 => "gembyok@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Orthopedic and Traumatology, School of Medicine, University of Syiah Kuala, Dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Spine Surgery, dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Medical Research Unit, School of Medicine, University of Syiah Kuala, Banda Aceh, Indonesia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Jl. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia. Tel.: +62 081235522287; fax: +62 0651 7551843." ] ] ] ] "textoCompleto" => "IntroductionTuberculosis spondylitis (TS) is one of the oldest known human diseases. This disease was first described in 1779 by Percival Pott, therefore this disease is also known as Pott's disease.<a class="elsevierStyleCrossRef" href="#bib0160">1</a> The average number of extra-pulmonary tuberculosis (TB) in the world has remained stable. TS is most commonly musculoskeletal TB, the prevalence of which is about 40–50% of all cases of musculoskeletal TB<a class="elsevierStyleCrossRef" href="#bib0165">2</a> and an estimated 1–2% of all cases of TB.<a class="elsevierStyleCrossRef" href="#bib0170">3</a> TS incidence is 1.17 per 100,000 in females and 0.916 per 100,000 in males.<a class="elsevierStyleCrossRef" href="#bib0175">4</a> Furthermore, the incidence of neurological complications of TB is about 10–43%.<a class="elsevierStyleCrossRef" href="#bib0180">5</a>TS is the most dangerous musculoskeletal TB. It can cause damage due to bone deformity, serious morbidity, bone disorders, and severe neurological deficits.<a class="elsevierStyleCrossRef" href="#bib0185">6</a> The regions of the spine that were most often affected by TS were 35% lumbar, 31% thoracal, 15% thoraco-lumbar, 13% cervical, and 6% cervico-thoracal,<a class="elsevierStyleCrossRef" href="#bib0190">7</a> but this percentage was varied in several other publications. Garg and Somvanshi<a class="elsevierStyleCrossRef" href="#bib0195">8</a> revealed that the thoracic region of the vertebral column was most frequently affected. Godlwana et al.<a class="elsevierStyleCrossRef" href="#bib0175">4</a> found that the spinal region affected was 42% thoracic, 30% lumbar, 11% cervical, 10% thoraco-lumbar, 5% lumbosacral, and 2% sacral. Turgut<a class="elsevierStyleCrossRef" href="#bib0170">3</a> found that the spinal region affected was 55.8% thoracic, 22.8% lumbar, 16.9% thoracolumbar, and 4.2% cervical. Kotil et al.<a class="elsevierStyleCrossRef" href="#bib0200">9</a> found that the most common region of Pott's disease was the thoracolumbar junction (41%), followed by the thoracic (36%), and lumbar (23%) regions.Until now, the management of TS is still controversial due to the high variation in clinical TS. The Medical Research Council of the United Kingdom (MRC, London) suggested the use of an isoniazid and rifampicin regimen for six months as standard therapy for TS, but it did not include TS with damage to three or more areas of the spine.<a class="elsevierStyleCrossRef" href="#bib0205">10</a> Other studies revealed that the risk of deformity, instability, and progressive neurological deficits were related to the number of spinal areas damaged and indicated that operative management should maintain spinal stability.<a class="elsevierStyleCrossRefs" href="#bib0185">6,11</a> Therefore, although the MRC<a class="elsevierStyleCrossRef" href="#bib0205">10</a> suggested that drug therapy is a standard treatment for TS, it is not applicable to all cases of TS.One of the operative procedures for TS is pedicle screw sublaminary wiring (PSSW). PSSW, besides correcting kyphosis degrees, is also expected to improve neurological deficits.<a class="elsevierStyleCrossRef" href="#bib0215">12</a> A study conducted by Jutte and Van Loenhout-Rooyackers<a class="elsevierStyleCrossRef" href="#bib0220">13</a> and Issack and Boachie-Adjei<a class="elsevierStyleCrossRef" href="#bib0225">14</a> revealed that surgical management could improve the degree of kyphosis.In this study, we conducted the observation of kyphosis improvement after PSSW combined with anti-tuberculosis drugs, as associated with neurological status.Material and methodResearch designThis was an observational analytical study. The design of this study is a cohort study with a pretest/posttest control design.Research schedule and locationThe study was conducted at the Orthopaedic Department of the Centre of Surgery Installation and the Radiology Installation at the Dr. Zainoel Abidin Teaching Hospital, from March 2005 to March 2007.Research population and sampleThe samples in this study were TS patients who agreed to receive a combination of anti-tuberculosis therapy with PSSW based on clinical indications. The sampling technique used in this study was judgement sampling. The inclusion criteria of this study were (1) patient age >18 years, (2) diagnosed clinically, microbiologically, and radiologically as TS, (3) the lesion's regions were found in the thoracal, thoraco-lumbar, and/or lumbar regions. Exclusion criteria of this study were (1) patients with other spine disorders and (2) patients with severe systemic disorders.Research proceduresThe procedure of this study was (1) provision of explanations and recording of baseline data, including personal, demographic, and clinical information, consisting of neurological deficits according to the Frankel classification and the kyphosis angle. (2) Examination of radiographs of the spine using a CT Scan or MRI. (3) Anti-tuberculosis treatment with isoniazid at 7.5mg/kg BW/day, rifampicin at 10mg/kg BW/day, and ethambutol at 20mg/kg BW/day, divided into two doses for six months. (4) PSSW operative procedure with a posterior approach (resection of spinous process lamina, transverse process, ribs, resection of pedicles, middle column, posterior wall, controlled closure of posterior defect, and cantilever Pedicle Screw Sublaminar Wiring instrumentation).<a class="elsevierStyleCrossRef" href="#bib0230">15</a> (5) After the wound healed, patients were re-examined about neurological deficits and radiology to determine the angle of kyphosis after surgery, (6) The data obtained was processed using SPSS ver 16.0 to assess descriptively and analytically to access the association between variables.Research variablesFrankel classificationThis method of classification is used as a system to evaluate and document the neurological progress of an individual patient, a large number of patients, or a subgroup of patients with spinal injuries following a full neurological examination.<a class="elsevierStyleCrossRef" href="#bib0235">16</a> Data was obtained by neurological examination, and the ordinal scale was used to assess this variable.Kyphosis angleThe angle measured from lines drawn from the superior border of the upper end vertebra and the inferior border of the lower end vertebra, with perpendicular lines drawn from the end vertebra lines to measure the intersecting angle.<a class="elsevierStyleCrossRef" href="#bib0240">17</a> The data were obtained by an X-ray measurement. The interval scale was used to assess this variable.Statistical analysisData was analyzed using univariate and bivariate analysis. Data on neurological deficits before and after treatment was analyzed using the Spearman test. Data of kyphosis angle before and after treatment was analyzed using the regression correlation test. Data was considered significant if P<0.05.<a class="elsevierStyleCrossRef" href="#bib0245">18</a>ResultsA total of 18 patients participated in this study. 61.1% of them were male and 38.9% of them were female. The average age of TS patients in this study was 27.88 years. The spinal region affected was 55.6% thoracic, 27.8% thoraco-lumbar, and 16.7% lumbar (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Neurological status of patients before the intervention was 11.1% Frankle C, 72.2% Frankle D, and 16.7% Frankle E. Neurological status after intervention was 5.6% Frankle C and 94.4% Frankle E (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). An explanation regarding is a Frankel classification<a class="elsevierStyleCrossRef" href="#bib0250">19</a> is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows neurological deficits before and after the intervention. The Spearman test was performed to find an association of neurological deficits before and after the intervention. The Spearman test results obtained P=0.212 (P>0.05), and it was concluded that there was no statistically significant association between a combination of PSSW and anti-tuberculosis therapy and improvement of neurological deficits in patients with TS.The Regression correlation test was performed to assess the degree of kyphosis before and after the intervention. It obtained P=0.000 (P>0.05), so we concluded that there was a statistically significant association between a combination of PSSW and anti-tuberculosis therapy with improved degree of kyphosis in TS patients (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionTuberculosis spondylitis (TS) is a secondary infection disease of the spine. TS is the most common and the most dangerous of TB infections. TS is a common musculoskeletal TB with that makes up nearly half of all cases of musculoskeletal TB.<a class="elsevierStyleCrossRef" href="#bib0165">2</a> The incidence of TS has no difference between male and female.<a class="elsevierStyleCrossRef" href="#bib0170">3</a> This study showed that TS was more common in males (61.1%) than females (38.9%), with the average age of patients at (27.89±2.48). These results were not much different from other studies. Several studies reported that the incidence of TS was 34.6% in females and 65.4% in males,<a class="elsevierStyleCrossRef" href="#bib0255">20</a> 39.5% in females and 60.5% in males,<a class="elsevierStyleCrossRef" href="#bib0260">21</a> 54.2% in females and 45.8% in males,<a class="elsevierStyleCrossRef" href="#bib0265">22</a> 25% in females and 75% in males,<a class="elsevierStyleCrossRef" href="#bib0270">23</a> 50% in females and 50% in males,<a class="elsevierStyleCrossRef" href="#bib0170">3</a> 48% in females and 52% in males,<a class="elsevierStyleCrossRef" href="#bib0200">9</a> 66.6% in females and 33.3% in males,<a class="elsevierStyleCrossRef" href="#bib0275">24</a> and 1.17 per 100,000 in the female population and 0.916 per 100,000 in the male population.<a class="elsevierStyleCrossRef" href="#bib0175">4</a>The generally affected spinal regions are often not significantly different. A review by Garg and Somvanshi<a class="elsevierStyleCrossRef" href="#bib0195">8</a> revealed that the thoracic region of the vertebral column was most frequently affected. A study by Punamiya et al.<a class="elsevierStyleCrossRef" href="#bib0190">7</a> showed that the spinal regions affected were 35% lumbar, 31% thoracic, 15% thoraco-lumbar, 13% cervical, and 6% cervico-thoracic. Godlwana et al.<a class="elsevierStyleCrossRef" href="#bib0175">4</a> found that the spinal regions affected were 42% thoracic, 30%lumbar, 11% cervical, 10% thoraco-lumbar, 5% lumbosacral, and 2% sacral. Turgut<a class="elsevierStyleCrossRef" href="#bib0170">3</a> found that the spinal regions affected were 55.8% thoracic, 22.8% lumbar, 16.9% thoracolumbar, and 4.2% cervical. Kotil et al.<a class="elsevierStyleCrossRef" href="#bib0200">9</a> found that the most common region of Pott's disease was the thoracolumbar junction (41%), followed by the thoracic (36%), and lumbar (23%) regions. Our results found that the spinal regions affected were thoracic (55.6%), thoraco-lumbar (27.8%), and lumbar (16.7%).This study also reported kyphosis angles and neurological deficits in patients with TS. In this study, the average angle of kyphosis in TS patients before the intervention was 23.05±11.9 and 10.5±5.9 after. Kyphosis occurs due to the destruction of the spine. Kyphosis can be found in almost all TS patients who have spinal damage in the affected region. Kyphosis occurs due to the destruction of the corpus vertebrae. It is caused by infection in the anterior region. Kyphosis has a greater tendency to occur in the thoracic region compared to other regions.<a class="elsevierStyleCrossRef" href="#bib0280">25</a> Furthermore, this study found that Frankel D neurologic deficits occurred in 83.3% of patients, and found that 94% of patients showed an improvement of neurological status after the intervention. Neurological deficits can be found in almost all cases of TS, with manifestations such as paraplegia, paresis, reduced sensibility, or cauda equina syndrome. The manifestations of neurological deficits depends on the region of the damage. TS manifestations appear between 3 and 4 months after infection of the spine. The manifestations appeared a little longer in the lumbar region. This is due to the spinal canal of the lumbar region being wider, and thus more tolerant to neurological disorders, while the spinal canal of the thoracic region is narrow, which results in neurological symptoms appearing faster.<a class="elsevierStyleCrossRef" href="#bib0220">13</a>A combination of anti-tuberculosis drugs and PSSW results in total management of TS. The restoration of the patient's condition is this management's goal, so that patient can return to social life, family, and the work environment.<a class="elsevierStyleCrossRef" href="#bib0230">15</a> PSSW, or shortening procedure, is part of the total treatment approach for TS. The shortening procedure is performed by removing laminae and facet joints, precessus transversus, adjacent ribs, and middle segments until circumferential decompression of the duramater and cord is achieved. Then, the correction is performed by closing the posterior gap with posterior segmental instrumentation (cantilever pedicle screw sublaminar wiring instrumentation).<a class="elsevierStyleCrossRef" href="#bib0285">26</a> Management of TS is different in each instance, but has the same basic principles. No study has reported a combination of PSSW and anti-tuberculosis drugs in patients with TS. However, several similar studies have reported results that were not much different from this study. Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0290">27</a> conducted a study on surgical management for multilevel noncontiguous thoracic spinal tuberculosis by single-stage posterior transforaminal thoracic debridement, limited decompression, interbody fusion, and posterior instrumentation (modified TTIF) combined with anti-tuberculosis chemotherapy for 3 months. Follow-up was conducted at 10 months after surgery. The results showed improvement in patients with TS. The kyphosis angle decreased from 19.21±12.63 to 8.07±6.91. The neurological status of the 12 patients with preoperative neurological deficits were 6 with grade D recovered to normal; 2 with grade B, both of them to grade D; 4 with grade C, 2 to grade D, 1 to grade E, and 1 still in grade C. Sahoo et al.<a class="elsevierStyleCrossRef" href="#bib0275">24</a> conducted a study about aposterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis combined with anti-tuberculosis drugs and chemotherapy for 6 months for the treatment of TS. Follow-up was observed at 24 months after surgery. The results showed that kyphosis improved from a preoperative value of 17.7±5.8 degrees to 9.4±4.6 degrees postoperatively and neurological recovery occurred in 94.4% of patients. Ma et al.<a class="elsevierStyleCrossRef" href="#bib0295">28</a> conducted a study about the outcomes of anterior and posterior instrumentation under different surgical procedures combined with anti-tuberculosis chemotherapy for 3 weeks for treating thoracic and lumbar spinal tuberculosis in adults. The sample was divided into 2 groups. Anterior instrumentation was used in 74 patients (group A) and 83 patients (group B) were fixed posteriorly. Follow-up was observed at 12 weeks after surgery. The results found that the kyphosis degree was corrected by a mean of 11.5° in group A and 12.6° in group B, respectively. Fu et al.<a class="elsevierStyleCrossRef" href="#bib0300">29</a> conducted a study about a combination of intensified anti-tuberculosis treatment, posterior transpedicular screw system internal fixation, intertransverse bone grafting, and an anterior approach focus debridement for the treatment of thoracolumbar tuberculosis. Follow-up was conducted at 12–23 months after surgery. The results showed that all the patients achieved successful bony fusion 6–18 months after operation, and the Cobb angle was 7–21 degrees (average 15.2 degrees) 12 months after operation, without aggravation. The Frankel grading system was used to assess postoperative neurological function. 1 patient in grade B before the operation was improved to grade C after the operation, 1 patient in grade B was improved to grade D, 1 patient in grade C was improved to grade D, 4 patients in grade B were improved to grade E, and 7 patients in grade D were improved to grade E. Xu et al.<a class="elsevierStyleCrossRef" href="#bib0305">30</a> conducted a study on the effects of one stage surgical treatment of thoracolumbar spinal tuberculosis by anterior radical debridement with bone graft fusion and posterior pedicle screw-rod system fixation combined with anti-tuberculosis chemotherapy for 9 months. The patients were all complicated, with kyphosis deformity and an average Cobb angle of (28.0+/−9.7) degrees (before surgery). According to the Frankel neurological function grade system, there were 3 cases in grade B, 5 in grade C, 1 in grade D, and 12 in grade E (before surgery). Follow up was conducted 2.5 years after surgery. The results showed that the kyphosis deformity was corrected by 17.2 degrees in the thoracolumbar region, on average. According to the Frankel neurological functional grade system, 1 case was in grade C, 3 in grade D, and 17 in grade E (after surgery). Yang et al.<a class="elsevierStyleCrossRef" href="#bib0310">31</a> conducted a study on the effect of one-stage anterior debridement of infection in function reconstruction of the anterior and middle column combined with anti-tuberculosis chemotherapy for 9 months for the treatment of thoracolumbar spinal tuberculosis. In 14 cases with spinal cord injury (before surgery), there were 5 cases of grade C and 9 cases of grade D, according to the Frankel classification. The kyphotic Cobb angle was 20–65 degrees (41 degrees on average). Follow-up was conducted 12 months after surgery. The results showed that at 12 months after operation, the pain disappeared, and there were 7 cases of grade D and 7 cases of grade E, according to the Frankel classification. The kyphotic Cobb angle was 0–33 degrees (24 degrees on average). This study assessed radical surgery and posterior implant placement combined with anti-tuberculosis chemotherapy for six months for the treatment of TS. The results showed that it was effective for patients with TS to correct spinal kyphosis.ConclusionPSSW, combined with anti-tuberculosis chemotherapy for six months, was effective for patients with TS to correct spinal kyphosis, but it did not show a statistically significant difference to improve the neurological deficits although approximately 94% of the patients showed an improvement in neurological status.Conflicts of interestThe authors have no conflicts of interest to declare.FundingNo financial support was provided." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres719229" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Purpose" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec724460" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and method" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Research design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Research schedule and location" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Research population and sample" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Research procedures" ] 4 => array:3 [ "identificador" => "sec0035" "titulo" => "Research variables" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Frankel classification" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Kyphosis angle" ] ] ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistical analysis" ] ] ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "xack238917" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-26" "fechaAceptado" => "2016-04-19" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec724460" "palabras" => array:4 [ 0 => "Tuberculosis spondylitis" 1 => "PSSW" 2 => "Kyphosis" 3 => "Neurological disorders" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundOperative procedures and anti-tuberculosis combinations are controversial for tuberculous spondylitis (TS) management in cases with risk of deformity, fragments, instability, and neurological disorders. PurposeTo assess the effectiveness of a combination of anti-tuberculosis and pedicle screw sublaminary wiring (PSSW) for treating TS. MethodThis study was a cohort study with a pre-test/post-test control design. This study was conducted at the Dr. Zainoel Abidin Hospital (Banda Aceh) from March 2005 to March 2007. Sampling technique was judgement sampling. Neurological data deficit (Frankel classification) was analyzed before and after treatment using the Spearman test. Kyphosis angles were analyzed before and after treatment using the regression correlation test. ResultsA total of 18 patients (61.1% male and 38.9% female) participated in this study. The spinal column involved in this study was 55.6% thoracic, 27.8% thoraco-lumbar, and 16.7% lumbar. Neurological status before the treatment was 11.1% Frankel C, 72.2% Frankel, D, and 16.7% Frankel E. Neurological status after the treatment was 5.55% Frankel C and 94.4% Frankel E. It showed that there was no significant association between a combination of anti-tuberculosis and PSSW for neurological deficit improvement (P=0.212). The mean angle of kyphosis before the treatment was 23.05±11.9 while after the treatment it was 10.5±5.9. It showed that there was a significant association between a combination of anti-tuberculosis and PSSW for kyphosis degree improvement (P=0.000). ConclusionsA combination of anti-tuberculosis and PSSW for six months provided significant results if assessed from degree of kyphosis, but did not provide significant results if assessed from Frankel classification." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Purpose" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Amount (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Gender</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">TS region</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoracal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoraco-lumbar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lumbar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1182411.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Gender and spine region of TS patients." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frankle classification<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> before intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frankle classification after intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Significance (P) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="18" align="left" valign="middle">0.212</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1182410.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Frankel's classification<a class="elsevierStyleCrossRef" href="#bib0250">19</a>: Grade A, complete loss of both motor and sensory functions. Grade B, complete motor loss, some sensations preserved. Grade C, motor functions present, but useless. Grade D, motor function useful, but weak. Grade E, neurologically intact." ] ] ] "descripcion" => array:1 [ "en" => "Frankel classification before and after intervention." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kyphosis angle before intervention (°) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kyphosis angle after intervention (°) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Significance (P) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correlation coefficient \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="18" align="left" valign="middle">0.000</td><td class="td" title="table-entry " rowspan="18" align="left" valign="middle">0.970</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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A. Azharuddina,b, J.K. Fajarc,

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gembyok@gmail.com

Corresponding author at: Jl. Tanoeh Abe, Darussalam, Banda Aceh 23111, Indonesia. Tel.: +62 081235522287; fax: +62 0651 7551843.

a Department of Orthopedic and Traumatology, School of Medicine, University of Syiah Kuala, Dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia

b Spine Surgery, dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia

c Medical Research Unit, School of Medicine, University of Syiah Kuala, Banda Aceh, Indonesia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis spondylitis &#40;TS&#41; is one of the oldest known human diseases&#46; This disease was first described in 1779 by Percival Pott&#44; therefore this disease is also known as Pott&#39;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> The average number of extra-pulmonary tuberculosis &#40;TB&#41; in the world has remained stable&#46; TS is most commonly musculoskeletal TB&#44; the prevalence of which is about 40&#8211;50&#37; of all cases of musculoskeletal TB<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a> and an estimated 1&#8211;2&#37; of all cases of TB&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> TS incidence is 1&#46;17 per 100&#44;000 in females and 0&#46;916 per 100&#44;000 in males&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; the incidence of neurological complications of TB is about 10&#8211;43&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">TS is the most dangerous musculoskeletal TB&#46; It can cause damage due to bone deformity&#44; serious morbidity&#44; bone disorders&#44; and severe neurological deficits&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> The regions of the spine that were most often affected by TS were 35&#37; lumbar&#44; 31&#37; thoracal&#44; 15&#37; thoraco-lumbar&#44; 13&#37; cervical&#44; and 6&#37; cervico-thoracal&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> but this percentage was varied in several other publications&#46; Garg and Somvanshi<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> revealed that the thoracic region of the vertebral column was most frequently affected&#46; Godlwana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> found that the spinal region affected was 42&#37; thoracic&#44; 30&#37; lumbar&#44; 11&#37; cervical&#44; 10&#37; thoraco-lumbar&#44; 5&#37; lumbosacral&#44; and 2&#37; sacral&#46; Turgut<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> found that the spinal region affected was 55&#46;8&#37; thoracic&#44; 22&#46;8&#37; lumbar&#44; 16&#46;9&#37; thoracolumbar&#44; and 4&#46;2&#37; cervical&#46; Kotil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> found that the most common region of Pott&#39;s disease was the thoracolumbar junction &#40;41&#37;&#41;&#44; followed by the thoracic &#40;36&#37;&#41;&#44; and lumbar &#40;23&#37;&#41; regions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Until now&#44; the management of TS is still controversial due to the high variation in clinical TS&#46; The Medical Research Council of the United Kingdom &#40;MRC&#44; London&#41; suggested the use of an isoniazid and rifampicin regimen for six months as standard therapy for TS&#44; but it did not include TS with damage to three or more areas of the spine&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Other studies revealed that the risk of deformity&#44; instability&#44; and progressive neurological deficits were related to the number of spinal areas damaged and indicated that operative management should maintain spinal stability&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;11</span></a> Therefore&#44; although the MRC<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> suggested that drug therapy is a standard treatment for TS&#44; it is not applicable to all cases of TS&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the operative procedures for TS is pedicle screw sublaminary wiring &#40;PSSW&#41;&#46; PSSW&#44; besides correcting kyphosis degrees&#44; is also expected to improve neurological deficits&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> A study conducted by Jutte and Van Loenhout-Rooyackers<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> and Issack and Boachie-Adjei<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> revealed that surgical management could improve the degree of kyphosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this study&#44; we conducted the observation of kyphosis improvement after PSSW combined with anti-tuberculosis drugs&#44; as associated with neurological status&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material and method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Research design</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was an observational analytical study&#46; The design of this study is a cohort study with a pretest&#47;posttest control design&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Research schedule and location</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted at the Orthopaedic Department of the Centre of Surgery Installation and the Radiology Installation at the Dr&#46; Zainoel Abidin Teaching Hospital&#44; from March 2005 to March 2007&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Research population and sample</span><p id="par0040" class="elsevierStylePara elsevierViewall">The samples in this study were TS patients who agreed to receive a combination of anti-tuberculosis therapy with PSSW based on clinical indications&#46; The sampling technique used in this study was judgement sampling&#46; The inclusion criteria of this study were &#40;1&#41; patient age &#62;18 years&#44; &#40;2&#41; diagnosed clinically&#44; microbiologically&#44; and radiologically as TS&#44; &#40;3&#41; the lesion&#39;s regions were found in the thoracal&#44; thoraco-lumbar&#44; and&#47;or lumbar regions&#46; Exclusion criteria of this study were &#40;1&#41; patients with other spine disorders and &#40;2&#41; patients with severe systemic disorders&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Research procedures</span><p id="par0045" class="elsevierStylePara elsevierViewall">The procedure of this study was &#40;1&#41; provision of explanations and recording of baseline data&#44; including personal&#44; demographic&#44; and clinical information&#44; consisting of neurological deficits according to the Frankel classification and the kyphosis angle&#46; &#40;2&#41; Examination of radiographs of the spine using a CT Scan or MRI&#46; &#40;3&#41; Anti-tuberculosis treatment with isoniazid at 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg BW&#47;day&#44; rifampicin at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg BW&#47;day&#44; and ethambutol at 20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg BW&#47;day&#44; divided into two doses for six months&#46; &#40;4&#41; PSSW operative procedure with a posterior approach &#40;resection of spinous process lamina&#44; transverse process&#44; ribs&#44; resection of pedicles&#44; middle column&#44; posterior wall&#44; controlled closure of posterior defect&#44; and cantilever Pedicle Screw Sublaminar Wiring instrumentation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> &#40;5&#41; After the wound healed&#44; patients were re-examined about neurological deficits and radiology to determine the angle of kyphosis after surgery&#44; &#40;6&#41; The data obtained was processed using SPSS ver 16&#46;0 to assess descriptively and analytically to access the association between variables&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Research variables</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Frankel classification</span><p id="par0050" class="elsevierStylePara elsevierViewall">This method of classification is used as a system to evaluate and document the neurological progress of an individual patient&#44; a large number of patients&#44; or a subgroup of patients with spinal injuries following a full neurological examination&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> Data was obtained by neurological examination&#44; and the ordinal scale was used to assess this variable&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Kyphosis angle</span><p id="par0055" class="elsevierStylePara elsevierViewall">The angle measured from lines drawn from the superior border of the upper end vertebra and the inferior border of the lower end vertebra&#44; with perpendicular lines drawn from the end vertebra lines to measure the intersecting angle&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a> The data were obtained by an X-ray measurement&#46; The interval scale was used to assess this variable&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Data was analyzed using univariate and bivariate analysis&#46; Data on neurological deficits before and after treatment was analyzed using the Spearman test&#46; Data of kyphosis angle before and after treatment was analyzed using the regression correlation test&#46; Data was considered significant if <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">18</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 18 patients participated in this study&#46; 61&#46;1&#37; of them were male and 38&#46;9&#37; of them were female&#46; The average age of TS patients in this study was 27&#46;88 years&#46; The spinal region affected was 55&#46;6&#37; thoracic&#44; 27&#46;8&#37; thoraco-lumbar&#44; and 16&#46;7&#37; lumbar &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Neurological status of patients before the intervention was 11&#46;1&#37; Frankle C&#44; 72&#46;2&#37; Frankle D&#44; and 16&#46;7&#37; Frankle E&#46; Neurological status after intervention was 5&#46;6&#37; Frankle C and 94&#46;4&#37; Frankle E &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; An explanation regarding is a Frankel classification<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows neurological deficits before and after the intervention&#46; The Spearman test was performed to find an association of neurological deficits before and after the intervention&#46; The Spearman test results obtained <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;212 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; and it was concluded that there was no statistically significant association between a combination of PSSW and anti-tuberculosis therapy and improvement of neurological deficits in patients with TS&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The Regression correlation test was performed to assess the degree of kyphosis before and after the intervention&#46; It obtained <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; so we concluded that there was a statistically significant association between a combination of PSSW and anti-tuberculosis therapy with improved degree of kyphosis in TS patients &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Tuberculosis spondylitis &#40;TS&#41; is a secondary infection disease of the spine&#46; TS is the most common and the most dangerous of TB infections&#46; TS is a common musculoskeletal TB with that makes up nearly half of all cases of musculoskeletal TB&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a> The incidence of TS has no difference between male and female&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> This study showed that TS was more common in males &#40;61&#46;1&#37;&#41; than females &#40;38&#46;9&#37;&#41;&#44; with the average age of patients at &#40;27&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;48&#41;&#46; These results were not much different from other studies&#46; Several studies reported that the incidence of TS was 34&#46;6&#37; in females and 65&#46;4&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> 39&#46;5&#37; in females and 60&#46;5&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a> 54&#46;2&#37; in females and 45&#46;8&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> 25&#37; in females and 75&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">23</span></a> 50&#37; in females and 50&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> 48&#37; in females and 52&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> 66&#46;6&#37; in females and 33&#46;3&#37; in males&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> and 1&#46;17 per 100&#44;000 in the female population and 0&#46;916 per 100&#44;000 in the male population&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The generally affected spinal regions are often not significantly different&#46; A review by Garg and Somvanshi<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> revealed that the thoracic region of the vertebral column was most frequently affected&#46; A study by Punamiya et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> showed that the spinal regions affected were 35&#37; lumbar&#44; 31&#37; thoracic&#44; 15&#37; thoraco-lumbar&#44; 13&#37; cervical&#44; and 6&#37; cervico-thoracic&#46; Godlwana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> found that the spinal regions affected were 42&#37; thoracic&#44; 30&#37;lumbar&#44; 11&#37; cervical&#44; 10&#37; thoraco-lumbar&#44; 5&#37; lumbosacral&#44; and 2&#37; sacral&#46; Turgut<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> found that the spinal regions affected were 55&#46;8&#37; thoracic&#44; 22&#46;8&#37; lumbar&#44; 16&#46;9&#37; thoracolumbar&#44; and 4&#46;2&#37; cervical&#46; Kotil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> found that the most common region of Pott&#39;s disease was the thoracolumbar junction &#40;41&#37;&#41;&#44; followed by the thoracic &#40;36&#37;&#41;&#44; and lumbar &#40;23&#37;&#41; regions&#46; Our results found that the spinal regions affected were thoracic &#40;55&#46;6&#37;&#41;&#44; thoraco-lumbar &#40;27&#46;8&#37;&#41;&#44; and lumbar &#40;16&#46;7&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This study also reported kyphosis angles and neurological deficits in patients with TS&#46; In this study&#44; the average angle of kyphosis in TS patients before the intervention was 23&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;9 and 10&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9 after&#46; Kyphosis occurs due to the destruction of the spine&#46; Kyphosis can be found in almost all TS patients who have spinal damage in the affected region&#46; Kyphosis occurs due to the destruction of the corpus vertebrae&#46; It is caused by infection in the anterior region&#46; Kyphosis has a greater tendency to occur in the thoracic region compared to other regions&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> Furthermore&#44; this study found that Frankel D neurologic deficits occurred in 83&#46;3&#37; of patients&#44; and found that 94&#37; of patients showed an improvement of neurological status after the intervention&#46; Neurological deficits can be found in almost all cases of TS&#44; with manifestations such as paraplegia&#44; paresis&#44; reduced sensibility&#44; or cauda equina syndrome&#46; The manifestations of neurological deficits depends on the region of the damage&#46; TS manifestations appear between 3 and 4 months after infection of the spine&#46; The manifestations appeared a little longer in the lumbar region&#46; This is due to the spinal canal of the lumbar region being wider&#44; and thus more tolerant to neurological disorders&#44; while the spinal canal of the thoracic region is narrow&#44; which results in neurological symptoms appearing faster&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A combination of anti-tuberculosis drugs and PSSW results in total management of TS&#46; The restoration of the patient&#39;s condition is this management&#39;s goal&#44; so that patient can return to social life&#44; family&#44; and the work environment&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> PSSW&#44; or shortening procedure&#44; is part of the total treatment approach for TS&#46; The shortening procedure is performed by removing laminae and facet joints&#44; precessus transversus&#44; adjacent ribs&#44; and middle segments until circumferential decompression of the duramater and cord is achieved&#46; Then&#44; the correction is performed by closing the posterior gap with posterior segmental instrumentation &#40;cantilever pedicle screw sublaminar wiring instrumentation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Management of TS is different in each instance&#44; but has the same basic principles&#46; No study has reported a combination of PSSW and anti-tuberculosis drugs in patients with TS&#46; However&#44; several similar studies have reported results that were not much different from this study&#46; Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> conducted a study on surgical management for multilevel noncontiguous thoracic spinal tuberculosis by single-stage posterior transforaminal thoracic debridement&#44; limited decompression&#44; interbody fusion&#44; and posterior instrumentation &#40;modified TTIF&#41; combined with anti-tuberculosis chemotherapy for 3 months&#46; Follow-up was conducted at 10 months after surgery&#46; The results showed improvement in patients with TS&#46; The kyphosis angle decreased from 19&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;63 to 8&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;91&#46; The neurological status of the 12 patients with preoperative neurological deficits were 6 with grade D recovered to normal&#59; 2 with grade B&#44; both of them to grade D&#59; 4 with grade C&#44; 2 to grade D&#44; 1 to grade E&#44; and 1 still in grade C&#46; Sahoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> conducted a study about aposterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis combined with anti-tuberculosis drugs and chemotherapy for 6 months for the treatment of TS&#46; Follow-up was observed at 24 months after surgery&#46; The results showed that kyphosis improved from a preoperative value of 17&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;8 degrees to 9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6 degrees postoperatively and neurological recovery occurred in 94&#46;4&#37; of patients&#46; Ma et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> conducted a study about the outcomes of anterior and posterior instrumentation under different surgical procedures combined with anti-tuberculosis chemotherapy for 3 weeks for treating thoracic and lumbar spinal tuberculosis in adults&#46; The sample was divided into 2 groups&#46; Anterior instrumentation was used in 74 patients &#40;group A&#41; and 83 patients &#40;group B&#41; were fixed posteriorly&#46; Follow-up was observed at 12 weeks after surgery&#46; The results found that the kyphosis degree was corrected by a mean of 11&#46;5&#176; in group A and 12&#46;6&#176; in group B&#44; respectively&#46; Fu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> conducted a study about a combination of intensified anti-tuberculosis treatment&#44; posterior transpedicular screw system internal fixation&#44; intertransverse bone grafting&#44; and an anterior approach focus debridement for the treatment of thoracolumbar tuberculosis&#46; Follow-up was conducted at 12&#8211;23 months after surgery&#46; The results showed that all the patients achieved successful bony fusion 6&#8211;18 months after operation&#44; and the Cobb angle was 7&#8211;21 degrees &#40;average 15&#46;2 degrees&#41; 12 months after operation&#44; without aggravation&#46; The Frankel grading system was used to assess postoperative neurological function&#46; 1 patient in grade B before the operation was improved to grade C after the operation&#44; 1 patient in grade B was improved to grade D&#44; 1 patient in grade C was improved to grade D&#44; 4 patients in grade B were improved to grade E&#44; and 7 patients in grade D were improved to grade E&#46; Xu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a> conducted a study on the effects of one stage surgical treatment of thoracolumbar spinal tuberculosis by anterior radical debridement with bone graft fusion and posterior pedicle screw-rod system fixation combined with anti-tuberculosis chemotherapy for 9 months&#46; The patients were all complicated&#44; with kyphosis deformity and an average Cobb angle of &#40;28&#46;0<span class="elsevierStyleHsp" style=""></span>&#43;&#47;&#8722;<span class="elsevierStyleHsp" style=""></span>9&#46;7&#41; degrees &#40;before surgery&#41;&#46; According to the Frankel neurological function grade system&#44; there were 3 cases in grade B&#44; 5 in grade C&#44; 1 in grade D&#44; and 12 in grade E &#40;before surgery&#41;&#46; Follow up was conducted 2&#46;5 years after surgery&#46; The results showed that the kyphosis deformity was corrected by 17&#46;2 degrees in the thoracolumbar region&#44; on average&#46; According to the Frankel neurological functional grade system&#44; 1 case was in grade C&#44; 3 in grade D&#44; and 17 in grade E &#40;after surgery&#41;&#46; Yang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> conducted a study on the effect of one-stage anterior debridement of infection in function reconstruction of the anterior and middle column combined with anti-tuberculosis chemotherapy for 9 months for the treatment of thoracolumbar spinal tuberculosis&#46; In 14 cases with spinal cord injury &#40;before surgery&#41;&#44; there were 5 cases of grade C and 9 cases of grade D&#44; according to the Frankel classification&#46; The kyphotic Cobb angle was 20&#8211;65 degrees &#40;41 degrees on average&#41;&#46; Follow-up was conducted 12 months after surgery&#46; The results showed that at 12 months after operation&#44; the pain disappeared&#44; and there were 7 cases of grade D and 7 cases of grade E&#44; according to the Frankel classification&#46; The kyphotic Cobb angle was 0&#8211;33 degrees &#40;24 degrees on average&#41;&#46; This study assessed radical surgery and posterior implant placement combined with anti-tuberculosis chemotherapy for six months for the treatment of TS&#46; The results showed that it was effective for patients with TS to correct spinal kyphosis&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">PSSW&#44; combined with anti-tuberculosis chemotherapy for six months&#44; was effective for patients with TS to correct spinal kyphosis&#44; but it did not show a statistically significant difference to improve the neurological deficits although approximately 94&#37; of the patients showed an improvement in neurological status&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">No financial support was provided&#46;</p></span></span>"
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              "identificador" => "sec0020"
              "titulo" => "Research schedule and location"
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                0 => array:2 [
                  "identificador" => "sec0040"
                  "titulo" => "Frankel classification"
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                1 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Kyphosis angle"
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            5 => array:2 [
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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        5 => array:2 [
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          "titulo" => "Discussion"
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          "titulo" => "Conclusion"
        ]
        7 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
        ]
        8 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Funding"
        ]
        9 => array:2 [
          "identificador" => "xack238917"
          "titulo" => "Acknowledgements"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-11-26"
    "fechaAceptado" => "2016-04-19"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec724460"
          "palabras" => array:4 [
            0 => "Tuberculosis spondylitis"
            1 => "PSSW"
            2 => "Kyphosis"
            3 => "Neurological disorders"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Operative procedures and anti-tuberculosis combinations are controversial for tuberculous spondylitis &#40;TS&#41; management in cases with risk of deformity&#44; fragments&#44; instability&#44; and neurological disorders&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Purpose</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness of a combination of anti-tuberculosis and pedicle screw sublaminary wiring &#40;PSSW&#41; for treating TS&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This study was a cohort study with a pre-test&#47;post-test control design&#46; This study was conducted at the Dr&#46; Zainoel Abidin Hospital &#40;Banda Aceh&#41; from March 2005 to March 2007&#46; Sampling technique was judgement sampling&#46; Neurological data deficit &#40;Frankel classification&#41; was analyzed before and after treatment using the Spearman test&#46; Kyphosis angles were analyzed before and after treatment using the regression correlation test&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 18 patients &#40;61&#46;1&#37; male and 38&#46;9&#37; female&#41; participated in this study&#46; The spinal column involved in this study was 55&#46;6&#37; thoracic&#44; 27&#46;8&#37; thoraco-lumbar&#44; and 16&#46;7&#37; lumbar&#46; Neurological status before the treatment was 11&#46;1&#37; Frankel C&#44; 72&#46;2&#37; Frankel&#44; D&#44; and 16&#46;7&#37; Frankel E&#46; Neurological status after the treatment was 5&#46;55&#37; Frankel C and 94&#46;4&#37; Frankel E&#46; It showed that there was no significant association between a combination of anti-tuberculosis and PSSW for neurological deficit improvement &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;212&#41;&#46; The mean angle of kyphosis before the treatment was 23&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;9 while after the treatment it was 10&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9&#46; It showed that there was a significant association between a combination of anti-tuberculosis and PSSW for kyphosis degree improvement &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A combination of anti-tuberculosis and PSSW for six months provided significant results if assessed from degree of kyphosis&#44; but did not provide significant results if assessed from Frankel classification&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Amount &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">TS region</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thoracal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thoraco-lumbar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lumbar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Gender and spine region of TS patients&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frankle classification<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> before intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Frankle classification after intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Significance &#40;<span class="elsevierStyleItalic">P</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="18" align="left" valign="middle">0&#46;212</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Frankel&#39;s classification<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a>&#58;</p> <p class="elsevierStyleNotepara" id="npar0010">Grade A&#44; complete loss of both motor and sensory functions&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">Grade B&#44; complete motor loss&#44; some sensations preserved&#46;</p> <p class="elsevierStyleNotepara" id="npar0020">Grade C&#44; motor functions present&#44; but useless&#46;</p> <p class="elsevierStyleNotepara" id="npar0025">Grade D&#44; motor function useful&#44; but weak&#46;</p> <p class="elsevierStyleNotepara" id="npar0030">Grade E&#44; neurologically intact&#46;</p>"
            ]
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Frankel classification before and after intervention&#46;</p>"
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kyphosis angle before intervention &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Kyphosis angle after intervention &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Significance &#40;<span class="elsevierStyleItalic">P</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correlation coefficient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="18" align="left" valign="middle">0&#46;000</td><td class="td" title="table-entry  " rowspan="18" align="left" valign="middle">0&#46;970</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Kyphosis angle before and after intervention&#46;</p>"
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  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665579616300552?idApp=UINPBA00004N"
]

Article information

ISSN: 16655796
Original language: English

DOI:10.1016/j.rmu.2016.04.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	10	2	12
2024 October	39	6	45
2024 September	50	14	64
2024 August	51	2	53
2024 July	49	6	55
2024 June	53	2	55
2024 May	56	7	63
2024 April	54	4	58
2024 March	55	2	57
2024 February	50	3	53
2024 January	77	8	85
2023 December	57	15	72
2023 November	54	6	60
2023 October	48	8	56
2023 September	44	3	47
2023 August	41	9	50
2023 July	42	5	47
2023 June	42	2	44
2023 May	34	8	42
2023 April	28	4	32
2023 March	25	3	28
2023 February	25	2	27
2023 January	24	7	31
2022 December	22	7	29
2022 November	40	8	48
2022 October	25	10	35
2022 September	14	13	27
2022 August	36	7	43
2022 July	25	11	36
2022 June	28	14	42
2022 May	38	6	44
2022 April	33	14	47
2022 March	47	9	56
2022 February	41	6	47
2022 January	70	8	78
2021 December	34	13	47
2021 November	54	6	60
2021 October	30	7	37
2021 September	43	11	54
2021 August	31	8	39
2021 July	20	12	32
2021 June	14	10	24
2021 May	45	9	54
2021 April	102	18	120
2021 March	54	15	69
2021 February	21	8	29
2021 January	27	13	40
2020 December	35	11	46
2020 November	11	7	18
2020 October	17	11	28
2020 September	24	8	32
2020 August	17	5	22
2020 July	22	3	25
2020 June	17	11	28
2020 May	12	7	19
2020 April	6	3	9
2020 March	19	10	29
2020 February	20	1	21
2020 January	17	10	27
2019 December	26	18	44
2019 November	14	8	22
2019 October	11	3	14
2019 September	8	1	9
2019 August	5	2	7
2019 July	12	11	23
2019 June	7	7	14
2019 May	54	6	60
2019 April	24	3	27
2019 March	9	6	15
2019 February	13	5	18
2019 January	15	4	19
2018 December	5	2	7
2018 November	8	2	10
2018 October	2	2	4
2018 September	2	4	6
2018 August	2	0	2
2018 July	8	2	10
2018 June	11	4	15
2018 May	5	8	13
2018 April	18	0	18
2018 March	5	0	5
2018 February	4	1	5
2018 January	6	0	6
2017 December	4	3	7
2017 November	12	5	17
2017 October	7	1	8
2017 September	9	6	15
2017 August	10	4	14
2017 July	19	3	22
2017 June	17	3	20
2017 May	24	3	27
2017 April	16	0	16
2017 March	21	41	62
2017 February	27	2	29
2017 January	20	1	21
2016 December	40	5	45
2016 November	47	6	53
2016 October	63	12	75
2016 September	83	6	89
2016 August	36	9	45
2016 July	2	3	5

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