Our next speaker is Dr. Hassani of Controversies in the Management of Thoracolumbar Pots Disease. Dr. Hassani is speaking for Dr. Bouzouba from Morocco. Thank you. Thank you. Colleagues, it's a real pleasure to attend this great meeting in the wonderful city of New Orleans. I'd like to thank the organizing committee. And my talk is about controversies in the management of the thoracolumbar pots disease. And I present this talk instead of Dr. Bouzouba who apologized to not be able to attend. Why we choose this topic? We choose it because there is almost 1.7 billion cases in the world. It is one of the priorities of the World Health Organization and this is a real epidemic situation. The high frequency of tuberculosis could be explained by the socioeconomical conditions where poverty is a major factor to get tuberculosis. Some history, pot disease was described for the first time by Percival Pot in the modern literature. However, we can found that Abul Qasis had described this disease seven centuries before. It is the first controversies, even if it's not the subject of our presentation. Since that date, three important discoveries have changed how we deal with this disease. The mycobacterium tuberculosis, the vaccination and drugs to treat this disease. Pot disease represents 50% of cases of the musculoskeletal subgroup. And thoracic and lumbar location is found in more than 75% of cases. Even we can deal with cervical and thoracolumbar location in some cases. And after more than two centuries that we have discovered this, the pot disease, the thoracolumbar spinal spondylolisthesis represents four main controversies about diagnosis, surgical management and osteosynthesis. Let's go to the first one. This is first case of 32 years old man. He had lumbar lesion and we did CT scan guided biopsy and the diagnosis was spinal tuberculosis and he had drugs and the outcome was good after three months. It's not always that easy, unfortunately. In this case, 70 years old man, lumbar lesion, L3, L4. He had CT scan guided biopsy, no diagnosis. 15 days after, he still had back pain with worsening and new MRI showed a progression of this lesion and he had CT scan, second CT scan guided biopsy with diagnosis of pyogenic spondylolisthesis. And we give him antibiotics but no recovery. He still have pain and even more, 13 days after, he had bone destruction with this abscess. And after with this, all these arguments, we take in count all these arguments and we put it under antidepressant drugs and he did well. So it's not always simple to have the right diagnosis. Even with CT scan biopsy, 25% of cases we don't have diagnosis. In fact, we have to look for presumptive arguments. Endemic area, socioeconomic level, vaccination, control of this vaccination, association to other location and of course, in addition to the clinical presentation, imaging, biological results, especially tuberculum skin test and quantifier. What about the other controversies? Usually, surgical management is indicated if there is an acute neurosurgical deficit, if you have spinal deformity or instability, if you have large spinal abscess and if you are not exposed to chemical chemotherapy. And we can do three approaches. Posterior approach with laminectomy, without osteosynthesis, posterior approach and anterior approach with debridement of arthrodesis and fixation. Usually, we use laminectomy with osteosynthesis when there is spinal instability, like in this case. We can also use costotransinfectomy with no need to fixation sometimes and anterior approach is indicated to deal with anterior compression and with deformity. In this case of thoracic spondylolisthesis, we had done coperectomy with the rib bone graft and the patient did well without fusion in this case and the outcome was good. But we recommend to use fixation in addition to coperectomy and bone graft to have a better clinical and radiological outcome and to correct kyphosis. In this Moroccan series of more than 347 cases, we noticed that besides a good preoperative neurosurgical statue, we had improvement using anterior approach more than posterior approach. And by using anterior approach, kyphosis was corrected by an average of 80.7 degree. However, in posterior approach, we had worsening of this kyphosis. And even if it is spinal infection, evidence-based medicine studies and basic science studies showed that we can use osteosynthesis without any risk to maintain tuberculosis infection. Indeed, we can use all kinds of osteosynthesis or arthritis in the post-disease. The follow-up should be done for a long period. In our national program, the medical treatment is followed weekly to avoid non-observance, to appreciate the neurological improvement, the evolution of deformity, and to detect multidrug resistance in these cases. When there is neurological symptoms with rapid intervention with a surgical treatment and fixation, we can expect a good outcome. Prevention. It is the real solution. After many decades of program against tuberculosis, we still have trouble with this disease and with these cases. We need to find a solution to end this epidemic, to put an end to tuberculosis, and we need to achieve the goals, global goals of sustainable development, and with no poverty and with no anger, we can expect having a good health. It may be applicated even to some developed countries. Within this moment, we need to manage tuberculosis spondylitis. Some commendation could be followed. Post-disease suspicion should be well investigated by good clinical assessment and adequate imaging. CT scans, guided biopsy could help to diagnosis, but very often, in 25%, it does not. Medical treatment alone gives a good outcome to early diagnosis, and surgery will help with neurological deformity and stability cases. Ontario approach with bone grafts and fixation gives the best outcome for these cases. And in 2 to 18, we travel more than ever. We meet people more than ever. Many ethnics and many countries, and immigration is the most phenomenon, amazing phenomenon, but interesting phenomenon also on our planet. Regarding globalization, we need to have another look to tuberculosis and the spinal location of tuberculosis. We need to share experience and to give more opportunities of training to manage the disease correctly. Every patient is unique in spinal tuberculosis, even if the medical treatment is mandatory for all cases. What we need to keep in mind is that the observance of chemotherapy, vaccination of healthy patients, and socioeconomic development may help to reach the World Health Organization to reduce tuberculosis cases and spinal tuberculosis cases during the next two decades. Thank you. And welcome to the next Man's Congress in Naples, next June, and the Pan-Arab Congress in October, next October, next October, yes, in Morocco. Thank you. APPLAUSE

thoracolumbar Pott's disease

spinal tuberculosis

diagnosis

treatment controversies

surgical approaches