Objective To summarize the effect of one-stage anterior debridement of infection in function reconstruction of anterior and middle column for the treatment of thoracolumbar spinal tuberculosis. Methods From January 2001 to January 2007, 65 patients with thoracolumbar spinal tuberculosis were treated with one-stage anterior debridement, decompression, autogenous bone grafts and internal fixation. There were 43 males and 22 females with an average age of 40.2 years (range, 19-64 years), including 18 cases of thoracic tuberculosis (T4-10), 44 cases of thoracolumbar tuberculosis (T11-L2) and 3 cases of lumbar tuberculosis (L3-5). The disease course was 3 months to 10 years (median 10 months). One segment was involved in 7 cases, two segments in 54 cases and three segments in 4 cases. In 14 cases with spinalcord injury, there were 5 cases of grade C and 9 cases of grade D according to Frankel classification. The kyphotic Cobb angle was 20-65° (41° on average). Results The operative time was 120-210 minutes (170 minutes on average), and the blood loss was 300-1 500 mL (600 mL on average). Fifty-eight patients were followed up for 1-6 years (23 months on average). Abscess occurred in 2 cases at 40 days and 3 months, and healed after symptomatic management. The other incisions achieved heal ing by first intention. The X-ray films showed bony fusion 4-12 months (6 months on average) after operation. No tuberculosis recurred. At 12 months after operation, pain disappeared, and there were 7 cases of grade D and 7 cases of grade E according to Frankel classification. The kyphotic Cobb angle was 0-33° (24° on average), showing statistically significant difference (P lt; 0.05) when compared with preoperation. Conclusion Early reconstruction of load-bearing function and stabil ity of anterior and middle column in the treatment of spinal tuberculosis is great significant. The appl ication of one-stage anterior surgery with debridement, decompression, autogenous bone grafts and internal fixation in the operative treatment of thoracolumbar tuberculosis is safe and effective after a rigorous anti-tuberculosis treatment.
Objective To investigate the perioperative management and the results of surgical treatment of spinal tuberculosis associated with diabetes mellitus. Methods The cl inical data were analysed retrospectively from 42 patients with spinal tuberculosis associated with type 2 diabetes mell itus who were surgically treated between July 2001 and January 2009.There were 22 males and 20 females with an average age of 56.5 years (range, 41-78 years). The disease duration was 4-18 months (mean, 7.5 months). The involved vertebrae included 2 cervical vertebrae, 13 thoracic vertebrae, 17 thoracolumbar vertebrae, and 10 lumbar vertebrae. Of them, 18 patients compl icated by paraplegia, and 25 patients had more than one of concomitant diseases. Anterior debridement and bony grafting with anterior instrumentation fixation were performed in 16 patients; anterior debridement and bony grafting with posterior instrumentation fixation in 4 patients; posterolateral costotransversectomy debridement and interbody fusion with posterior instrumentation fixation in 8 patients; posterior debridement and bony grafting with posterior fixation in 7 patients; sinus resectomy and focus debridement in 2 patients; anterior debridement and bony grafting in 3 patients; and CT guided percutaneous catheter drainage in 2 patients. Postoperative anti-tuberculosis treatment was given for 12-24 months. Results The patients were followed up 1.5-5.0 years, with a mean period of 3.5 years. One patient died of pulmonary infection after 1 week of operation; 1 patient died of myocardial infarction after 2 years of operation; and other patients survived without tuberculosis recurrence. Among 38 patients who received bony grafting, 34 patients achieved bony fusion, 3 suffered bony grafting failure without kyphotic deformity or instabil ity except 1 patient who died from pulmonary infection. Among 18 cases compl icated by paraplegia, nerve function improved to a certain extent. The intraoperative and postoperativecompl ications occured in 28 cases. The systemic compl ications mainly included heart insufficiency in 5, heart rrhythmia in 3, pulmonary infection in 2, urinary tract infection in 2, and stree ulcer in 1; they were cured after medical treatment. The local complications mainly included sinus tract formation in 5, pleural tear in 2, neurologic injury in 2, intraoperative tear of inferior vena cava in 2, and the loosening of transpedicular screws in 4; they all were cured effectively. Conclusion Surgical treatment of spinal tuberculosis associated with diabetes mell itus appears to be a beneficial procedure on the condition that the blood glucose is controlled and the associated disorders and postoperative complications are properly handled, and reasonably selection of surgical procedures is very important. Instrumentation fixation provides adequate stabil ity to allow early mobilization.
To explore the advantage and indication of combined anterior and posterior surgeries for lumbarsacral junction tuberculosis. Methods Eleven cases of the lumbarsacral junction tuberculosis were treated with combined anterior (radical debridement and autograft) and posterior (instrumentation and fusion) surgeries in one stage between January 2002 and December 2006. There were 9 males and 2 females with the age of 20-56 years old. The courseof disease was 4 to 15 months, 6 months on average. The lessons were located at L5, S1 in 7 patients, at L4,5, S1 in 2 patients and at L5, S2 in 2 patients. The involved vertebral bodies were at 2 segments in 7 patients; and 3 segments in 5 patients. The preoperative kyphosis was 5 to 8° with an average 9°. The sinus was associated in 3 patients, 3 patients had radiculopathy; 4 had paeumonophthisis and 9 had abscess. Results The followed-up period was from 6 months to 3 years, 18 months on average. According to Chen score, among the 11 cases, there were excellent in 9, good in 2. All incisions were healed up primarily. After operation, spinal fusion was achieved in 10 cases within 5 months to 7 months, 6 months on average, and pseudoarthrosis in 1 case was found by the CT examination. The postoperative kyphosis was 0 to 4° with the mean of 2° and the radiculopathy in 3 cases all got nerve function recovery. Conclusion Lumbarsacral junction tuberculosis treated with this surgical technique can achieve a high satisfactory rate with restoring the spinal stabil ity, arresting the disease early, providing early fusion, correcting the kyphosis and preventing progression of kyphosis particularly if lumbosacral spine tuberculosis is associated with sinus or preoperative diagnosis cannot exclude suppurative spondyl itis.
Objective To study the clinical results of focal debridement and primary internal fixation with CD rod in treatment of multisegmental spinaltuberculosis.Methods From July 1999 to November 2002, 16 patients with multisegmental spinal tuberculosis were given focal debridement and primary internal fixation with CD rod trans sick vertebra. There were 9 males and 7 females, aging from 21 to 59 years. The course of disease was 2 to 11 months. The locations of lesion were T 6T 11 in 11 patients and T 10 -L2 in 5 patients.The involved vertebral bodies were 3 segments in 13 patients, 4 or more than 4 segments in 3 patients. There were 5 cases of Pott’s paralysis (according to Frankel classification system: 3 cases of degree C, 2 cases of degree D) and 4 cases of kyphosis and 2 cases of collapse. Focal debridement and internal fixation was performed in 1 or 2 incisions according to concrete conditions. Results All patients were followed up 11 months (6 months-3years), spinal tuberculosis was completely cured and the grafted bones were fused in all 16 patients. All patients obtainedprimary healing of the incision. Postoperative complication met with cerebrospinal fluid leakage in 1 case. After 6 months, 5 cases of paraplegia recovered. The kyphosis was corrected partly. No loose and dislocation of the nails and rods was found. Conclusion Focal debridement and primary internal fixation with CD rod can stabilize involved spinal segments, prevent and correct local deformity,and improve its curative ratio and fused ratio of grafted bone.
ObjectiveTo investigate the reasons for failure to treat thoracolumbar tuberculosis by anterior internal fixation and its countermeasures. MethodsA total of 485 patients with thoracolumbar spinal tuberculosis underwent anterior focus clearance and fixation from January 2005 to January 2012. Eighteen of them failed with a rate of 3.71%. Screws were pulled out in two patients. Vertebra cutted by screws occurred in three patients. In another three patients, screws dropped into the intervertebral disc. Tuberculosis relapsed in 10 patients (5 accompanied with spinal deformity, 2 with pure malunion, 2 with abscess formation, and 1 with sequestra). Twelve of the patients underwent two-stage posterior pedicle screw internal fixation and anterior focus clearance and autogenous bone grafts fusion. Four were treated by shifting antituberculosis drugs and staying in bed. Two were cured by multiple abscesses puncture and antituberculosis injection. ResultsThese patients were followed up for 15~30 months. Twelve cases of spinal tuberculosis were completely cured and 6 cases of them got clinical cure. However, 3 cases of them had scoliosis deformity followed and 1 had kyphosis. No tuberculosis relapse, cold abscess or sinus formation, or pedicle screw internal fixation failure occurred again. ConclusionAlthough there are many complications of anterior internal fixation for spinal tuberculosis, anterior internal fixation is still a perfect choice if we can make an appropriate choice of operation and strengthen the management after operation.
ObjectiveTo systematically evaluate the effectiveness of anterior versus posterior approaches with one-stage debridement and bone grafting for surgical treatment of spinal tuberculosis. MethodsDatabases including PubMed, MEDLINE, Ovid, Elsevier, CBM, WanFang Data, CNKI and VIP were electronically searched from 2004 to 2015 to collect relevant clinical studies about the effectiveness of anterior versus posterior approaches with one-stage debridement and bone grafting for surgical treatment of spinal tuberculosis. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies, and then meta-analysis was performed using RevMan 5.2 software. ResultsA total of 11 studies involving 1 063 patients were included. The results of meta-analysis showed that: correction of Cobb angle with the posterior approach was significantly larger than that of anterior approach (MD=-2.78, 95%CI -3.73 to -1.82, P<0.000 01); the allograft fusion time of anterior approach was shorter than that of posterior approach (MD=-0.21, 95%CI -0.35 to -0.08, P=0.002). But there were no significant differences between the two groups in operation time, intraoprative blood loss, loss of Cobb angle at final follow-up and time of total hospital stay (all P values >0.05). ConclusionPosterior approach can correct the Cobb angle significantly for the spinal tuberculosis patients with kyphosis, and anterior approach has a shorter allograft fusion time, but it is not able to correct the deformity of the patient to maintain the normal sequence of the spine. For the quantity and quality limitation of the included studies, this conclusion still needs to be proved by conducting more high quality studies.
Objective To compare the clinical efficacy between one-stage combined posterior and anterior approaches (PA-approach) and simple posterior approach (P-approach) for lower lumbar tuberculosis so as to provide some clinical reference for different surgical procedures of lower lumbar tuberculosis. Methods A retrospective analysis was made on the clinical data of 48 patients with lower lumbar tuberculosis treated between January 2010 and November 2014. Of them, 28 patients underwent debridement, bone graft, and instrumentation by PA-approach (PA-approach group), and 20 patients underwent debridement, interbody fusion, and instrumentation by P-approach (P-approach group). There was no significant difference in gender, age, course of the disease, and destructive segment between 2 groups (P>0.05). The operation time, blood loss, bed rest time, visual analogue scale (VAS) and complication were recorded and compared between 2 groups; American Spinal Injury Association (ASIA) grade was used to evaluate the nerve function, Bridwell classification and CT fusion criteria to assess bone fusion, erythrocyte sedimentation rate (ESR) to evaluate the tuberculosis control, and Oswestry disability index (ODI) to estimate lumbar function. Results The operation time, blood loss, and the bed rest time of the P-approach group were significantly less than those of the PA-approach group (P<0.05). Iliac vessels rupture was observed in 1 case of the PA-approach group and sinus tract formed in 2 cases of the P-approach group. The patients were followed up 13-35 months (mean, 15.7 months) in the PA-approach group and 15-37 months (mean, 16.3 months) in the P-approach group. At last follow-up, common toxic symptom of tuberculosis disappeared and the ASIA scale was improved to grade E. The VAS score and ESR at 1 year after operation and last follow-up, and ODI at last follow-up were significantly improved when compared with preoperative ones in 2 groups (P<0.05), but there was no significant difference between the 2 groups (P>0.05). During follow-up, no internal fixation broken, loosening, or pulling was found. Bridwell bone fusion rates were 89.29% (25/28) and 80.00% (16/20) respectively, and CT fusion rates were 96.43% (27/28) and 90.00% (18/20) respectively, showing no significant difference between the 2 groups (P>0.05). Conclusion Both one-stage PA-approach and simple P-approach could obtain good clinical efficacy. The PA-approach should be selected for patients with anterior-vertebral destroy, presacral or psoas major muscles abscess, and multiple vertebral body destroy, while P-approach should be selected for patient who could gain a good debridement evaluated by imaging before operation, especially for patients with middle-vertebral body destroy, block the iliac blood vessels and old patients.
Objective To review the progress of surgical treatment for the thoracolumbar spinal tuberculosis. Methods The related literature of surgical treatment for the thoracolumbar spinal tuberculosis was reviewed and analyzed from the aspects such as surgical approach, fixed segments, fusion ranges, bone graft, and bone graft material research progress. Results Most scholars prefer anterior or combined posterior approach for surgical treatment of thoracic and lumbar tuberculosis because it possessed advantage of precise effectiveness. In recent years, a simple posterior surgery achieved satisfactory effectiveness. The fixation segments are mainly composed of short segments or intervertebral fixation. The interbody fusion is better for the bone graft fusion range and manner, and the bone graft materials is most satisfied with autologous iliac Cage or titanium Cage filled with autologous cancellous bone. Conclusion The perfect strategy for treating the thoracolumbar spinal tuberculosis has not yet been developed, and the personalized therapy for different patients warrants further study.
ObjectiveTo compare the short-term effectiveness of one-stage posterior debridement with non-structural bone graft and structural bone graft in the treatment of single segment thoracic tuberculosis.MethodsThe data of 61 patients with single segment thoracic tuberculosis, who were treated by one-stage posterior debridement, bone graft fusion, and internal fixation between June 2011 and August 2015, was retrospectively analyzed. All of them, 26 cases were treated with structural bone graft (group A) and 35 cases with non-structural bone graft (group B). No significant difference was found between the two groups in gender, age, disease duration, comorbidity, involved segments, paravertebral abscess, and preoperative American Spinal Injury Association (ASIA) grade, C reactive protein (CRP), visual analogue scale (VAS) score, and Cobb angle of involved segments (P>0.05). But the preoperative erythrocyte sedimentation rate (ESR) in group B was significantly lower than that in group A (t=3.128, P=0.003). The operation time, intraoperative blood loss, hospitalization stay, VAS score, ESR, CRP, ASIA grade, postoperative complications, Cobb angle of involved segments and its correction rate and loss rate, and bone fusion time were recorded and compared between the two groups.ResultsCompared with group A, group B had shorter operation time, less intraoperative blood loss, and longer hospitalization stay, showing significant differences (P<0.05). The follow-up time of group A was (36.3±10.0) months, which was significantly longer than that of group B [(18.4±4.2) months] (t=10.722, P=0.000). At last follow-up, the VAS score, ESR, and CRP in the two groups all significantly improved when compared with those before operation (P<0.05); the CRP of group B was significantly higher than that of group A (t=–2.947, P=0.005); but there was no significant difference in ESR and VAS score between the two groups (P>0.05). At last follow-up, the ASIA grade of the two groups significantly improved when compared with those before operation, and there was no significant difference between the two groups (Z=–1.104, P=0.270). There were 9 cases and 10 cases of complications in groups A and B, respectively, and there was no significant difference (χ2=0.254, P=0.614). The Cobb angle in group B was significantly higher than that in group A at 3 days after operation (t=–2.861, P=0.006), but there was no significant difference in Cobb angle between the two groups at last follow-up (t=–1.212, P=0.230). The postoperative correction rate and loss rate of Cobb angle in group A were higher than those in group B, and there was a significant difference in the loss rate between the two groups (t=2.261, P=0.031). All patients got bone graft fusion and the bone fusion time of group B was significantly shorter than that of group A (t=4.824, P=0.000).ConclusionNon-structural and structural bone graft can both achieve good effectiveness in the treatment of single segment thoracic tuberculosis, but the former has the advantages of less surgical trauma and shorter fusion time.
Objective To review current status of surgical treatment for angular kyphosis in spinal tuberculosis and provide reference for clinical treatment. Methods The literature on the surgical treatment for angular kyphosis of spinal tuberculosis in recent years was extensively reviewed and summarized from the aspects of surgical indications, surgical contraindications, surgical approach, selection of osteotomy, and perioperative management. Results Angular kyphosis of spine is a common complication in patients with spinal tuberculosis. If kyphosis progresses gradually, it is easy to cause neurological damage, deterioration, and delayed paralysis, which requires surgical intervention. At present, surgical approaches for angular kyphosis of the spine include anterior approach, posterior approach, and combined anterior and posterior approaches. Anterior approach can be performed for patients with severe spinal cord compression and small kyphotic Cobb angle. Posterior approach can be used for patients with large kyphotic Cobb angle but not serious neurological impairment. A combined anterior and posterior approaches is an option for spinal canal decompression and orthosis. Osteotomy for kyphotic deformity include Smith-Peterson osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection(VCR), vertebral column decancellation (VCD), posterior vertebral column resection (PVCR), deformed complex vertebral osteotomy (DCVO), and Y-shaped osteotomy. SPO and PSO are osteotomy methods with relatively low surgical difficulty and low surgical risks, and can provide 15°-30° angular kyphosis correction effect. VCR or PVCR is a representative method of osteotomy and correction. The kyphosis correction can reach 50° and is suitable for patients with severe angular kyphosis. VCD, DCVO, and Y-shaped osteotomy are emerging surgical techniques in recent years. Compared with VCR, the surgical risks are lower and the treatment effects also improve to varying degrees. Postoperative recovery is also a very important part of the perioperative period and should be taken seriously. Conclusion There is no consensus on the choice of surgical treatment for angular kyphosis in spinal tuberculosis. Osteotomy surgery are invasive, which is a problem that colleagues have always been concerned about. It is best to choose a surgical method with less trauma while ensuring the effectiveness.