Surgical management for thoracic spinal tuberculosis in the elderly: posterior only versus combined posterior and anterior approaches

Bilateral Endoscopic Debridement Combined with Local Antituberculosis Drugs for Thoracic Tuberculosis with Large Paravertebral Abscess: A Multicenter Study with 4-year Follow-Up

BACKGROUND

Paravertebral abscess represents a prevalent manifestation of thoracic tuberculosis, often necessitating surgical intervention. In this study, we introduced a novel approach by employing bilateral endoscopic debridement (BED) to address large Paravertebral abscesses associated with thoracic tuberculosis, a method not previously proposed in the literature. The clinical efficacy was examined through a comprehensive 4-year follow-up.

METHODS

We conducted a retrospective analysis on patients diagnosed with thoracic tuberculosis and paravertebral abscess who underwent BED combined with local antituberculosis drugs (BED + LAD) between February 2015 and February 2019. A total of 29 eligible patients (12 males and 17 females) with a median (interquartile ranges) of 59.0(16.5) years were included in the study. All patients received the BED + LAD treatment. After the surgery, the patients were treated with a 4-drug antituberculosis therapy (Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol). All relevant indicators were meticulously recorded and analyzed.

RESULTS

The surgical procedures were successfully completed for all subjects, with an average intraoperative bleeding volume of (25.2 ± 8.9) ml, an average surgical time of (68.4 ± 14.0) minutes, an average fluoroscopy frequency of (21.7 ± 8.2) times, an average hospital stay of (14.2 ± 4.3) days, and an average medication period of (42.1 ± 9.6) weeks. All subjects completed at least a 4-year follow-up period. At the final follow-up, ESR and CRP levels returned to normal, and there was no significant increase in the Cobb angle (P>0.05).

CONCLUSIONS

The application of BED + LAD in the treatment of thoracic tuberculosis and paravertebral abscess proved to be a safe, effective, and feasible approach.

Posterior Approach With Osteotomized Debridement Versus Combined Anterior and Posterior Approach in Treating Thoracolumbar Tuberculosis: A Retrospective Cohort Study

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

To compare outcomes of posterior osteotomized debridement (OD) with combined anterior and posterior approach (AP) in treating thoracolumbar tuberculosis (TB).

METHODS

This study reviewed 178 patients who were diagnosed as active thoracolumbar TB and surgically treated in our center. One hundred and two patients underwent posterior OD, interbody fusion with titanium mesh cage (TMC), and instrumentation (group A). Seventy-six patients underwent one-stage posterior instrumentation, anterior debridement, and interbody fusion with TMC (group B). Patients' clinical outcomes were compared between the 2 groups.

RESULTS

Erythrocyte sedimentation rate and C-reactive protein in all patients returned to normal levels within 3 months after surgery, and no recurrence occurred during the follow-up. Compared with AP approach, OD surgery was less invasive and with a lower cost (¥ 70 581 ± 17 645 vs ¥ 87 600 ± 27 328; P < .05). Patients treated by OD showed more significant improvements in Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) than those treated by AP approach 3 months postoperatively (VAS: 3.0 ± .7 vs 3.7 ± .9; ODI: 14.7 ± 4.4 vs 20.6 ± 4.6). Two groups showed similar postoperative kyphosis correction and final follow-up correction loss (P = .361 and P = .162, respectively). The OD method had a lower complication rate than AP approach (9.8% [10/102] vs 35.5% [27/76]; P < .05).

CONCLUSIONS

Posterior OD is effective in treating active thoracolumbar TB. Compared with traditional AP approach, OD surgery has less surgical invasiveness, lower complication rate, and shorter fusion time.

Clinical outcomes and surgical strategy for spine tuberculosis: a systematic review and meta-analysis

PURPOSE

Spinal tuberculosis (TB) is a slow-developing disease that often causes cord compression, spinal instability, and deformity. Surgery is generally required in cases of refractory disease, severe kyphosis, neurological deficits, or lack of improvement. However, there is a lack of comprehensive evidence in comparing the efficacy of various surgical approaches. The study aims to provide a clearer understanding of the relative effectiveness of the available surgical modalities in the management of spinal TB.

METHODS

This review adhered to the PRISMA statement with searching conducted until 11th April 2023. Inclusion criteria included studies involving surgical procedures for spinal tuberculosis, with relevant clinical outcomes reported. Data extraction involved the collection of information on study and population characteristics, interventions used, relevant clinical outcomes, and reported complications. The risk of bias was evaluated using Cochrane's Risk of Bias in Non-randomized Studies tool.

RESULTS

Searching resulted in 20 cohort studies that analyzed surgical methods for spinal tuberculosis. Eleven studies had low bias and nine studies had moderate bias. The anterior approach was associated with faster perioperative duration [- 2.02 (- 30.71, 26.67), p < 0.00001], less blood loss [- 4242 (- 176.02, 91.18), p < 0.00001], shorter hospitalization [- 0.19 (- 2.39, 2.01), p < 0.00001], better angle correction [1.01 (- 1.82, 3.85), p < 0.00001], and better correction rates [11.36 (- 7.32, 30.04), p < 0.00001] compared to the posterior approach. Regarding neurological function recovery, the anterior and posterior approaches were equally effective, while the posterior approach was associated with a higher incidence of complications. The review also reported on the complications associated with the surgical approaches, and 9 out of 20 studies reported complications. The anterior approach was found to have fewer complications overall.

CONCLUSION

The anterior approach is thought to have fewer complications than both combined and posterior-only approaches, but the variability of the findings indicates that the decision-making process for selecting a surgical approach must consider individual patient and disease characteristics, as well as surgeon training.

Trends and prospects in spinal tuberculosis research: a future-oriented approach

PURPOSE

Tuberculosis is one of the oldest diseases in human history, and spinal tuberculosis (STB) is the most common form of extrapulmonary tuberculosis. A large number of research has been conducted in this field. However, there has been no bibliometric analysis performed in recent years in STB. The aim of this study was to analyze trends and hotspots in research on STB.

METHODS

Publications regarding STB between 1980 and 2022 were extracted from the Web of Science database. CiteSpace (V5.7.R2) and VOSviewer (1.6.10) were used to perform global analyses of the number of publications, countries, institutions, authors, journals, keywords, and cited references.

RESULTS

A total of 1262 articles were published between 1980 and 2022. We observed rapid growth in the number of publications since 2010. Spine had the highest number of publications (47, 3.7%). Zhang HQ and Wang XY were key researchers. The Central South University published the most papers (90, 7.1%). China was the leading contributor in this field with 459 publications and 29 H-index. National partnerships are dominated by the USA, and there is a lack of active cooperation between other countries and authors.

CONCLUSION

research on STB has achieved great progress, with an increasing number of publications since 2010. Surgical treatment and debridement are current research hots pots, and diagnosis, drug resistance, and kyphosis are likely research frontiers. Cooperation between countries and authors needs to be further strengthened.

Comparative evaluation of multi-fold rib and structural iliac bone grafts in single-segment thoracic and thoracolumbar spinal tuberculosis: clinical and radiological outcomes

OBJECTIVE

To compare clinical and radiological outcomes of multi-fold rib and structural iliac bone grafts, the primary autologous graft techniques in anterolateral-only surgery for single-segment thoracic and thoracolumbar spinal tuberculosis.

METHODS

This retrospective study included 99 patients treated from January 2014 to March 2022, categorized into 64 with multi-fold rib grafts (group A) and 35 with structural iliac bone grafts (group B). Outcomes assessed included hospital stay, operation time, intraoperative blood loss, postoperative drainage, complications, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the Visual Analog Scale (VAS) for pain, the Oswestry Disability Index (ODI), bone fusion time, and the American Spinal Injury Association (ASIA) impairment scale grade. Segmental kyphotic angle and intervertebral height were measured radiologically before surgery and follow-up.

RESULTS

The mean follow-up was 63.50 ± 26.05 months for group A and 64.97 ± 26.43 months for group B (P > 0.05). All patients had achieved a clinical cure. Group A had a shorter operation time (P = 0.004). Within one week post-surgery, group B reported higher VAS scores (P < 0.0001). Neurological performance and quality of life significantly improved in both groups. No significant differences were observed in segmental kyphotic angle and intervertebral height between the groups pre- and postoperatively (P > 0.05). However, group A showed a greater segmental kyphotic angle at the final follow-up, while group B had better maintenance of kyphotic angle correction and intervertebral height (P < 0.05). Bone fusion was achieved in all patients without differences in fusion time (P > 0.05).

CONCLUSIONS

Multi-fold rib grafts resulted in shorter operation times and less postoperative pain, while structural iliac bone grafts provided better long-term maintenance of spinal alignment and stability, suggesting their use in cases where long-term outcomes are critical.

A novel classification of osteotomized debridement based on the range of focus in treating active thoracolumbar tuberculosis: a multicenter study

INTRODUCTION

Osteotomized debridement (OD) is increasingly used in the treatment of active thoracolumbar tuberculosis (TB). So far, no nomenclature has been established to describe the patterns of OD, and thus the surgical outcomes cannot be directly analyzed and compared among the patients treated with different extents of OD. The purpose of this study was to establish a reliable classification of OD for further study of spinal TB.

MATERIALS AND METHODS

This was a multicenter retrospective study. The proposed classification included 6 grades of OD based on sagittal range of vertebral body destruction: grade 0 involves single-level intervertebral disc and adjacent superficial endplates; grade 1 involves adjacent endplates and vertebral bodies, but no pedicle is involved; grade 2 involves adjacent endplates, vertebral bodies, and a lower or upper pedicle; grade 3 involves adjacent endplates, vertebral bodies, and both of lower and upper pedicles; grade 4 involves an entire vertebral body and an adjacent lower or upper pedicle; grade 5 involves two continuous entire vertebral bodies. Two hundred and five patients with active thoracolumbar TB who underwent OD surgery were included, and all ODs were classified. The reliability of this classification was evaluated twice by 10 readers, and Fleiss kappa coefficients were calculated.

RESULTS

In the 205 patients, 208 ODs were performed. Grade 2 OD was the commonest type (98/208, 47.1%), followed by grade 1 (50/208, 24.0%), grade 3 (26/208, 12.5%), grade 0 (20/208, 9.6%), grade 4 (8/208, 3.8%), and grade 5 (6/208, 2.9%). The average accuracy of the two readings was 86.2% and 90.1%, respectively. The intra-rater reliability for the classification was "almost perfect agreement" with a Fleiss kappa coefficient average of 0.92. The inter-rater reliability was "almost perfect agreement" with a coefficient average of 0.89 for two readings.

CONCLUSIONS

This classification proved to be intuitive and reliable. The graded OD provides a platform for preoperative evaluation and allows comparative analysis of clinical outcomes in different extents of OD.

Prognostic values of geriatric nutrition risk index on elderly patients after spinal tuberculosis surgery

Background

Spinal tuberculosis (STB) is a significant public health concern, especially in elderly patients, due to its chronic and debilitating nature. Nutritional status is a critical factor affecting the prognosis of STB patients. The geriatric nutritional risk index (GNRI) has been established as a reliable predictor of adverse outcomes in various diseases, but its correlation with surgical outcomes in elderly STB patients has not been studied.

Objective

The study aimed to assess the prognostic value of the GNRI in elderly patients with STB who underwent surgery.

Methods

We conducted a retrospective analysis of medical records of elderly patients (65 years or older) diagnosed with active STB who underwent surgical treatment. Data collection included patient demographics, comorbidities, clinical history, laboratory testing, and surgical factors. GNRI was calculated using serum albumin levels and body weight. Postoperative complications were observed and recorded. The patients were followed up for at least 1 year, and their clinical cure status was assessed based on predefined criteria.

Results

A total of 91 patients were included in the study. We found that a GNRI value of <98.63 g/dL was a cutoff value for predicting unfavorable clinical prognosis in elderly STB patients undergoing surgery. Patients with a low GNRI had higher Charlson Comorbidity Index scores, were more likely to receive red blood cell transfusions, and had a higher prevalence of overall complications, particularly pneumonia. The unfavorable clinical prognosis group had lower GNRI scores compared to the favorable prognosis group. Multivariate analysis showed that lower GNRI independently predicted unfavorable clinical outcomes in elderly STB patients.

Conclusion

The study concluded that the GNRI is a valuable biomarker for predicting prognosis in elderly STB patients undergoing surgical intervention. Patients with lower GNRI scores had worse outcomes and a higher incidence of complications.

Clinical efficacy and imaging analysis for the surgical treatment of thoracolumbar infections in elderly patients: a retrospective study

Few reports have been conducted to comparing surgical results and safety evaluations between the different types of infections in geriatric patients with thoracolumbar infections. The aim of this study is to investigate the safety and efficacy of surgical treatment for thoracolumbar infections in elderly patients. 21 patients with pyogenic spondylodiscitis (PS) and 26 patients with tuberculous spondylodiscitis (TS) were enrolled in the study. All patients were treated using one-stage posterior debridement, decompression, and pedicle screw fixation. Comparison of operative safety parameters between the two groups. Clinical efficacy was evaluated using visual analogue scale (VAS) score, the American Spinal Injury Association (ASIA) grade, the short form (SF)-36 survey and Oswestry disability index (ODI) to determine patient quality of life pre- and post-operatively. Hospitalisation and intensive care unit duration in the PS group were significantly shorter than in the TS group (P < 0.05). The total incidence of post-operative complications for both groups was 44.7%. More complications occurred in the TS group, but the difference was not significant. The scores of VAS, ODI and SF-36 of all 47 patients were significantly improved compared with those before operation.The VAS and SF-36 scores (physical component) were significantly better in the PS group 6 months post-operatively, and the SF-36 (mental component) scores were significantly better in the PS group at the 1-year follow-up. Neurological status in both groups improved post-operatively, and 83% of patients reported satisfactory results based on the modified MacNab standard. Imaging results showed that bone graft fusion improved in both groups at 6 months, 1 year and at the final follow-up. One-stage posterior debridement, decompression, interbody fusion, and internal fixation can be considered a safe and effective method of treating spinal infections in the elderly. This method can improve nerve function, reconstruct spinal stability, and enhance the quality of life of elderly patients. Both PS and TS who underwent surgery achieve similar clinical and radiological results.

Bilateral Percutaneous Transpedicular Drainage under Local Anesthesia for Thoracic Tuberculous Spondylitis

Tuberculous spondylitis is a common spinal infection. If surgical intervention is necessary, anterior debridement and anterior fixation are typically performed. However, a minimally invasive surgical strategy under local anesthesia seems rarely implemented. A 68-year-old man presented with severe pain in the left flank. Whole spinal magnetic resonance imaging revealed abnormal intensity of vertebral bodies from T6-9. A bilateral paravertebral abscess extending from T4-10 was suspected. The T7/T8 intervertebral disc was destroyed, but severe vertebral deformity or spinal cord compression was not observed. Bilateral percutaneous transpedicular drainage under local anesthesia was planned. The patient was set in the prone position. Under the guide of a biplanar angiographic system, the bilateral drainage tubes were placed paravertebrally in the abscess cavity. The left flank pain improved after the procedure. Laboratory culture of the pus specimen confirmed a diagnosis of tuberculosis. A chemotherapy regimen for tuberculosis was soon initiated. The patient was discharged during postoperative week 2, with continuation of chemotherapy for tuberculosis. Percutaneous transpedicular drainage under local anesthesia can be effective in the management of thoracic tuberculous spondylitis without severe vertebral deformity or compression of the spinal cord by an abscess.

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

Background

Posterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.

Methods

Patients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.

Results

A total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.

Conclusion

Posterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.

Antibiotic-loaded calcium sulfate beads in spinal surgery for patients with spondylodiscitis: a clinical retrospective study

Background

Various surgical techniques for treating spondylodiscitis have been proposed, but the optimal surgical treatment remains controversial. In this study, we propose a new procedure that is implanting antibiotic-loaded calcium sulfate (CS) beads into the disc after debridement using the Quadrant channel combined with percutaneous fixation through a single-stage posterolateral approach for the treatment of spondylodiscitis. Thus, the purpose of this study is to assess the safety and efficacy of this procedure.

Methods

This study collected the data of 32 patients with spine spondylodiscitis and was surgically treated in our department from July 2015 to August 2020. The Demographic data included age, gender, involved segment, and complications were collected. The intra-operative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay, laboratory examination were recorded.

Results

The mean age of the 32 patients was 61.1 ± 9.7 years old. The mean operative time was 135.0 ± 30.6 minutes, and the mean blood loss was 243.4 ± 92.1 ml. The positive rate of culture was 72%. The mean Visual analogue scale (VAS) and Oswestry Disability Index (ODI) score significantly improved from 7.5 to 1.6 and from 65% to 10%. Cobb angle was significantly improved and could be maintained at final follow-up. New bone formation was observed in all patients. There were no recurrences of infection in our study.

Conclusions

The posterolateral debridement and percutaneous fixation combined with antibiotic-loaded calcium sulfate beads filling are effective in the treatment of spondylodiscitis in terms of infection control, early mobilization, and recovery.

Osteotomized debridement versus curetted debridement in posterior approach in treating thoracolumbar tuberculosis: a comparative study

PURPOSE

This study aimed to compare osteotomized debridement (OD) with traditional curetted debridement (CD) in treating thoracolumbar tuberculosis (TB).

METHODS

A total of 188 patients were diagnosed with active thoracolumbar TB and underwent one-stage posterior surgery at our institution. Of the 188 patients, 85 patients were treated with OD, and 103 patients were treated with traditional CD. The patient information, laboratory results, imaging findings, and clinical effectiveness were, respectively, compared between the two groups.

RESULTS

Group OD consumed less operation time and blood loss than group CD (P < 0.05 for both values). No significant difference in hospitalization time was found between the two groups (P > 0.05). The values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in both groups returned to the normal range within one month postoperatively. All patients had significant improvement in visual analog scale (VAS) and oswestry disability index (ODI) postoperatively. The mean fusion time in group OD was shorter than that in group CD (P < 0.05). There was no statistically significant difference in preoperative kyphotic angle between the two groups (P > 0.05), but group OD showed less correction loss than group CD at the final follow-up (P < 0.05). The rate of recurrence and surgery-related complications in group OD was lower than group CD.

CONCLUSIONS

Posterior OD, reconstruction with titanium mesh cages (TMCs), and instrumentation is feasible and effective in treating thoracolumbar TB. Compared with the traditional CD, OD can achieve radical lesion removal, more effective kyphosis correction, lower recurrence rate, and fewer complications.

Posterior-only stabilization versus global reconstruction in thoracic and thoracolumbar spinal tuberculosis; a prospective randomized study

PURPOSE

Although the guidelines for surgical indications in spinal tuberculosis (TB) are well-established, ambiguity still exists in deciding between posterior-only stabilization and global reconstruction in thoracic and thoracolumbar (TL) disease especially in patients with borderline vertebral destruction. The current prospective, randomized study was thus planned to compare safety and efficacy of these two surgical interventions.

METHODS

Patients, aged between 18 and 65 years, with spinal TB involving thoracic and TL spine with pre-operative vertebral body loss (VBL) between 0.5 and 1 were randomly allocated into two groups [groups A (who underwent posterior-only stabilization) and B (global reconstruction through a single-stage all-posterior approach). Patient's demographic data, clinical, intra-operative and post-operative details were recorded. Minimum follow-up period was two years. Neurological assessment was performed using ASIA impairment scale. Functional outcome measurements included VAS and ODI scores (pre-operative and final follow-up). Radiological measurements included Cobb's angle, kyphosis correction, loss of correction, angle loss rate and fusion time.

RESULTS

Fifty-eight patients (groups A and B = 29 each) were included. Mean age in groups A and B was 48.3 ± 16.5 years and 51.2 ± 11.7 years. Mean surgical duration was significantly shorter in group A (119.9 ± 14.1 minutes; p = 0.0001). Mean follow-up duration was 35.5 ± 6.4 months. There was no statistically significant difference in neurological outcome at final follow-up between the groups (p > 0.05). Group A demonstrated significantly better ODI at final follow-up (13.8 ± 2.9 vs 16.2 ± 4.1; p = 0.02). Immediate post-operative correction (6.8° ± 5.6) and maintenance of kyphosis correction at final follow-up [loss of correction (2.1° ± 1.7) and angle loss rate (16.3 ± 14.9%)] were marginally better in group B (p > 0.05). Mean fusion time in groups A and B was 7.8 ± 1.5 and 8.4 ± 1.6 months (p > 0.05). A sub-group analysis in group B between autograft and metallic cages for anterior reconstruction did not show significant difference in radiological outcome (p > 0.05).

CONCLUSION

All-posterior surgeries (posterior-only stabilization or global reconstruction) represent an effective approach in the management of TB disease affecting thoracic and TL vertebrae. For a pre-operative VBL between 0.5 and 1, clinical (including neurological), functional and radiological outcomes following both these surgeries (posterior-only stabilization and global reconstruction) are comparable.

Posterior-only approach with titanium mesh cages versus autogenous iliac bone graft for thoracic and lumbar spinal tuberculosis

Objective: This study aimed to compare the effectiveness of titanium mesh cages (TMCs) with autogenous iliac bone grafts (AIBG) in posterior-only surgery for thoracic and lumbar spinal tuberculosis.Design: Retrospective investigative design.Setting: The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.Participants: A total of 146 patients with thoracic or lumbar tuberculosis.Interventions: All patients underwent a posterior-only approach with either a TMC (86 cases) or AIBG (60 cases).Outcomes measures: Operation duration, intraoperative blood loss, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS), and related complications were used to compare the effectiveness and feasibility of the two techniques. Frankel grading system, Cobb angle, and loss of angular correction were employed to assess neurological and kyphotic improvements.Results: There were significant improvements in ESR, CRP, VAS, Frankel grade, and Cobb angle at the last follow-up (P < 0.05) when compared with the preoperative state. The TMC group was superior in operation duration (P < 0.001), intraoperative blood loss (P = 0.007), VAS (P < 0.001), loss of angular correction (P < 0.001), and surgical complications as compared with the AIBG group. There were no significant differences in the improvement of the Frankel grade and Cobb angle between the TMC and AIBG groups (P > 0.05). A recurrence of tuberculosis was not found in either of the groups.Conclusion: Compared to autogenous iliac bone grafts, titanium mesh cages could serve as a superior material in posterior-only operative therapy for thoracic and lumbar spinal tuberculosis.

Surgical management for lumbar brucella spondylitis: Posterior versus anterior approaches

There has been no ideal surgical approach for lumbar brucella spondylitis (LBS). This study aims to compare clinical efficacy and safety of posterior versus anterior approaches for the treatment of LBS.From April 2005 to January 2015, a total of 27 adult patients with lumbar brucella spondylitis were recruited in this study. The patients were divided into 2 groups according to surgical approaches. Thirteen cases in group A underwent 1-stage anterior debridement, fusion, and fixation, and 14 cases in group B underwent posterior debridement, bone graft, and fixation. The clinical and surgical outcomes were compared in terms of operative time, intraoperative blood loss, hospitalizations, bony fusion time, complications, visual analog scale score, recovery of neurological function, deformity correction.Lumbar brucella spondylitis was cured, and the grafted bones were fused within 11 months in all cases. It was obviously that the operative time and intraoperative blood loss of group A were more than those of group B (P = .045, P = .009, respectively). Kyphotic deformity was signifcantly corrected in both groups after surgery; however, the correction rate was higher in group B than in group A (P = .043). There were no significant differences between the two groups in hospitalizations, bony fusion time, and visual analog scale score in the last follow-up (P = .055, P = .364, P = .125, respectively).Our results suggested that both anterior and posterior approaches can effectively cure lumbar brucella spondylitis. Nevertheless, posterior approach gives better kyphotic deformity correction, less surgical invasiveness, and less complications.

Changes in Serum Prealbumin and Incision Complications Following Spinal Tuberculosis Surgery: A Preliminary Study

Objectives

To explore the trend of changes in the serum prealbumin (PA) level in patients with spinal tuberculosis during the perioperative period and its relationship with postoperative incision complications.

Methods

A retrospective study was performed by enrolling 162 patients (82 men and 80 women) with spinal tuberculosis who had been admitted to the Tianjin Haihe Hospital from June 2013 to June 2017. The included patients were then assigned to the elderly group (≥65 years of age, n = 35) and the non‐elderly group (<65 years of age, n = 127). The chemotherapy regimen was 3HREZ/9HRE, in combination with nutritional support for 3–4 weeks, as well as one‐stage debridement and (or) bone graft fusion and internal fixation. The serum PA levels of patients with spinal tuberculosis at admission, prior to surgery, and at 2 and 4 weeks after surgery were collected, and incision healing and sinus formation were observed for 3 months. Changes in serum PA levels of all patients at different time points were observed using one‐way analysis of variance. Pairwise comparison at different time points was performed using the least significant difference method and comparison of serum PA levels between different groups at the same time points was subjected to t‐test. The χ²‐test was used for comparison of the incidence of incision complications between different groups and between different subgroups based on different PA levels.

Results

There was a gradual increased trend in the PA level from admission to 4 weeks after surgery in all patients [(0.14 ± 0.03) g/L < (0.16 ± 0.04)g/L < (0.22 ± 0.04) g/L < (0.25 ± 0.04) g/L]. The increase in the non‐elderly group was higher than that in the elderly group (P < 0.01). Furthermore, the incidence of incision complications in the elderly group was higher than in the non‐elderly group (14.29% > 1.78%, P < 0.01). The serum PA level was graded in accordance with NRS2002. There were 88 patients with preoperative grade 0–1 serum PA level (≥0.16g/L) who had no incision complications. The incidence of incision complications in patients with grade 3 serum PA level (<0.10 g/L, 9 patients) was higher than in patients with grade 2 (0.100–0.159 g/L, 66 patients) (44.44% > 6.06%, P < 0.01).

Conclusion

Changes in serum PA level in patients with spinal tuberculosis during the perioperative period are consistent with the trend of inflammation control and nutrition improvement, and are correlated with the incidence of incision complications after surgery. The relationship between the changes and the timing of surgery is worthy of future research.

Efficacy of surgery via the single anterior and single posterior approaches for treatment of thoracic spinal tuberculosis

Objective

The type of surgical treatment that should be adopted for thoracic tuberculosis (TB) remains controversial. This study was performed to compare the clinical efficacy of surgery via the single anterior and single posterior approaches for treatment of thoracic spinal TB.

Methods

Seventy-eight patients with thoracic TB undergoing surgical treatment were divided into two groups on the basis of the surgical methods employed: Group A (single anterior debridement + bone graft fusion and internal fixation) and Group B (single posterior debridement + bone graft fusion and internal fixation). Results of clinical and imaging examinations were analysed and compared between the two groups.

Results

The surgical duration and mean hospital stay were significantly longer and the perioperative bleeding volume was significantly higher in Group A than B. At the last follow-up, changes in the American Spinal Injury Association grade showed no obvious differences between the two groups. Before and after the surgery and at the last follow-up, no significant differences were detected in the Cobb angle change or correction rate between the two groups.

Conclusion

Surgery via the single anterior and single posterior approaches achieved good clinical efficacy in the treatment of thoracic spinal TB.

Single Posterior Approach versus Combined Anterior and Posterior Approach in the Treatment of Spinal Tuberculosis: A Meta-Analysis

BACKGROUND

Spinal tuberculosis is the most common form of tuberculosis affecting bone and often needs surgical treatment. Single anterior, single posterior, and combined anterior and posterior approaches are the 3 most commonly used approaches in surgical treatment. Clinically, the choice of optimal surgical approach remains controversial. The purpose of this meta-analysis was to evaluate clinical efficacy of single posterior approach versus combined anterior and posterior approach.

METHODS

Studies comparing surgical treatment of spinal tuberculosis by single posterior approach versus combined anterior and posterior approach were identified in a literature search conducted from study inception to July 2020. Selection of studies, extraction of data, and evaluation of bias risk of studies were performed independently by 2 authors, and meta-analysis was conducted using RevMan 5.3 software.

RESULTS

The meta-analysis included 15 studies and 793 spinal tuberculosis cases. Single posterior approach was used in 397 patients, and combined anterior and posterior approach was used in 396 patients. There were no statistical differences in visual analog scale score (P = 0.51), correction of Cobb angle (P = 0.14), neurological improvement (P = 0.71), erythrocyte sedimentation rate (P = 0.32), C-reactive protein after operation (P = 0.81), and loss of correction at final follow-up (P = 0.44) between approaches. Single posterior approach was associated with less intraoperative hemorrhage (P < 0.00001), shorter operative time (P < 0.00001), shorter length of hospital stay (P < 0.00001), and fewer complications (P < 0.00001). Combined anterior and posterior approach was associated with shorter fusion time (P = 0.04).

CONCLUSIONS

Both approaches can achieve satisfactory clinical outcomes. Posterior-only approach can safely and effectively achieve lesion débridement, decompression, and stability reconstruction and maintenance with advantages of less invasive surgery, less bleeding, shorter surgery time and hospital stay, and fewer complications and seems to be superior to combined posterior-anterior approach.

Surgical management of consecutive multisegment thoracic and lumbar tuberculosis: anterior-only approach vs. posterior-only approach

Purpose

To compare the efficacy, safety, and technical characteristics of anterior-only and posterior-only approach surgeries for the treatment of consecutive multisegment thoracic and lumbar tuberculosis.

Methods

Thirty-five patients who developed consecutive multisegment thoracic and lumbar tuberculosis from September 2012 to May 2016 were retrospectively analyzed. Group A was the posterior-only surgery group, and group B was the anterior-only surgery group. The data on the surgery, deformity correction, functional scores, and complications were compared between the two groups.

Results

There was no significant difference in the operation time or blood loss between groups A and B (P > 0.05). The preoperative average Cobb angle of kyphosis in groups A and B were 36.2 ± 15.2° and 27.9 ± 7.7°, respectively, which significantly decreased to 4.9 ± 11.8° and 10.4 ± 5.6° after the operation, respectively (P < 0.05). At the final follow-up, the angles were 7.1 ± 10.5° and 14.6 ± 8.0°. The correction angle and correction rate in group A (31.3 ± 16.6°, 88.6 ± 43.6%) were greater than those in group B (17.5 ± 4.4°, 64.9 ± 14.0%) (P < 0.05). There was no significant difference in the loss angle between groups A and B (P > 0.05), but the loss rate in group B (24.0 ± 27.8%) was higher than that in group A (9.6 ± 10.2%) (P < 0.05). There was no significant difference in the incidence of complications between the two groups (P > 0.05).

Conclusion

The posterior-only and anterior-only approaches can lead to satisfactory clinical results in the treatment of patients with consecutive multisegment thoracic and lumbar tuberculosis. With posterior-only surgery, kyphosis can be better corrected, and the correction can be better maintained than with anterior-only surgery.

Invited commentary 'Comparison of three different bone graft methods for single segment lumbar tuberculosis: A retrospective single-center cohort study

The study is designed to contrast the clinical efficacy of one stage posterior debridement with iliac bone graft, titanium mesh bone graft or granular bone graft in the surgical treatment of single segment lumbar tuberculosis [1].

Extended Posterior Decompression and Instrumented Fusion for Spinal Tuberculosis

Study Design

Retrospective cohort.

Purpose

To evaluate clinical outcomes, including pain and neurologic status, and to evaluate radiographic outcomes of patients treated with extended posterior decompression, posterior fixation, and fusion in different vertebral segments.

Overview of Literature

The standard surgical treatment of spinal tuberculosis is radical debridement via anterior approach. However, this approach may lead to several serious complications. Meanwhile, extended posterior approach, the posterior surgical approach, involving the removal of posterior elements, ribs, and pedicles, is an alternative option that can achieve the aims of treatment in this disease and may reduce the serious complications from anterior approach.

Methods

The medical records and imaging of 50 patients admitted with spinal tuberculosis from January 2010 to June 2016 were reviewed. The Visual Analog Scale (VAS), Frankel grading scale, and kyphotic Cobb angle between the pre- and postoperative periods were used to evaluate the patients.

Results

The patients had significant improvement of VAS score in all the groups. The T/T–L, L, and L–S group scores improved from 7.2±1.5 to 1.7±1.2 (p<0.01), from 8.1±1.8 to 1.7±1.4 (p<0.01), and from 7.9±2.2 to 1.7±0.8 (p<0.01), respectively, and overall, the patient scores (n=50) improved from 7.8±1.4 to 1.7±1.3 (p<0.01). Ten patients (20%) had Frankel grade E preoperatively, which was improved to 38 patients (76%) postoperatively. A significant improvement of the kyphotic Cobb angle was observed when compared at the preoperative, early postoperative, and final follow-up period in the T/T–L, L, and L–S groups. The loss of correction angle in the LS group was 7.7°±4.3° at the final follow-up compared with the early postoperative correction angle at 9.1°±5.8°, with no statistically significant difference.

Conclusions

Extended posterior decompression, posterior instrumentation, and fusion are effective methods of surgery for treatment of spinal tuberculosis involved in the thoracic, thoracolumbar, lumbar, and lumbosacral regions.

Tuberculous spondylitis after percutaneous vertebroplasty: A case series of 9 cases

Background

Percutaneous vertebroplasty has become the treatment of choice for compression fractures. Although the incidence is low, infection after vertebroplasty is a serious complication. The pathogens most often responsible for infection are bacteria. Meanwhile, mycobacterium tuberculosis-induced infection is extremely rare. In this study, we reported our treatment experience with 9 cases of tuberculous spondylitis after vertebroplasty.

Methods

Between January 2001 and December 2015, 5749 patients underwent vertebroplasty or kyphoplasty in our department. Nine cases developed tuberculous spondylitis after vertebroplasty (0.16%). Data on clinical history, laboratory examinations, image, treatment and outcomes were examined.

Results

One male and 8 female patients with a mean age of 75.1 years developed tuberculous spondylitis after vertebroplasty. 5 patients had a history of pulmonary tuberculosis (TB). Revision surgeries were performed from 5 days to 1124 days after vertebroplasty. Seven patients underwent anterior debridement and fusion with or without posterior instrumentation, and 2 cases received posterior decompression and instrumentation only. After operation, the diagnosis of tuberculous spondylitis was confirmed by TB polymerase chain reaction (TB-PCR) or mycobacteria culture. Mean follow-up period after revision surgery was 36.8 months. At the end of follow-up, 1 patient with paraplegia had passed away, 2 needed a wheel chair, 4 required a walker and 2 were able to walk unassisted.

Conclusions

Vertebroplasty is a minimally invasive procedure but still retains some possibility of complications, including TB infection. Patients with a history of pulmonary TB or any elevation of infection parameters should be reviewed carefully to avoid infective complications.

Late-onset neurological deficits induced by proximal adjacent segment degeneration related to severe post-tuberculous kyphotic deformities of the spine: a series of 7 cases and surgical correction concept

OBJECTIVE

Late-onset neurological deficits are a rare complication of spinal tuberculosis that may be caused by proximal adjacent segment degeneration (ASD) above the kyphus. The objective of this study was to report several cases of neurological deficits due to proximal ASD in patients with post-tuberculous kyphotic deformity and discuss the characteristics of the authors' corrective surgical technique.

METHODS

The inclusion criteria in this study were severe angular kyphosis due to a post-tuberculous kyphotic deformity and a late-onset neurological deficit. The cause of these deficits was related to a lesion in the proximal cephalad portion of the kyphotic deformity. Surgical intervention, including decompression and compromised restoration of the sagittal imbalance, was performed in all patients. Preoperative surgical planning with a radiological evaluation included CT, plain radiograph, and MRI studies. Clinical outcomes were evaluated using the American Spinal Injury Association Impairment Scale and the Oswestry Disability Index (ODI).

RESULTS

The main goal of our surgical technique was the correction of sagittal malalignment by positioning the patient's head above the kyphotic deformity on the sagittal plane, excluding aggressive osteotomy. The neurological symptoms showed immediate improvements postoperatively, except in 1 patient. Compared to the preoperative value of 66.9, the mean ODI score improved to 42.6 at the final follow-up for all patients. Preoperatively, the mean values of the angles of deformity and the sagittal vertical axis were 99.7° and 157.7 mm, respectively, and decreased to 75.3° and 46.0 mm, respectively, at the final follow-up. No major complications were observed, and the patients' self-satisfaction was high with respect to both cosmetic and functional outcomes.

CONCLUSIONS

Clinicians should be aware of the degeneration of the vertebrae above the kyphotic segment in patients with post-tuberculosis deformity. Successful neurological recovery and compromised sagittal balance could be obtained by using our "head on kyphus" surgical concept.

Comparison of anterior, posterior, and anterior combined with posterior surgical treatment of thoracic and lumbar spinal tuberculosis: a systematic review

Background

This study was performed to compare different surgical approaches in the treatment of spinal tuberculosis.

Methods

We conducted a literature search to identify and analyze papers published from January 1966 to April 2018 relevant to comparison of the anterior, posterior, and anterior combined with posterior approaches in the treatment of spinal tuberculosis of the thoracic and lumbar regions.

Results

Twenty-five studies involving 2295 patients were identified in this systematic review. The operative time was significantly longer in the anterior combined with posterior approach than in the other two approaches. Blood loss was significantly greater in the anterior combined with posterior approach (1125.0 ± 275.5 mL) than in the posterior approach (710.4 ± 192.4 mL). The difference in correction of the kyphosis angle among the three procedures was not significant. The overall surgical and transthoracic complications were significantly lower in the posterior approach. The clinical outcome of all patients improved, but there was no significant difference among the three procedures.

Conclusions

Blood loss, overall surgical and transthoracic complications, and the operative time are different among the three approaches. Therefore, different factors must be carefully assessed in deciding among the three procedures.

Can a posterior approach effectively heal thoracic and lumbar tuberculosis? Microbiology outcomes of the operative area

Background

There was a controversy about surgery approach of thoracic and lumbar tuberculosis (TB) treatment. The aim of this study was to compare the microbiology outcomes of the drainage liquid and the clinical outcomes of a posterior and anterior approach in the treatment of thoracic and lumbar TB.

Materials and methods

A total of 105 patients were enrolled in this prospective study from February 2011 to September 2015. Patients were divided into two groups: group A (51 patients, posterior approach surgery) and group B (54 patients, anterior approach surgery). Intraoperative TB samples were sent for Mycobacterium tuberculosis culture (MTBC). Drainage fluid was postoperatively collected for polymerase chain reaction (PCR), acid-fast strains (AFS), MTBC, and DNA molecular detection (DNAMD) analyses. Compare the drainage liquid positive rate of the two groups and estimate relationship between the positive results of drainage fluid and the lesion region. In addition, the clinical outcomes including the bony fusion, relapse rate, complications, and neurological status were collected.

Results

There was no significant difference in the positive rate of AFS, PCR, DNAMD, MTBC, or any positive rate (APR) of drainage liquid between the two groups (P > 0.05). In both groups, the MTBC-positive rate of postoperative drainage fluid was significantly lower than that of the intraoperative sample (P < 0.01). There was no significant relationship between APR and the lesion region (P > 0.05). All the patients had at least 2 years of follow-up, with an average of 34.4 ± 15.8 months. There were four patients in group A and two patients in group B who had recurrent spine TB, and the rest of the patients had fusion in the surgical area. There was no significant difference in the incidence of TB recurrence or other complications between the two groups (P > 0.05). All the patients with neurological dysfunction had improved after surgery.

Conclusion

Compared with anterior approach surgery, posterior approach surgery had equal effectiveness of debridement. The two kinds of surgery can effectively clear the lesions surrounding the spine and heal thoracic and lumbar TB.

Surgical management for middle or lower thoracic spinal tuberculosis (T5-T12) in elderly patients: Posterior versus anterior approach

BACKGROUND

Spinal tuberculosis accounts for more than 50% of bone tuberculosis cases. This study compared clinical, radiological and functional outcomes between anterior and posterior approaches for treatment of middle or lower thoracic spinal tuberculosis in elderly patients.

METHODS

We retrospectively examined middle or lower thoracic spinal tuberculosis (T5-T12) in patients over 65 years. All procedures included debridement, decompression, autologous bone graft and fixation. Surgical procedure, surgical duration, estimated blood loss during surgery and laboratory results were recorded. Pleural effusion volume, thoracic cavity volume, Oswestry Disability Index score, neurological status, radiological parameters and complication rate were evaluated.

RESULTS

No significant difference was found in surgical duration, blood loss, kyphosis angle correction, loss of correction, thoracic cavity volume, or complication rate between the two groups (P > 0.05). Average postoperative pleural effusion volumes were 605.9 ± 209.5 mL (377-1074 mL) and 262.9 ± 228.1 mL (0-702.4 mL) in the anterior and posterior groups, respectively (P = 0.004). Average hospitalization durations were 26.4 ± 10.5 days (17-53 days) and 19.2 ± 5.0 days (14-30 days) (P = 0.04). Average postoperative serum albumin levels were 24.19 ± 3.84 g/L (19-29.5 g/L) and 28.24 ± 2.52 g/L (24.4-31.6 g/L) (P = 0.01). No relapse or reinfection was observed in either group at the final follow-up. Surgical revision was not required in either group.

CONCLUSIONS

Both anterior and posterior surgeries can be used to treat middle or lower thoracic spinal (T5-T12) tuberculosis in elderly patients. In general, the posterior approach might be superior, especially for patients with poor general health.

The reasons and clinical treatments of postoperative relapse of Pott's disease

Literature about postoperative relapse of Pott's disease is rare. Accordingly, the risk factors and clinical treatments for postoperative relapse of Pott's disease remain controversial. In order to evaluate the clinical outcomes of surgical treatment of postoperative Pott's disease relapse, and to investigate its optimal therapeutic procedures with respect to focal characteristics, we performed a retrospective review of clinical and radiographic data that were prospectively collected between July 2008 and May 2014 from 753 consecutive spinal tubercular patients including 67 patients who were diagnosed and treated as postoperative relapse of Pott's disease in our hospital. Apart from 9 patients being treated conservatively, the remaining 58 cases received surgery in our series. Specifically, 12 cases underwent anterior debridement, interbody fusion with instrumentation; 15 cases received posterior instrumentation anterior debridement, and bone grafting; 10 cases underwent posterior decompression, bone grafting, and instrumentation; 7 cases with debridement, 5 with debridement and sinus resection. Nine cases received percutaneous drainage and low-dose local continuous chemotherapy. Clinical outcomes before and after treatment were evaluated with statistical analysis based on hematologic and radiographic examinations, bone fusion, and neurologic status. Patients were followed-up for a mean of 39.2 ± 8.2 months (range, 24-60 months). Postoperatively, the erythrocyte sedimentation rate (ESR) became normal within 4-6 months in all patients, and solid bone fusion was achieved within 8 months. Patients exhibited significant improvements in neurological deficits postoperatively, while the visual analog scale for pain showed significant improvements in all patients at final follow-up. The outcomes of follow-up showed that the reasons for postoperative relapse of Pott's disease were multiple. Individualized therapeutic methods should be chosen in accordance with the patient's general condition, recurrence focal characteristic, surgeon's experience, but above all is administration of appropriate chemotherapy.

[Research progress of surgical treatment of thoracolumbar spinal tuberculosis]

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.

Single posterior surgical management for lumbosacral tuberculosis: titanium mesh versus iliac bone graft: A retrospective case-control study

Recently, the one-stage posterior approach for treating spinal tuberculosis (TB) has gained popularity. However, large bony defects after debridement remain a major challenge in posterior surgery. The present retrospective study aims to compare the clinical outcomes of posterior-only surgical management by titanium mesh versus iliac bone grafts for treating lumbosacral TB. This was a retrospective cohort study. From January 2006 to April 2012, 36 patients with lumbosacral TB were treated at our department. The 36 cases were divided into 2 groups: 17 patients in Group A (titanium mesh) underwent one-stage posterior internal fixation, debridement, and titanium mesh bone fusion. The 19 patients in Group B (iliac bone graft) underwent posterior instrumentation, debridement, and iliac bone graft in a single procedure. The clinical and radiographic results for the 2 groups were analyzed and compared. The mean year of patients was 49.9 ± 15.4 months in group A and 55.5 ± 12.6 months in group B. All patients were followed up for an average of 47.3 ± 8.1 months (range 36-60 months). Spinal TB was completely cured and no intraspinal infection and central nervous system complications of TB infection occurred. Bone fusion was achieved 6.4 ± 1.9 months in group A and 7.8 ± 2.1 months in group B. There was no significant statistical difference in bone fusion between the 2 groups (P > .05). The Oswestry Disability Index score (ODI) significantly improved between the preoperative and the last visit in either group. However, no significant difference was observed between the 2 groups at last visit (P > .05). There were significant differences between groups regarding the postoperative lumbosacral angle and angle correction loss at the final follow-up (P < .05). The average operative complication rate of Group A was less than that of Group B. Both iliac bone and titanium mesh can effectively construct anterior column defects in posterior surgery. The titanium mesh has the advantage of minor surgical invasion, effective reconstruction of large defects, and ideal sagittal alignment in lumbosacral TB for patients with osteoporosis and poor iliac bone quality.

Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis

Object

To compare the clinical efficacy of titanium mesh cages and autogenous iliac bone graft to restore vertebral height through posterior approach in patients with thoracic and lumbar spinal tuberculosis.

Method

59 patients with spinal tuberculosis underwent interbody fusion and internal fixation through posterior approach in our department from January 2011 to December 2013. In group A, 34 patients obtained titanium mesh for the reconstruction of vertebral height, among them 25 patients (group A1) suffered from single-segment spinal tuberculosis, and 9 patients, (group A2) had multi-segment spinal tuberculosis. In group B, 25 patients got autogenous iliac bone graft to restore vertebral height, including 24 patients with single-segment spinal tuberculosis (group B1), and 1 patient with multi-segment spinal tuberculosis (group B2). The clinical efficacy was evaluated based on average operation time, blood loss, hospital stays, hospitalization expenses, visual analog scale (VAS), Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-Reactive protein (CRP), neurological function recovery, bony fusion, intervertebral height, Cobb angle and postoperative complications.

Results

Final follow-up time was an average of 35.5 months ranging from 15 to 56 months. All patients were completely cured and obtained solid bone fusion. The bony fusion time was 9.4±6.1 months in group A1, 10.2±2.7 months in group A2 and 8.7±3.6 months in group B1. There were no significant difference among three groups (P>0.05). The Cobb correction and restoration of intervertebral height significantly improved compared with those in preoperation, but without significant difference among three groups (P>0.05). The loss of angular correction and intervertebral height in group A1 were found to be less than those in group B1 (P<0.05), but with no significant difference between group A1 and group A2, and between group A2 and group B1 (P>0.05). Patients in group B1 got the most loss of angular correction and intervertebral height. In addition, neurological function was revealed to be significantly improved after surgery. There were significant differences of VAS, ODI, ESR and CRP between preoperation and postoperation at the final follow-up time (P<0.05), with no significant difference among three groups (P>0.05). No statistically significant difference was found when analyzing blood loss, hospital stays, hospitalization expenses, and corrective cost among three groups (P>0.05). Complications included cerebrospinal fluid leakage (2 cases in group A1 and group A2), sinus formation (3 cases in group A1, group A2 and group B1), and intervertebral infection (1 case in group B1), but no implant failure or donor site complications was found in any patient.

Conclusions

Titanium mesh cages could obtain good clinical efficacy comparable to autogenous iliac bone graft when treating single-segment spinal tuberculosis, and may be better than autogenous iliac bone graft for treating multi-segment spinal tuberculosis.

The Versatile Approach: A Novel Single Incision Combined with Anterior and Posterior Approaches for Decompression and Instrumented Fusion to Treat Tuberculosis of the Thoracic Spine

STUDY DESIGN

Retrospective case series.

PURPOSE

To describe a novel single incision that combines anterior and posterior approaches for decompression and instrumented fusion to treat tuberculosis of the thoracic spine and study the neurological and radiological outcomes.

OVERVIEW OF LITERATURE

Tuberculosis of the spine remains a major health issue in many developing countries. The options for treating tuberculosis of the thoracic spine include the anterior, posterior, and combined approaches, each with its advantages and disadvantages.

METHODS

Totally, 143 patients with tuberculosis of the thoracic spine were surgically treated using the "Versatile approach". Posterior fixation was performed using sublaminar wires and a Hartshill rectangle in all patients. Anterior reconstruction was accomplished using bone graft harvested from autologous rib, iliac crest, or fibula.

RESULTS

The study included 45 males and 98 females, with a mean age of 33.18±18.65 years (range, 3-82 years) and a mean follow-up of 60.23±24.56 months (range, 18-156 months). Kyphosis improved from a mean value of 24.02 preoperatively to 10.25 postoperatively. A preoperative neurological deficit was observed in 131 patients, with 130 patients regaining ambulatory power. No patient had deterioration of neurological status following surgery. Fusion was achieved in all cases. The visual analogscale score improved from an average score of 7.02 preoperatively to 1.51 at final follow-up. Eight patients had superficial macerations, which healed spontaneously. One patient had buckling of the anterior graft, and one patient had implant breakage following road traffic accident.

CONCLUSIONS

The "Versatile approach" is an effective, single-stage, single-incision method that combines anterior and posterior approaches for the surgically treating tuberculosis of the thoracic spine. It offers the advantage of direct visualization for decompression and reconstruction of the anterior and posterior vertebral columns, thus providing an excellent, long-lasting clinical outcome.

Debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only

PURPOSE

To analyse the efficacy and feasibility of surgical management for elderly patients with multilevel non-contiguous spinal tuberculosis(MNSTB)by using one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion.

METHODS

From September 2009 to October 2013, 15 elderly patients with MNSTB were treated with one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion. There were 10 males and 5 females with a mean age of 63.2 years (range: 60-68 years) at the time of surgery. The mean follow-up time was 40 months(range 26-68 months). Patients were evaluated before and after surgery in terms of erythrocyte sedimentation rate(ESR), neurological status, pain and kyphotic angle.

RESULTS

The spinal tuberculosis was completely cured, and the grafted bones were fused in all 15 patients. There were no recurrent tuberculous infections. The ESR reached a normal level within 3 months in all patients. The ASIA neurological classification improved in all cases, and pain relief was reported by all patients. The average preoperative kyphosis was 20.1° (range 8-38°) and decreased to 7.6° (range 1-18°) postoperatively. There was no significant loss of the correction at the latest follow-up.

CONCLUSIONS

Our results showed that one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion was an effective treatment for elderly patients with MNSTB. It is characterized by minimum surgical trauma, good neurological recovery, and good correction of kyphosis.

Single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis

PURPOSE

To review the outcome of single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis in 45 patients.

METHODS

Records of 16 men and 29 women aged 20 to 59 (mean, 34.1) years who underwent single-stage posterior instrumentation for active thoracic (n=27) or thoracolumbar (n=18) tuberculosis by a single surgeon and were followed up for a minimum of 5 years were reviewed. Neurological status was evaluated using the Frankel grading system. Pain was assessed using the visual analogue score (VAS). Disability status was assessed using the Oswestry Disability Index (ODI). Outcome was graded according to the Kim and Lee criteria. Kyphosis at presentation, preoperation (after one month of conservative therapy), immediate postoperation, and 5-year follow-up was measured on radiographs to determine the kyphosis progression, correction of deformity, postoperative loss of correction, and residual deformity.

RESULTS

Respectively for 27 and 18 patients with thoracic or thoracolumbar involvement, at 5 years the mean VAS score improved from 5.5 to 1.9 (p<0.001) and from 6.8 to 1.5 (p<0.001), whereas the mean ODI improved from 60.8 to 11.7 (p<0.001) and from 57.5 to 7.6 (p<0.001). The outcome was excellent in 17 and 11, good in 7 and 5, and fair in 3 and 2 patients, respectively. The mean kyphosis progression from presentation to preoperation was from 20.2º to 26.2º and from 10.3º to 14.1º, respectively, whereas the corresponding mean predicted kyphosis progression was from 15.5º to 48.1º and from 13.8º to 50.4º. The respective mean correction of deformity was -8.1º and -8.5º; the respective mean residual deformity was 4.1º and 6.8º; and the respective mean loss of correction at 5 years was 1.9 and 1.9. Two patients had a dural tear, and 3 patients had a transient root injury. Two diabetic patients had superficial wound infection. One patient had downward migration of one rod at 30 months but remained asymptomatic.

CONCLUSION

Single-stage posterior instrumentation combined with continued chemotherapy for a minimum 12 months is a viable option for early progressive thoracic and thoracolumbar tubercular kyphosis.

Surgical Management in Elderly Patients with Tuberculous Spondylodiscitis: Ten Year Mortality Audit Study

Study Design

Retrospective study.

Purpose

To evaluate the factors affecting immediate postoperative mortality in elderly patients with tuberculous spondylodiscitis.

Overview of Literature

Treatment of spinal tuberculosis in the elderly involves consideration of age and co-morbidities, and often leads to an extended conservative management. Surgical intervention in these patients becomes a complex decision. There are no studies on risk factors of mortality in surgically treated elderly with tuberculous spondylodiscitis.

Methods

Two hundred and seventy-six patients with spondylodiscitis were operated between 2005 and 2015. 20 consecutive patients over 70 years of age with and proven tuberculosis who met the inclusion/exclusion criteria were included. Demographic, clinical and radiological profile data with operative details of instrumentation, blood loss, surgical duration, and mortality were noted. There were 20 patients (6 males, 14 females) with a mean age of 73.5 years. The patients were divided into those with mortality (M) and those who survived (non-mortality, NM). Various variables were statistically tested for immediate postoperative medical complications and mortality.

Results

There were four mortalities (20%). Age, sex, number of medical co-morbidities, American Society of Anaesthesiologists grade, Frankel grade C or worse, number of vertebrae involved, number of levels fused, blood loss and operative time did not have statistically significant impact on immediate postoperative mortality. Only preoperative immobility duration was statistically higher in the M group (p=0.016) than in the NM group.

Conclusions

Preoperative immobility is associated with immediate postoperative mortality in elderly patients with spinal tuberculosis undergoing surgery. The findings identify preoperative immobility as a risk factor for mortality, which could contribute to a more detailed prognostic discussion between surgeon and patient before surgery.

Trends of spinal tuberculosis research (1994-2015): A bibliometric study

BACKGROUND

Spinal tuberculosis is the most common form of skeletal tuberculosis. However, there were limited data to evaluate the trend of spinal tuberculosis research. This study aims to investigate the trend of spinal tuberculosis research and compare the contribution of research from different countries and authors.

METHODS

Spinal tuberculosis-related publications from 1994 to 2015 were retrieved from the Web of Science database. Excel 2013, GraphPad Prism 5, and VOSviewer software were used to analyze the search results for number of publications, cited frequency, H-index, and country contributions.

RESULTS

A total of 1558 papers were identified and were cited 16,152 times as of January 25, 2016. The United States accounted for 15.1% of the articles, 22.3% of the citations, and the highest H-index (33). China ranked third in total number of articles, fifth in citation frequency (815), and ranked seventh in H-index (13). The journal Spine (IF 2.297) had the highest number of publications. The author Jain A.K. has published the most papers in this field (20). The article titled "Tuberculosis of the spine: Controversies and a new challenge" was the most popular article and cited a total of 1138 times. The keyword "disease" was mentioned the most for 118 times and the word "bone fusion" was the latest hotspot by 2015.

CONCLUSION

Literature growth in spinal tuberculosis is slowly expanding. Although publications from China are increasing, the quality of the articles still requires improvements. Meanwhile, the United States continues to be the largest contributor in the field of spinal tuberculosis. According to our bibliometric study, bone fusion may be an emerging topic within spinal tuberculosis research and is something that should be closely observed.

V, Jayaswal A. Management of Tuberculous Infection of the Spine

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.

Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?: A retrospective case-control study

Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6 ± 5.7 months in group A and 22.3 ± 6.2 months in group B (P = 0.47). The average operative duration was 257.5 ± 91.1 minutes in group A and 335.7 ± 91.0 minutes in group B (P = 0.002). The mean total blood loss was 769.6 ± 150.9 mL in group A and 1048.6 ± 556.9 mL in group B (P = 0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (P < 0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (P = 1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (P = 0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.

Short to Mid-Term Term Surgical Outcome Study with Posterior Only Approach on Tuberculous Spondylodiscitis in an Elderly Population

Study Design

Retrospective study.

Purpose

To study short to mid-term outcome of surgically managed elderly patients of tuberculous spondylodiscitis with posterior only approach in terms of decision making and challenges in treatment, choice of implants and outcomes.

Overview of Literature

Tuberculous spondylodiscitis in the elderly is increasing due to longer survival rates. It presents with varied clinical manifestations needing surgical management. Management in tuberculous spondylodiscitis has been scarcely reported in the elderly, with a paucity of data on the choice of implants and approach.

Methods

Sixteen patients (five males, 11 females) older than 70-years-of-age culture and/or histopathology proven tuberculous spondylodiscitis were included in the study. All patients were operated using a single posterior approach. Pedicle screw with rods (PS/rods) or spinal loop with sublaminar wires (SL/SLW) were used for fixation. Clinical and surgical details were recorded. Sagittal correction achieved postoperatively and loss of correction at follow-up were noted.

Results

The mean age was 73.6 years (range, 70 to 80 years). The mean follow up was 44.5 months (range, 24 to 84 months). The mean immediate postoperative correction of sagittal deformity was 11.3 degrees; this correction was lost by a mean of 3.1 degrees at last follow-up. All 10 patients with deficit showed neurological recovery and all but one of the seven non-walkers were capable of independent ambulation at follow-up. Patients with SL/SLW and PS/rods had similar radiological outcome at final follow up.

Conclusions

Operative management gives satisfactory results in elderly patients with tuberculous spondylodiscitis. The posterior approach provides adequate exposure for decompression and rigid fixation, providing satisfactory clinical and radiological outcomes. SSL/SLW and pedicle screw rod construct both give similar radiological results if used appropriately in patients.

Anterior versus posterior debridement fusion for single-level dorsal tuberculosis: the role of graft-type and level of fixation on determining the outcome

PURPOSE

This study compared the clinical, radiological and functional outcome of anterior versus posterior approaches for single-level dorsal tuberculosis with analysis of effect of graft type and fixation level on the outcome.

METHODS

Anterior group (AG): 43 cases (mean age: 49.5 years) fixed with Z-plate by anterior transthoracic-transpleural approach. Posterior group (PG): 49 cases (47.0 years) fixed with transpedicular-screws with unilateral facetectomy ± pediculectomy. Assessment was done using Frankel classification, blood-loss, operative-time, Kyphus-angle, correction loss, union and Oswestry disability index (ODI).

RESULTS

Both groups had similar operative-time, blood-loss, time to union, follow-up, and hospital-stay. Kyphus-angle improved from 36.6 ± 8.4° to 7.5 ± 2.3° (AG) and from 38.5 ± 5.9° to 11.1 ± 3.6° (PG) and this was significant. Postoperative Kyphus-angles were significantly better than preoperative ones in both groups. The correction percentage was 79.2 % (AG) and 69.9 % (PG) and this was significant. ODI was 3.4 ± 4.1 (AG) and 3.0 ± 4.2 % (PG) and this was insignificant. Correction loss was .8 ± 1.2° (AG) and 1.9 ± 2.2° (PG) and this was significant. Union was faster with iliac graft but with lower correction degree and higher correction loss than rib-strut graft. All patients achieved union. All but three patients achieved full neurological recovery. Superficial infection occurred in three cases (PG:2; AG:1) lung parenchymal injury in two case (AG), and DVT in one case (AG).

CONCLUSIONS

Both approaches give very good union and kyphosis correction rate that were maintained overtime. Anterior approach gives statistically better kyphosis correction and less correction-loss, but this is clinically insignificant. Besides, it is more risky and difficult. Strut-graft is essential in reconstruction and correction of kyphosis and vertebral height.

LEVEL OF EVIDENCE

III therapeutic.

Single-stage transpedicular decompression, debridement, posterior instrumentation, and fusion for thoracic tuberculosis with kyphosis and spinal cord compression in aged individuals

BACKGROUND CONTEXT

The single-stage posterior approach only for spinal tuberculosis (TB) has been reported by some surgeons recently, but few studies have reported single-stage transpedicular decompression, debridement, posterior instrumentation, and fusion in treatment of thoracic TB with kyphosis and spinal cord compression in patients older than 65 years.

PURPOSE

The purpose of this study was to investigate the effectiveness and feasibility of single-stage transpedicular decompression, debridement, posterior instrumentation, and fusion in the treatment of thoracic TB with kyphosis and spinal cord compression in aged individuals.

STUDY DESIGN

The study used a retrospective review.

PATIENT SAMPLE

Between January 2004 and March 2010, 37 cases of thoracic TB with kyphosis and spinal cord compression in individuals older than 65 were treated with single-stage transpedicular decompression, debridement, posterior instrumentation, and fusion.

OUTCOME MEASURES

The patients were evaluated based on ASIA (American Spinal Injury Association) classification, kyphotic Cobb angle, fusion status of affected segment via computed tomography scans, and visual analog scale pain score.

METHODS

There were 23 men and 14 women with an average age of 72.08±4.49 years (range, 65-81 years). The mean disease duration was 6 months (range, 3 to 21 months). The involved vertebral bodies were T2-T11, including two segments in 29 cases and three segments in 8 cases. The kyphosis Cobb angle was 39.46±4.71° before operation.

RESULTS

The follow-up period ranged from 24 to 61 months (mean 41.43±3.40 months). No mortality occurred. One case of recurrence due to irregular antitubercular treatment was cured by abscess clearing and regular chemotherapy. A solid fusion was achieved in the other 36 cases. According to the ASIA score system, 10 cases were rated as grade D, and 27 cases as grade E at last follow-up. The kyphosis Cobb angle was 22.32±3.41°, showing significant difference when compared with the value before operation (t=17.146, p<.001).

CONCLUSION

Single-stage transpedicular decompression, debridement, posterior instrumentation, and fusion is an effective and safe method in treatment of thoracic TB with kyphosis and spinal cord compression in aged individuals.

Two approaches for treating upper thoracic spinal tuberculosis with neurological deficits in the elderly: A retrospective case-control study

OBJECTIVE

The current study compared clinical outcomes of two diverse therapeutic strategies for upper thoracic (T1-4) spinal tuberculosis with neurological deficits in elderly patients.

METHODS

A retrospective analysis was performed on 18 cases undergoing single-stage posterior transpedicular decompression, debridement, interbody fusion, and instrumentation (Group A). Sixteen cases underwent single- or two-stage anterior debridement, bone grafting, and posterior instrumentation (Group B). The clinical and radiographic results for these patients were analyzed and compared.

RESULTS

Patients were followed up for an average of 40.9 ± 4.0 months (range 36-48 months). Results demonstrated that the average operative duration, blood loss, hospital stays, and operative complication rate were lesser for Group A than for Group B. The average fusion time was 8.1 ± 1.5 months and 7.8 ± 2.9 months in Groups A and B, respectively (p>0.05). Cobb's angles were significantly corrected after surgical management, but loss of correction occurred in both groups. All patients had significant postoperative neurological improvement.

CONCLUSIONS

Single-stage posterior transpedicular debridement, decompression, interbody fusion and instrumentation might be a better surgical treatment compared with combined posterior and anterior approaches. Such techniques may result in fewer complications and a better quality of life for elderly patients.

Debridement, internal fixation, and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach: a 4-year follow-up of 28 patients

Background

The standard recommended method for surgical treatment of spinal tuberculosis is an anterior approach for debridement and fusion combined with posterior instrumentation. However, the method has its disadvantages. The aim of this study was to analyze the effectiveness and safety of treating thoracic and lumbar spinal tuberculosis with debridement, internal fixation reconstruction, and using specially formed titanium mesh cages via a posterior-only approach.

Methods

The authors retrospectively reviewed the cases of 28 patients with spinal tuberculosis treated by debridement, internal fixation, and reconstruction with a specially formed titanium mesh cage via a posterior-only approach. The levels involved were less than two contiguous vertebrae: 13 thoracic vertebrae, 5 thoracolumbar vertebrae, and 10 lumbar vertebrae. All patients suffered from back pain, and nine patients had neurologic deficits (two were class C and seven were in class D according to the American Spinal Injury Association classification). All patients were followed up every 3 months after surgery, with a minimum 48-month follow-up. The clinical efficacy was evaluated based on the visual analog scale (VAS), the Oswestry Disability Index (ODI), neurological status, kyphosis angle, and erythrocyte sedimentation rate (ESR).

Results

All patients obtained solid bony fusions without failure of fixation. The infections were resolved in all patients, as noted by normalization of their ESR. The average surgery time was 2 h and 15 min, with an average blood loss of 435 ml. The VAS scores dropped from a preoperative level of 6.31 ± 1.25 to the final follow-up level of 0.57 ± 0.14. The ODI scores dropped from 39.14 ± 12.38 preoperatively to 7.29 ± 3.09 at 1 year postoperatively and 6.77 ± 2.53 at final follow-up. The kyphosis Cobb’s angle was corrected from 22.31° ± 4.26° preoperatively to 5.86° ± 0.57° at final follow-up. No subsidence of titanium mesh cage or posterior instrumentation failure was observed postoperatively. The neurological outcome increased by 1–2 grades in the patients with neurological deficits.

Conclusions

Debridement, internal fixation, and reconstruction using specially formed titanium mesh cages via a posterior-only approach is effective and safe for treating adults with thoracic and lumbar spinal tuberculosis involving less than two contiguous levels.

Two one-stage posterior approaches for treating thoracic and lumbar spinal tuberculosis: A retrospective case-control study

The aim of this retrospective study was to analyze the results of two surgical treatments for thoracic and lumbar spinal tuberculosis. A total of 73 patients with monosegmental thoracic or lumbar spinal tuberculosis were enrolled from January 2006 to April 2011. The patients were divided into two groups. Patients in group A (n=34) underwent one-stage posterior debridement, limited decompression, bone grafting and internal fixation combined with lamina reconstruction, while those in group B (n=39) underwent one-stage posterior debridement, decompression, bone grafting and posterior instrumentation. Clinical and radiographic results were analyzed and compared between the groups. Patients were followed for a mean 31.3 months (range, 21-42 months). Fusion occurred at 4-12 months (mean, 7.7 months). Surgical complications affected one and five patients in groups A and B, respectively. There was extraction of internal fixation in two group B patients. Postoperatively, there was significant Cobb angle correction in the two groups. By the last follow-up, the Cobb angle and correction loss in group A were significantly better than that in group B; the group A Oswestry Disability Index and Frankel grade were better than that in group B. In conclusion, one-stage posterior limited decompression, bone grafting and internal fixation combined with lamina reconstruction enables rapid management of monosegmental thoracic and lumbar spinal tuberculosis with fewer complications and minimal invasion.

Correlation between Serum Level of Monocyte Chemoattractant Protein-1 and Postoperative Recurrence of Spinal Tuberculosis in the Chinese Han Population

Objective

To correlate serum level of monocyte chemoattractant protein-1 (MCP-1) with postoperative recurrence of spinal tuberculosis in the Chinese Han population.

Methods

Patients of Han nationality with newly diagnosed spinal tuberculosis were consecutively included in this study. At different time points postoperatively, serum level of MCP-1 was determined using an enzyme linked immunosorbent assay. Recurrence of spinal tuberculosis after surgery and during the follow-up period was recorded. The correlation between serum MCP-1 level and recurrence of spinal tuberculosis was analyzed.

Results

A total of 169 patients with spinal tuberculosis were included in the study and followed up for an average of2.2±1.3 years (range, 1–5 years). Of these patients, 11 had postoperative recurrence of spinal tuberculosis. The patients’ serum level of MCP-1 increased significantly after postoperative recurrence of spinal tuberculosis. Once the symptoms of recurrence were cured, the serum level of MCP-1 decreased significantly and it did not differ from patients without disease recurrence.

Conclusion

Postoperative recurrence of spinal tuberculosis is likely to increase the serum level of MCP-1.

Surgical management for thoracic spinal tuberculosis posterior only versus anterior video-assisted thoracoscopic surgery

STUDY DESIGN

A comparable retrospective study.

OBJECT

To compare the clinical outcomes of surgical treatment by posterior only and anterior video-assisted thoracoscopic surgery for thoracic spinal tuberculosis (TSTB).

METHOD

145 patients with TSTB treated by two different surgical procedures in our institution from June 2001 to June 2014 were studied. All cases were retrospectively analyzed and divided into two groups according to the given treatments: 75 cases (32F/43M) in group A performed single-stage posterior debridement, transforaminal thoracic interbody fusion and instrumentation, and 70 cases (30F/40M) in group B underwent anterior video-assisted thoracoscopic surgery (VATS). Clinical and radiographic results in the two groups were analyzed and compared.

RESULTS

Patients in group A and B were followed up for an average of 4.6±1.8, 4.4±1.2 years, respectively. There was no statistically significant difference between groups in terms of the operation time, blood loss, bony fusion, neurological recovery and the correction angle of kyphotic deformity (P>0.05). Fewer pulmonary complications were observed in group A. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the anterior VATS and posterior approaches can effectively treat thoracic tuberculosis. Nevertheless, the posterior approach procedure obtained less morbidity and complications than the other.

Efficacy and Safety of Posterior Versus Combined Posterior and Anterior Approach for the Treatment of Spinal Tuberculosis: A Meta-Analysis

OBJECTIVE

Surgical treatment is an important strategy for the treatment of spinal tuberculosis (TB). Several approaches have been reported for the surgery. However, no single study has had a large enough sample population to definitively determine whether the single posterior approach is as effective and safe as the combined posterior and anterior approach for the treatment of spinal TB. A meta-analysis was conducted to evaluate the clinical efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal TB.

METHODS

In this meta-analysis, electronic databases, such as PubMed, MEDLINE, EMBASE, Google scholar, and Cochrane library, were searched to select the potentially relevant reports that compared the outcomes of the posterior approach (group A) with the combined posterior and anterior approach (group B) in the treatment of spinal TB. Relevant journals and references were also searched manually. Data extraction and quality assessment were according with Cochrane Collaboration guidelines. Outcome assessments were operation time, blood loss, correction of angle, loss of correction, hospital stay, fusion time of the grafting bone, neurological improvement, and complications after surgery. Results were expressed as odds ratio for dichotomous outcomes and mean difference for continuous outcomes with 95% confidence interval.

RESULTS

Five controlled clinical trials published between 2012 and 2014, involving 253 patients (group A, 129; group B, 124) with spinal TB were retrieved in this study. The overall meta-analysis showed that there were significant differences (P< 0.01) between groups A and B in operation time, blood loss, hospital stay, and complications after surgery. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after surgery between groups A and B.

CONCLUSIONS

The posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of sinal TB. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making.