Current management of spinal tuberculosis: a multimodal approach

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.

Efficacy of One-Stage Posterior Debridement and Bone Grafting with Internal Fixation in the Treatment of Monosegmental Thoracolumbar Tuberculosis

BACKGROUND

We explored the clinical effect of one-stage posterior debridement and bone grafting with internal fixation for the treatment of monosegmental thoracolumbar tuberculosis (TB).

METHODS

The data from 90 patients with thoracolumbar TB, who had undergone one-stage posterior debridement and bone grafting with internal fixation, were retrospectively reviewed. Data on the operative time, blood loss, length of hospital stay, erythrocyte sedimentation rate, C-reactive protein, improvement of neurological function, visual analog scale score, vertebral Cobb angle, bone healing, and complications were collected.

RESULTS

A total of 88 patients were finally included in the present retrospective study, included 42 men and 46 women. The mean patient age was 45.4 ± 12.3 years (range, 27-70), and the mean duration of disease until treatment was 11 ± 4.5 months (range, 3-19). The mean operative time was 167.0 minutes (range, 130-210), and the mean blood loss was 767.4 mL (range, 500-1150). At the final follow-up examination, the correction in the Cobb angle was 19°, the visual analog scale score had decreased to 3 ± 1.72, the neurologic deficits using the Frankel grade had improved, and the erythrocyte sedimentation rate and C-reactive protein level had returned to normal levels.

CONCLUSION

One-stage posterior debridement and bone grafting with internal fixation might be a better choice for treating patients with monosegment thoracolumbar TB.

Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation

BACKGROUND The aim of this study was to evaluate the efficiency and clinical outcomes of mini-open anterior approach focal cleaning combined with posterior internal fixation compared to conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in the treatment of lumbar tuberculosis (TB). MATERIAL AND METHODS Medical records from 124 patients were collected from February 2010 to April 2015; patients were divided into two groups: group A (mini-open anterior approach focal cleaning combined with posterior internal fixation) and group B (conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in period I). The data on postoperative mechanical ventilation time, preoperative, postoperative, and last follow-up Cobb angle, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and Frankel classification were collected and analyzed. Operative complications, internal stability, and bone graft fusion were also observed. RESULTS All patients were followed-up for 12 to 36 months (average 22.5 months). Seven cases (five in group A and two in group B) had side psoas abscess and were cured after secondary drainage surgery. The rest of the cases were all cured after primary surgery, with no formation of sinus, incisional hernia, cerebrospinal fluid leakage, or recurrence of spinal TB, with no TB symptoms. Bone graft fusion ranged from 3 to 8 months (average 4.7 months). Compared to group B, group A, which had less time on postoperative mechanical ventilation, had a higher VAS score. Both groups had distinct improvements in Cobb angle, ESR, and Frankel classification after surgery. CONCLUSIONS Treating lumbar TB by mini-open anterior approach focal cleaning combined with posterior internal fixation was safe and effective.

Comparison of Three Surgical Approaches for Thoracic Spinal Tuberculosis in Adult: Minimum 5-Year Follow Up

STUDY DESIGN

Retrospective study.

OBJECTIVE

To assess the minimum 5-year follow up outcomes of the surgical management of adults with thoracic tuberculosis by comparing posterior only (PO), anterior only (AO), and combined posterior and anterior (AP) surgical approaches.

SUMMARY OF BACKGROUND DATA

Surgeons use multiple methods to treat spinal tuberculosis, including an anterior, posterior, and combined anterior and posterior approach. However, there are a few reports comparing the mid- and long-term outcomes of these surgical methods.

METHODS

The medical records for 184 patients treated for thoracic tuberculosis between January 2003 and November 2010 were retrospectively reviewed. Among them, 62 patients were treated with a single-stage posterior debridement and interbody fusion with instrumentation (Group A), 65 patients with posterior instrumentation, anterior debridement, and bone graft in a single or two-stage procedure (Group B), and 57 patients with anterior debridement and strut grafting with instrumentation (Group C). Operative time, blood loss, Visual Analog Scale for pain, complications, recovery of neurological function, Cobb angle, correction rate, and loss angle were compared among all groups.

RESULTS

Groups A, B, and C were followed for 72.7 ± 3.8 months, 74.3 ± 4.2 months, and 73.6 ± 4.5 months, respectively. The operative time, blood loss, and rate of complications for Group A were significantly less than Groups B and C (P < 0.05). The correction rate and loss angle were superior in Groups A and B compared with C, whereas the Visual Analog Scale for pain and fusion time showed no statistically significant difference among the groups (P > 0.05).

CONCLUSION

For patients with thoracic tuberculosis, use of the AO approach should be limited. Although the AP approach produced satisfactory outcomes, it remains more traumatic. Therefore, the PO approach is recommended, not only because it achieves good results, but because it has reduced complications, operative time, and blood loss.

LEVEL OF EVIDENCE

3.

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.

Clinical characteristics and neurologic recovery of patients with cervical spinal tuberculosis: should conservative treatment be preferred? A retrospective follow-up study of 115 cases

OBJECTIVE

To present the clinical characteristics and prognostic factors of neurologic recovery in patients with cervical spinal tuberculosis (CST).

METHODS

General description and multivariate analysis were used to detect possible predictors of the outcome of patients with neurologic deficit. Follow-up data were used to generate a Kaplan-Meier curve of neurologic recovery.

RESULTS

Protective factors in neurologic recovery included less involved vertebrae, surgery, and higher Japanese Orthopaedic Association score before treatment; not shorter symptom duration was not a protective factor. Normal neurologic function was present in 30% of patients 6 months after treatment, in 56% of patients 12 months after treatment, and in 93% of patients 28 months after treatment. The cumulative complete neurologic recovery rates at 6 months, 12 months, and 28 months were 44%, 68%, and 91.7% in the surgery group and 16.7%, 38.8%, and 94.4% in the nonsurgery group.

CONCLUSIONS

Surgery and Japanese Orthopaedic Association score before treatment are important predictors of neurologic recovery in patients with CST. A neurologic recovery curve could predict neurologic recovery in patients with CST and indicate in patients with neurologic deficit how long it will take to achieve complete neurologic recovery. The effect of surgery is quick, and the effect of conservative treatment is slower, but no difference in neurologic recovery was found in the long-term. Conservative treatment should be tried in every patient with CST with no obvious indication for surgery. In contrast to patients with tuberculosis without cervical spine involvement but with more complications, comprehensive conservative therapy should be preferred for patients with neurologic deficit to avoid unnecessary surgery and overtreatment and to conserve medical resources. Indications for surgical intervention for CST should be carefully selected.