Debridement and Internal Fixation from a Single Posterior Approach for the Treatment of Lumbosacral Tuberculosis

Comparative Clinical Efficacy and Safety of Sacral-2-Alar Iliac Screw Versus Iliac Screw in the Lumbosacral Reconstruction of Spondylodiscitis

OBJECTIVE

This study aimed to evaluate the clinical efficacy and safety of S2-alar-iliac (S2AI) and iliac screw (IS) techniques in treating lumbosacral spondylodiscitis.

METHODS

Between January 2020 and January 2022, 28 patients suffering from lumbosacral spondylodiscitis underwent lumbosacral fixation and were divided into the IS group (14 patients) and the S2AI group (14 patients). Surgical details, demographic characteristics, preoperative and postoperative Oswestry Disability Index, visual analog scale, and complications were analyzed.

RESULTS

Twenty-eight patients were included in this study, including 14 patients treated with IS and 14 patients treated with S2AI. The 2 groups were similar in sex, age, follow-up period, total drainage volume, hospitalization stay, and fusion time. (P > 0.05) The estimated blood loss and surgical time of S2AI during surgery were significantly lower than those of IS. (P < 0.05) The visual analog scale and Oswestry Disability Index scores significantly improved in both groups from preoperative to the last follow-up. Sacroiliac joint pain was found in both groups in the follow-up period, but the incidence was not significantly different (P = 0.663). Compared with the IS approach, the incidence of symptomatic screw prominence was lower in the S2AI group, but the difference was not significant. (P = 0.088).

CONCLUSIONS

S2AI, as well as IS techniques, can achieve promising results for reconstructing lumbosacral stability in spondylodiscitis. In addition, the S2AI technique can also reduce surgical trauma and operation time.

Comparison of Long-Term Clinical and Radiographical Outcomes between the Anterior and Combined Anterior and Posterior Approaches for Treating Lumbosacral Tuberculosis

OBJECTIVE

Both anterior and combined anterior and posterior approaches have been used to treat lumbosacral tuberculosis. However, long-term follow-up studies of each approach have not been conducted. We aimed to compare the long-term clinical and radiographical outcomes between the two approaches.

METHODS

In this retrospective cohort study, we included 49 patients with a minimum 6-year follow-up between January 2008 and March 2012. Twenty-four patients underwent the anterior approach (anterior group), and 25 underwent the combined anterior and posterior approach (anterior-posterior group). Student's t test, Mann-Whitney U test, and Pearson's chi-square test were used to compare the two groups regarding clinical data, such as visual analogue scale scores, Oswestry disability index scores and neurological status, and radiographical data, such as lumbosacral angle, lumbar lordosis, and L5-S1 height. Furthermore, operative time, length of stay, and intraoperative and postoperative blood loss (IBL, PBL) were recorded.

RESULTS

Both groups had satisfactory clinical and radiographical outcomes until the final follow-up. All patients achieved bony fusion, and no group differences were found in any of the clinical indices. Both groups corrected and maintained the lumbosacral angle, lumbar lordosis, and L5-S1 height. However, the operative time, length of stay, maximum Hb drop, IBL, and PBL of the anterior group (140.63 ± 24.73 min, 12.58 ± 2.45 days, 28.33 ± 9.70 g/L, 257.08 ± 110.47 ml, and 430.60 ± 158.27 ml, respectively) were significantly lower than those of the anterior-posterior group (423.60 ± 82.81 min, P < 0.001; 21.32 ± 3.40 days, P < 0.001; 38.48 ± 8.03 g/L, P < 0.001; 571.60 ± 111.04 ml, P < 0.001; and 907.01 ± 231.99 ml, P < 0.001).

CONCLUSION

This retrospective study demonstrated long-term efficacy of the anterior approach with a single screw fixation, which was as effective as that of the combined anterior and posterior approach, with the advantage of less trauma.

Comparison of clinical and radiological outcomes of local morselized bone grafts and structural iliac bone grafts in the treatment of lumbar tuberculosis with posterior-only surgery

Background

Many surgeons have reported results similar to those of anterior debridement and bone grafting in treating spinal tuberculosis in the lumbar region using only a posterior approach. However, there is still no consensus regarding bone graft methods. This study aims to compare the clinical and radiological outcomes of morselized versus structural iliac bone grafts in the treatment of lumbar tuberculosis via one-stage posterior surgery.

Methods

A retrospective study was performed with 82 patients with lumbar tuberculosis who had undergone posterior-only debridement, bone grafting, and instrumentation between January 2014 and June 2018. Morselized bone grafts were used in 43 patients, whereas structural iliac bone grafts were used in 39 patients. The clinical data and imaging results of the patients were compared between the two groups to evaluate the clinical effects of the two types of grafts.

Results

The operation time, blood loss and hospital stay values in the morselized bone group were significantly lower than those in the structural iliac bone group (p < 0.05). No significant differences were observed with respect to erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Cobb angle, or improvement of neurological function between the two groups. The VAS pain scores for low back and leg pain decreased significantly after the operation (p < 0.05). However, postoperatively, the VAS score was higher in the structural iliac bone group than in the morselized bone group, and there was no significant difference at the last follow-up between the two groups (p > 0.05). Bone fusion was achieved in 41 patients (95%) in the morselized bone group and 38 patients (97%) in the structural iliac bone group. There was no significant difference between the fusion rates of the two groups (p > 0.05).

Conclusion

The two graft techniques achieved comparable clinical outcomes in lumbar spinal tuberculosis treatment. However, the morselized bone graft was more beneficial in terms of reducing surgical trauma and postoperative complications.

One-stage freehand minimally invasive pedicle screw fixation combined with mini-access surgery through OLIF approach for the treatment of lumbar tuberculosis

Objective

To compare one-stage freehand minimally invasive pedicle screw fixation (freehand MIPS) combined with mini-access surgery through OLIF approach with posterior approach for treatment of lumbar tuberculosis (TB), and evaluate its feasibility, efficacy and safety in debridement, bone graft fusion and internal fixation.

Methods

48 patients with single segment lumbar TB from June 2014 to June 2017 were included. Among them, 22 patients underwent one-stage freehand MIPS combined with mini-access surgery through OLIF approach (group 1), 26 patients were treated with posterior open surgery (group 2). Duration of operation, blood loss, and stay time in hospital were compared. Pre- and postoperative visual analog scale (VAS) pain scores, Oswestry disability index (ODI), erythrocyte sedimentation rate, complications and images were also recorded.

Results

Patients in group 1 showed significantly less blood loss (165 ± 73 ml vs 873 ± 318 ml, P < 0.001), shorter stay time in hospital (6/4–8 days vs 12/8–15 days, P < 0.001), while longer duration of operation (185 ± 14 min vs 171 ± 12 min, P < 0.001) than group 2 did. VAS scores significantly decreased after surgery in both groups, however, VAS scores of group 1 were significantly lower than that of group 2 immediately after surgery and during follow-ups (P < 0.001). ODI of group 1 was also significantly lower than that of group 2 at 12-month after surgery (P < 0.001).

Conclusion

One-stage freehand MIPS combined with mini-access surgery through OLIF approach is a feasible, efficient and safe method in treating single segment lumbar TB. It shows advantages of less surgical trauma and faster postoperative recovery.

Spinous Process Combined With a Titanium Mesh Cage as a Bone Graft in the Stability Reconstruction of Lumbar or Lumbosacral Spinal Tuberculosis

Background

Autogenous bone grafts, such as iliac bone or rib struts, have been used in the anterior reconstruction of spinal tuberculosis (STB) and have their own benefits and limitations. Here, we introduced a new method, the spinous process (SP), combined with a titanium mesh cage (TMC) as a bone graft in the stability reconstruction of lumbar or lumbosacral STBs. By retrospectively comparing patients who received SP+TMC to traditional TMC bone grafts or allogeneic bone grafts in terms of safety, efficacy and cost-effectiveness, we aimed to evaluate whether SP+TMC could be a possible alternative method.

Methods

From 2010 to 2018, 69 patients who underwent one-stage posterior debridement with grafts and internal fixation within a single lumbar or lumbosacral segment were included in this study. Twelve patients who received SP combined with a TMC (SP+TMC, group A), 30 patients who received a TMC only (group B), and 27 patients who received allografts (group C) were included. Measurements including operative time, blood loss, length of hospital stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), American Spinal Injury Association Impairment (ASIA) grade, final follow-up (FFU) duration and postoperative complications were recorded. Radiological measurements, including the number of segments fixated, the number of pedicle screws used, the Cobb angle, pelvic parameters, and the bony fusion time, were reviewed. All outcomes were analyzed using SPSS 25.

Results

We found that the SP+TMC group had fewer fixation segments, fewer pedicle screws implanted, a shorter operative time, reduced blood loss, and a considerably lower hospital cost than allografts. In addition, the TMC group had a comparable clinical outcome with the TMC group regarding lower economic cost.

Conclusion

Our study demonstrates that compared to a TMC or allograft, the use of SP combined with a TMC as a bone graft is an effective and reliable approach for the surgical management of one-level lumbar or lumbosacral spinal tuberculosis, leading to effective restoration of spinal stability. Furthermore, this approach is a cost-effective structural bone grafting method, especially for patients in developing countries.

Surgical strategy of lumbopelvic instrumentation in the treatment of lumbosacral tuberculosis: S2-alar-iliac screws vs iliac screws

The objective of this study was to evaluate the feasibility and clinical outcomes of S2-alar-iliac (S2AI) and iliac screw (IS) techniques in the lumbopelvic reconstruction of lumbosacral tuberculosis patients. From January 2014 to August 2016, 26 patients with lumbosacral tuberculosis attending the 8th Medical Centre of Chinese PLA General Hospital were included in this retrospective study. The subjects were divided into two groups based on the lumbopelvic fixation type (16 patients in the S2AI group, 10 patients in the IS group). The operation time, blood loss, length of hospitalisation, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, visual analogue scale (VAS), Oswestry Disability Index (ODI), ambulatory status, and 36-Item Short-Form Health Survey (SF-36) scores of the patients in two groups were recorded and compared. In addition, surgical complications were collected and analysed. The operation time and intraoperative blood loss were significantly lower in the S2AI group than that in the IS group (P < .05). Compared with preoperative data, postoperative data showed significant improvement in ESR, CRP level, ODI scores, VAS scores, ambulatory status, and SF-36 (P < .05), but there was no significant difference in remission degree between the two groups. Compared with IS group, The S2AI group had significantly lower rates of symptomatic screw prominence (P < .05). Both the IS and S2AI fixation techniques can achieve satisfactory outcomes for the restoration of lumbosacral stability of lumbosacral tuberculosis. Furthermore, compared to the traditional IS fixation technique, the S2AI fixation technique can shorten operation time and reduce surgical trauma for the treatment of lumbosacral tuberculosis.

Treatment of Lumbosacral Tuberculosis with Significant Vertebral Body Loss Using Single-Stage Posterior Surgical Management with a Structural Autograft Combined with a Titanium Mesh Cage

OBJECTIVE

Treatment of lumbosacral tuberculosis is still controversial. In our study, we assessed the efficacy and feasibility of single-stage posterior debridement, interbody fusion using a structural autograft combined with a titanium mesh cage, and posterior instrumentation for the treatment of lumbosacral tuberculosis with significant vertebral body loss.

METHODS

From May 2011 to June 2018, 15 patients with lumbosacral tuberculosis with significant vertebral body loss had undergone single-stage posterior debridement, interbody fusion using a structural autograft combined with a titanium mesh cage, and posterior instrumentation. The pre- and postoperative lumbosacral angle, visual analog scale score, erythrocyte sedimentation rate, C-reactive protein, and neurological status were assessed.

RESULTS

Surgery was successful for all patients, and no patient experienced tuberculosis recurrence during an average follow-up period of 27.3 months (range, 12-60 months). After surgery, the erythrocyte sedimentation rate and C-reactive protein for all patients had returned to normal within 3 months. At the final follow-up examination, the neurological status had improved in all patients who had had neurological deficits preoperatively. The mean preoperative lumbosacral angle was 12.6° (range, 6.7°-17.9°), and had increased to 27.7° (range, 24.3°-34.6°) after surgery. The average lumbosacral angle was 26.4° (range, 22.1°-32.3°), with an average loss of 1.4° (range, 0.6°-2.3°) at the final follow-up visit.

CONCLUSIONS

The combination of single-stage posterior debridement, interbody fusion using structural autografts with a titanium mesh cage, and posterior instrumentation is an effective and safe option for the treatment of lumbosacral tuberculosis with significant vertebral body loss.

Treatment of single-segment lumbar tuberculosis with minimally invasive posterior internal fixation combined with anterior small incision debridement

To review the clinical efficacy of minimally invasive pedicle fixation combined with anterior small incision focus debridement for single-segment lumbar spine tuberculosis, a total of 31 patients with single-segment marginal lumbar tuberculosis were enrolled in the study. All the patients received quadruple anti-tuberculosis chemotherapy for 2 weeks before surgery and treatment with minimally invasive posterior internal fixation, anterior small incision focus debridement, and bone graft fusion. Those patients with preoperative kyphosis deformity were initially treated with appropriate posterior distraction correction. Except for 1 patient who healed 2 weeks after medical dressing change, the remaining 30 patients healed as expected. All the patients had no screwrelated surgical complications, neurological dysfunction, vascular injury, and other complications. The average visual analog scale scores at 3 months postoperatively were significantly decreased to 1.4 ± 1.5 ( P < 0.05). In conclusion, under the premise of treatment using appropriate, effective anti-tuberculosis agents, this surgical procedure for managing patients with lumbar vertebral tuberculosis achieved satisfactory results, effectively reducing the exposure range and fusion segments in simple anterior focus debridement and internal fixation. Using minimally invasive posterior pedicle screw fixation can effectively increase spine stability, reduce fusion segment, and decrease anterior surgical trauma and complications.

Could Nonstructural Interbody Fusion Be an Alternative Surgical Technique for Treatment of Single Segment Thoracic and Lumbar Spinal Tuberculosis via a Posterior- Only Approach?

OBJECTIVE

To compare and evaluate the efficacy and safety of nonstructural versus structural interbody fusion, using a combination of autograft and allograft bone for treatment of single segment thoracic and lumbar spinal tuberculosis (TB) via a posterior-only approach.

METHODS

We retrospectively analyzed 37 patients who were surgically treated in our department for thoracic and lumbar spinal TB between March 2015 and March 2018 and met our inclusion criteria. Eighteen of these 37 patients underwent nonstructural interbody fusion (group A), whereas the other 19 underwent structural interbody fusion with the aid of titanium mesh cages (group B). We compared and analyzed visual analog scale scores, erythrocyte sedimentation rate, blood loss, operation time, bone fusion rates, and correction angles.

RESULTS

The average duration of follow-up was 20.33 ± 4.73 months (range, 12-26 months) in group A and 19.63 ± 4.63 months (range, 12-26 months), in group B. All patients showed significant improvement in neurologic function by 1 or 2 grades. Bone fusion was achieved in all patients, with no statistically significant difference between the 2 groups (P > 0.05). However, there were significant between-group differences in operation time (mean, 196.28 ± 43.49 minutes [range, 128-300 minutes] in group A vs. 223.26 ± 46.34 minutes [range, 150-300 minutes] in group B; P < 0.05) and estimated blood loss (mean, 474.44 ± 224.37 mL [range, 200-900 mL] in group A vs. 585.79 ± 378.82 mL [range, 200-1500] in group B; P < 0.05).

CONCLUSION

The 2 surgical techniques may well have achieved similar results in terms of decreasing bone fusion time, improving neurologic function, and correcting kyphotic angles. However, the nonstructural interbody fusion technique exhibited less blood loss and faster operation time, and thus could serve as an alternative surgical technique for treatment of single-segment thoracic and lumbar spinal TB.

Initial stability of one-stage anterior debridement and cage implantation combined with anterior-lateral fixation by a dual screw-rod construct in the treatment of lumbosacral tuberculosis: a cadaveric biomechanical study

Background

Although various surgical methods are used to treat lumbosacral tuberculosis, no unified surgical approach exists. Thus, exploring an optimal operation method has substantial clinical importance. Evaluate the initial stability of a new surgical method, a one-stage anterior debridement and cage implantation combined with anterior-lateral fixation by a dual screw-rod construct, in the treatment of lumbosacral tuberculosis and provide biomechanical support for its further promotion in clinical applications.

Methods

Fifteen fresh human lumbosacral spine specimens without fractures, deformities or osteoporosis were randomly divided into intact (I), anterior fixation (AF) and posterior fixation (PF) groups. All AF and PF group specimens had subtotal resections of the L5 vertebra and adjacent discs, while the I group specimens were kept intact. Then, titanium cages were implanted in the surgical site and a dual screw-rod construct was fixed anterior-laterally in the AF group, while the PF group specimens were fixed posteriorly with only the dual screw-rod construct. Mechanical tests were conducted for initial stability evaluations.

Results

The load at the maximum displacement (5 mm) or rotation angle (5 °) was less for the I group specimens than for the AF and PF group specimens in all directions (P < 0.05). The load at the maximum displacement (5 mm) was greater for the AF group specimens than for the PF group specimens in flexion, lateral bending and axial compression (P < 0.05) and lower than in the PF group specimens in extension (P < 0.05). In torsion, there was no difference between the loads in the AF and PF groups at the maximum rotation angle (5 °) (P > 0.05).

Conclusions: The proposed surgical approach can provide better immediate stability than anterior debridement with posterior dual screw-rod fixation in the treatment of lumbosacral tuberculosis in flexion, lateral bending and axial compression.