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

Reconstruction of complicated spinal tuberculosis with long-segment fibula transplantation: a case report

BACKGROUND

Treating complex cases of spinal tuberculosis (STB) that involve multiple vertebral bodies and cause destruction of the spinal structure, kyphotic deformity, and acute nerve injury can be challenging. This report describes the course of treatment and 5-year follow-up of a complex case of multisegmental STB.

CASE PRESENTATION

This report describes a case of tuberculosis affecting the vertebrae extending from thoracic 12 to lumbar 5 in a 60-year-old woman who suffered sudden paralysis in both lower extremities. The patient underwent emergency posterior paraspinal abscess clearance, laminectomy with spinal decompression. Partial correction of the kyphotic deformity via long-segment fixation from the T9 vertebral body to the ilium in a one-stage posterior procedure. The patient's neurological status was diagnosed as grade E on the American Spinal Injury Association (ASIA) scale after the one-stage operation. Following standardized 4-combination anti-tuberculosis drug therapy for three months in postoperative patients, the patient underwent two-stage transabdominal anterior abscess removal, partial debridement of the lesion and bilateral fibula graft support. One year after the two-stage operation, the patient's visual analog scale (VAS) score of back pain was 1 point, and the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels returned to normal. Five years after the second-stage operation, the Oswestry disability index (ODI) of patient quality of life was 14 points. There was a 4-degree change in the Cobb angle over five years. During the five-year follow-up period, the grafted fibula did not experience any subsidence.

CONCLUSION

For patients with spinal tuberculosis and acute paralysis, it is essential to relieve spinal cord compression as soon as possible to recover spinal cord function. For lesions that cannot be debrided entirely, although limited debridement combined with anti-tuberculosis drug therapy has the risk of sinus formation and tuberculosis recurrence, it is much safer than the risk of thorough debridement surgery. In this case, an unconventional long-segment fibula graft, pelvis-vertebral support, was an effective reconstruction method.

One-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment TB

To evaluate the clinical efficacy of 1-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment thoracic tuberculosis with paraplegia or incomplete paralysis. A total of 16 adult patients with short segment thoracic spinal thoracic tuberculosis who underwent surgery were enrolled in this retrospective study. All patients received anterior focus debridement, interbody bone graft and anterior instrumentation and fusion. All patients were followed up for 24 to 48 months. Clinical manifestations, laboratory examinations, neurological symptoms, bone fusion and imaging results were analyzed. All patients successfully underwent operations. The symptoms of chest and back pain were alleviated and even disappeared during postoperative 1 to 6 months. There was no recurrence. All patients got bony spinal fusion within postoperative 4 to 8 months assessed by spinal X-ray film. The levels of erythrocyte sedimentation rate and C-reactive protein were significantly decreased from 72.6 ± 27.5 mm/h and 75.7 ± 25.9 mg/L to 15.9 ± 4.6mm/h and 4.7 ± 2.0mg/L at the final follow-up, respectively (P < .05). The thoracic kyphosis angle was also notably decreased from 15.0 ± 3.4° to 9.1 ± 1.9° after operation(P < .05). During the follow-up, the symptom of paraplegia or incomplete paralysis was significantly improved. Neurologic status in all patients was also improved to some extent. The combination of 1-stage anterior focus debridement, interbody bone graft and anterior instrumentation and fusion is an effective and feasible treatment method for short segmental thoracic tuberculosis with paraplegia or incomplete paralysis.

Global Spinal Realignment After Osteotomized Debridement in Active Lumbar Spinal Tuberculosis: Correlation with Patient-Reported Outcomes

OBJECTIVE

Osteotomized debridement (OD) has been proven to be highly effective in treating active thoracolumbar tuberculosis (TB); however, no research has investigated how OD affects spinal alignment. The goal of this study was to explore the global alignment compensatory mechanism after lumbar OD, as well as the correlation between spinopelvic parameters and patient-reported outcomes (PROs).

METHODS

Sixty-two patients with active lumbar spinal TB who underwent OD surgery were included. Spinopelvic parameters (C2-7 Cobb angle [C2-7 CA], sagittal vertical axis [SVA], proximal thoracic kyphosis (PTK), thoracic kyphosis [TK], lumbar lordosis [LL], sacral slope [SS], pelvic tilt [PT], pelvic incidence [PI], spinosacral angle [SSA], and pelvic incidence minus lumbar lordosis [PI-LL]) and PROs (Oswestry Disability Index [ODI] and Visual Analog Scale [VAS]) were reviewed. The correlation between spinopelvic realignment and improved PROs was evaluated.

RESULTS

Compared with preoperative measurements, C2-7 CA, PTK, TK, LL, SS, and SSA significantly increased after OD, while SVA, PT, and PI-LL significantly decreased. ODI and VAS significantly improved postoperatively. The improvement of VAS was observed to be correlated with variations of C2-7 CA, SVA, LL, and PI-LL. The improvement of ODI were found to be correlated with variations of SVA, LL, and PI-LL. The multiple stepwise regression analysis revealed LL was an independent predictor for ODI and VAS.

CONCLUSIONS

The whole spine and pelvis are involved in realignment after lumbar spinal OD, which is closely related to PROs. More attention should be drawn to restoring an appropriate LL in lumbar TB surgery.

Efficacy of anterior debridement and bone grafting with fusion using internal fixation combined with anti-tuberculosis chemotherapy in the treatment of subaxial cervical tuberculosis

Background

To evaluate the efficacy of anterior debridement and bone grafting with fusion using internal fixation (BFIF) combined with anti-tuberculosis chemotherapy in the treatment of subaxial cervical spine tuberculosis (SCS-TB).

Methods

Clinical and radiographic data of patients with SCS-TB treated by anterior debridement and BFIF at our hospital from January 2010 to December 2017 were analyzed retrospectively. The SCS sagittal parameters at the preoperative, postoperative, and final follow-up were documented and compared, including the Occiput-C2 angle, C2–C7 Cobb angle, local Cobb angle, spinal canal angle (SCA), C2–C7 sagittal vertical axis (C2–C7 SVA), the center of gravity of the head-C7 sagittal vertical axis (CGH-C7 SVA), T1 slope (T1S), neck tilt (NT), and thoracic inlet angle (TIA). The ASIA grade, NDI index, JOA score, and VAS score were utilized to assess the postoperative function recovery, and the complications were recorded.

Results

A total of 23 patients were included in the study with a mean age of 46.74 ± 15.43 years, including 8 males and 15 females. All patients with SCS-TB were treated with anterior debridement and BFIF, with a mean postoperative follow-up time of 37.17 ± 12.26 months. The poisoning symptoms of TB were relieved in all patients, and ESR (42.09 ± 9.53 vs 8.04 ± 5.41, P < 0.05) and CRP (30.37 ± 16.02 vs 7.4 ± 2.68, P < 0.05) were decreased at the 3 postoperative months in the comparison of the preoperative. The C0–C2 Cobb angle, C2–C7 Cobb angle, local Cobb angle, SCA, TIS, C2–C7 SVA, and CGH-C7 SVA were corrected remarkably after surgery (P < 0.05). Further, there was a significant improvement in the JOA, VAS, and NDI with the comparison of the preoperative (P < 0.05).

Conclusions

Anterior debridement and BFIF combined with anti-TB chemotherapy was a practical tool for the treatment of SCS-TB with the help of SCS sagittal parameters, which can remove the lesion completely, decompress the spinal cord compression, and correct the kyphotic deformity to restore the spine sagittal balance.

Analysis of the Therapeutic Effects of Staged Posterior-Anterior Combined Surgery for Cervicothoracic Segmental Tuberculosis with Kyphosis in Pediatric Patients

Objective

The present study aimed to investigate the surgical efficacy of staged posterior–anterior combined surgery for the treatment of cervicothoracic segmental tuberculosis (TB) with kyphosis in pediatric patients.

Methods

The clinical data of 15 pediatric patients admitted to our hospital from January 2010 to December 2017 who underwent staged posterior–anterior combined surgery for cervicothoracic segmental TB with kyphosis were collected. A posterior median incision was made for patients after general anesthesia. Autologous bone particles or allogeneic bone particles were taken, trimmed, and placed in the articular eminence of the diseased vertebral body. Fifteen pediatric patients underwent second-stage lesion removal using the anterior approach. The left sternocleidomastoid muscle was selected as the medial oblique incision approach. The abscess and caseous necrotic material were removed and sent for pathological examination. The sagittal and coronal parameters (including the local Cobb angle, the sagittal vertical axis [SVA], and the coronal balance distance [CBD]) were measured at three time points: preoperatively, postoperatively, and at the final follow-up. The American Spinal Injury Association’s spinal-cord injury classification, the Japanese Orthopaedic Association’s (JOA) cervical spine function score, the neck disability index (NDI), and the visual analogue score (VAS) for cervicothoracic segment pain were adopted for the assessment of functional improvement and quality of life.

Results

All 15 pediatric patients completed the surgery successfully, with an operation duration of 3.56 ± 0.68 h, an intraoperative hemorrhage of 289.7 ± 84.3 mL, an average fixation of 7.3 ± 1.8 segments, and a follow-up duration of 28.1 ± 9.7 months. The preoperative and postoperative sagittal local Cobb angle was 67.06 ± 17.54° vs 19.48 ± 2.32° (P < 0.01), the SVA was 35.19 ± 10.69 mm vs 7.67 ± 1.40 mm (P < 0.01), and CBD was 22.58 ± 7.59 mm vs 8.99 ± 1.25 mm (P < 0.01). The levels of the postoperative erythrocyte sedimentation rate and C-reactive protein were significantly lower in all patients. The preoperative and postoperative JOA scores were 8.93 ± 3.51 and 14.67 ± 1.34, respectively, the preoperative and postoperative VAS was 7.40 ± 1.35 and 2.67 ± 0.62, respectively, and the preoperative and postoperative NDI was 32.67 ± 4.83 and 13.73 ± 2.08, respectively. There were statistically significant differences in the above indicators before and after surgery (P < 0.05).

Conclusion

In the surgical treatment of cervicothoracic TB with kyphosis in pediatric patients, staged posterior–anterior combined surgery significantly corrects deformity, achieves the safe and effective neurological decompression of the spinal cord, and obtains good neurological recovery and bone-graft fusion according to the extent of the involved segments of kyphosis, the characteristics of the lesion, and the degree of neurospinal injury.

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.

One-stage posterior debridement and single-segment interbody fusion for treating mono-segmental lumbar and lumbosacral spinal tuberculosis in adults following minimum 5-year follow-up

Background

To evaluate the mid-long-term outcomes of surgical management of mono-segmental lumbar and lumbosacral spinal tuberculosis (TB) in adults by one-stage posterior debridement, single-segment fixation, and titanium mesh cage interbody fusion.

Methods

A total of 62 patients with mono-segmental lumbar or lumbosacral spinal tuberculosis were enrolled. One-stage posterior debridement, single-segment fixation, and titanium mesh cage interbody fusion was performed. Clinical and radiographic outcomes were compared and analyzed.

Results

All patients were followed-up for an average of 75.0 ± 11.5 months and completely cured at the final follow-up. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) returned to normal within three months postoperatively. Postoperative Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) and Oswestry Disability index (ODI) were significantly improved compared with preoperative values. Bony fusion occurred after an average of 9.8 ± 2.6 months. The lordosis angle and lumbosacral angle were increased from preoperative 20.4 ± 2.9° and 14.7 ± 3.4° to postoperative 32.8 ± 3.6° and 22.4 ± 5.5°, with angle loss of 1.0 ± 0.7° and 0.8 ± 0.7° at the final follow-up, respectively. No significant differences between preoperative and postoperative adjacent segment disc height (DH) were found.

Conclusions

One-stage posterior debridement, single-segment fixation, and titanium mesh cage interbody fusion represent effective and feasible treatment option for mono-segmental lumbar and lumbosacral spinal tuberculosis in adults. This approach may preserve lumbar normal motor units and decrease adjacent segment degeneration (ASD) with the advantages of minimal invasiveness and rapid postoperative rehabilitation.

Analysis of the Curative Effect of the Anterior Approach to the Lower Cervical Spine for Cervicothoracic Spinal Tuberculosis

BACKGROUND

The purpose of this study was to explore the clinical effect of the anterior approach to the lower cervical spine for cervicothoracic spinal tuberculosis (CTSTB).

METHODS

A total of 8 patients (6 males and 2 females) with CTSTB diagnosed by imaging examination and γ-interferon test, underwent the first stage lesion removal, bone grafting and internal fixation through the anterior approach to the lower cervical spine, were studied. Then, the clinical efficacy was evaluated using statistical analysis based on the materials about the Cobb angle of kyphosis, visual analog scale (VAS), Frankel grade, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).

RESULTS

All patients' age ranged from 28 to 64 years (mean 46.2 ± 16.3). The mean operation time was 145 minutes (range 90-180 mins), intraoperative blood loss was 425 mL (range 200-1000 mL), and the average bone fusion time was 7.4 months. Postoperative neurological function of Frankel grading was significantly improved compared with that of preoperative. At final follow-up, the kyphosis angle was significantly decreased to 10 ± 2.1°, the mean VAS score was 1.6 ± 0.9 showing significant improvement, ESR and CRP returned to normal. The incidence of complications within 3 months after surgery was 25%, and the incidence of complications directly related to surgery was 12.5% (cerebrospinal fluid leakage).

CONCLUSION

On the basis of familiarity with the anatomical structure and combining with the experience of the surgeon, the anterior approach to the lower cervical spine can be an effective treatment method for CTSTB.