Clinical Effectiveness of the Posterior Affected-Vertebrae Fixation Method in Posterior-Anterior Surgery to Treat Thoracic Spinal Tuberculosis

Structural Versus Nonstructural Bone Grafting Via the Posterior Approach in the Treatment of Thoracic and Lumbar Tuberculosis: A Systematic Review and Meta-Analysis

BACKGROUND

Bone grafting is necessary in spinal tuberculosis surgery. Structural bone grafting is considered the gold standard treatment for spinal tuberculosis bone defects; however, nonstructural bone grafting via the posterior approach has recently gained attention. In this meta-analysis, we evaluated the clinical efficacy of structural versus nonstructural bone grafting via the posterior approach in the treatment of thoracic and lumbar tuberculosis.

METHODS

Studies comparing the clinical efficacy of structural and nonstructural bone grafting via the posterior approach in spinal tuberculosis surgery were identified from 8 databases from inception to August 2022. Study selection, data extraction, and evaluation of the risk of bias were performed, and meta-analysis was conducted.

RESULTS

Ten studies including 528 patients with spinal tuberculosis were enrolled. Meta-analysis revealed no between-group differences in fusion rate (P = 0.29), complications (P = 0.21), postoperative Cobb angle (P = 0.7), visual analog scale score (P = 0.66), erythrocyte sedimentation rate (P = 0.74), or C-reactive protein level (P = 0.14) at the final follow-up. Nonstructural bone grafting was associated with less intraoperative blood loss (P < 0.00001), shorter operation time (P < 0.0001), shorter fusion time (P < 0.01), and shorter hospital stay (P < 0.00001), while structural bone grafting was associated with lower Cobb angle loss (P = 0.002).

CONCLUSIONS

Both techniques can achieve a satisfactory bony fusion rate for spinal tuberculosis. Nonstructural bone grafting has the advantages of less operative trauma, shorter fusion time, and shorter hospital stay, making it an attractive option for short-segment spinal tuberculosis. Nevertheless, structural bone grafting is superior for maintaining corrected kyphotic deformities.

Pulmonary embolism following the third thoracic tuberculosis surgery: A case report and literature review

Background

The study aimed to analyze the clinical effects of pulmonary embolism succeeding a third surgery conducted for multiple recurrences in thoracic tuberculosis (TB).

Case report

A 74‐year‐old female patient developed thoracic tuberculosis and was subsequently treated in our hospital in March 2019, October 2020, and February 2021. The third surgical intervention included anterolateral thoracic lesion resection, internal fixation, posterior spinal tuberculous sinus resection, and debridement with suture. The operative time was 172 min resulting in a substantial intraoperative blood loss (2321 ml). Postoperative re‐examination of chest CTPA indicated a strip filling defect and pulmonary embolism in the external branch of the right middle lobe of the lung. After completing the active treatment, the D‐dimer quantification, WBC, CRP, and ESR values were 1261 ng/ml, 7.71 × 10⁹/L, 74.66 mg/L, and 63 mm, respectively. Chest CTPA re‐examination after the treatment showed no signs of pulmonary embolism.

Conclusion

Patients with a long‐term history of multiple operations, high BMI, cerebral infarction, diabetes, and older age group were more likely to develop pulmonary embolism after spinal tuberculosis surgery. Thus, the possibility of postoperative pulmonary embolism should be thoroughly analyzed before any subsequent surgical treatment in patients with recurrent spinal tuberculosis.

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.

Mid- and Long-Term Efficacy of Surgical Treatment of L1-2 Vertebral Tuberculosis with Subdiaphragmatic Extraperitoneal Approach

Background

The L1–2 vertebral segment is the most common site of spinal tuberculosis. Traditional thoracoabdominal surgery in this segment risks trauma and complications. This study analyzed the surgical efficacy of the subdiaphragmatic extraperitoneal approach in the treatment of L1–2 spinal tuberculosis.

Material/Methods

Retrospective analysis of 67 patients with L1–2 vertebral tuberculosis who underwent posterior internal fixation was performed: 35 patients underwent the subdiaphragmatic extraperitoneal approach (group A) and 32 underwent the thoracoabdominal approach (group B). Operation time, intraoperative blood loss, postoperative hospital stay, postoperative nerve function recovery, deformity correction, bone graft fusion, lesion healing, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complications were observed.

Results

In group A and group B, intraoperative blood loss was 712.00±64.66 mL and 1104.38±131.34 mL; average operation time was 3.16±0.67 h and 5.16±1.07 h; and postoperative hospital stay was 9.60±2.64 days and 13.69±3.87 days, respectively. At 6 months and 5 years after surgery, neurological function, visual analog scale score, and Cobb angle of all patients were significantly improved compared with those before surgery; ESR and CRP decreased to normal levels; lesions completely cured; and all patients had good bone graft fusion. Pulmonary complications occurred in 2 patients in group A and in 14 patients in group B.

Conclusions

The efficacy of subdiaphragmatic extraperitoneal approach was similar to that of the thoracoabdominal approach for L1–2 spinal tuberculosis, but the former has the advantages of less surgical trauma, shorter operation time, less intraoperative bleeding, and fewer postoperative pulmonary complications.

Selection of the fusion and fixation range in the intervertebral surgery to correct thoracolumbar and lumbar tuberculosis: a retrospective clinical study

Background

To compare the diseased verses the non-diseased intervertebral surgery used in the treatment of thoracolumbar and lumbar spinal tuberculosis and to explore the best choice of fusion of fixation range.

Methods

Two hundred twenty-one patients with thoracolumbar and lumbar tuberculosis were categorized into two groups. One hundred eighteen patients underwent the diseased intervertebral surgery (lesion vertebral pedicle fixation, Group A) and 103 patients underwent the non-diseased intervertebral surgery (1 or 2 vertebral fixation above and below the affected vertebra, group B). Spinal tuberculosis diagnosis was confirmed in both groups of patients before lesion removal, bone graft fusion, and internal fixation. Clinical data and efficacy of the two surgical methods were then evaluated.

Results

The mean follow-up duration for both procedures was 65 months (50–68 months range). There were no significant differences in laboratory examinations, VAS scores, and the Cobb angle correction rate and the angle loss. However, significant differences existed in the operation time, blood loss, serosanguineous drainage volume, and blood transfusion requirement between the two groups. The diseased intervertebral surgery group performed significantly better than the non-diseased intervertebral surgery group in all of these areas. In both cases, the bone graft fused completely with the normal bone by the last follow-up, occuring at 50–86 months post surgery.

Conclusion

The diseased intervertebral surgery is a safe and feasible option for the treatment of thoracolumbar and lumbar tuberculosis. It effectively restores the physiological curvature of the spine and reduces the degeneration of adjacent vertebral bodies in the spinal column.

Nonstructural bone graft for single-segment lumbar tuberculosis: surgical indications, clinical efficacy, and preliminary experiences in 34 patients

OBJECTIVE

This study was performed to evaluate the surgical indications, clinical efficacy, and preliminary experiences of nonstructural bone grafts for lumbar tuberculosis (TB).

METHODS

Thirty-four patients with lumbar TB who were treated with nonstructural bone grafts were retrospectively assessed. The operative time, operative blood loss, hospital stay, bone graft fusion time, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, visual analog scale (VAS) score, Oswestry Disability Index (ODI), American Spinal Injury Association (ASIA) impairment grade, and Cobb angle were recorded and analyzed.

RESULTS

The mean operative time, operative blood loss, hospital stay, Cobb angle correction, and Cobb angle loss were 192.59 ± 42.16 minutes, 385.29 ± 251.82 mL, 14.91 ± 5.06 days, 9.02° ± 3.16°, and 5.54° ± 1.09°, respectively. During the mean follow-up of 27.53 ± 8.90 months, significant improvements were observed in the ESR, CRP concentration, VAS score, ODI, and ASIA grade. The mean bone graft fusion time was 5.15 ± 1.13 months. Three complications occurred, and all were cured after active treatment.

CONCLUSIONS

Nonstructural bone grafts may achieve satisfactory clinical efficacy for appropriately selected patients with lumbar TB.

Biomechanical Evaluation and the Assisted 3D Printed Model in the Patient-Specific Preoperative Planning for Thoracic Spinal Tuberculosis: A Finite Element Analysis

Posterior fixation is superior to anterior fixation in the correction of kyphosis and maintenance of spinal stability for the treatment of thoracic spinal tuberculosis. However, the process of selecting the appropriate spinal fixation method remains controversial, and preoperative biomechanical evaluation has not yet been investigated. In this study, we aimed to analyze the application of the assisted finite element analysis (FEA) and the three-dimensional (3D) printed model for the patient-specific preoperative planning of thoracic spinal tuberculosis. An adult patient with thoracic spinal tuberculosis was included. A finite element model of the T7−T11 thoracic spine segments was reconstructed to analyze the biomechanical effect of four different operative constructs. The von Mises stress values of the implants in the vertical axial load and flexion and extension conditions under a 400-N vertical axial pre-load and a 10-N⋅m moment were calculated and compared. A 3D printed model was used to describe and elucidate the patient’s condition and simulate the optimal surgical design. According to the biomechanical evaluation, the patient-specific preoperative surgical design was prepared for implementation. The anterior column, which was reconstructed with titanium alloy mesh and a bone graft with posterior fixation using seven pedicle screws (M+P) and performed at the T7–T11 level, decreased the von Mises stress placed on the right rod, T7 pedicle screw, and T11 pedicle. Moreover, the M+P evaded the left T9 screw without load bearing. The 3D printed model and preoperative surgical simulation enhanced the understanding of the patient’s condition and facilitated patient-specific preoperative planning. Good clinical results, including no complication of implants, negligible loss of the Cobb angle, and good bone fusion, were achieved using the M+P surgical design. In conclusion, M+P was recommended as the optimal method for preoperative planning since it enabled the preservation of the normal vertebra and prevented unnecessary internal fixation. Our study indicated that FEA and the assisted 3D printed model are tools that could be extremely useful and effective in the patient-specific preoperative planning for thoracic spinal tuberculosis, which can facilitate preoperative surgical simulation and biomechanical evaluation, as well as improve the understanding of the patient’s condition.

Is It Necessary to Perform the Second Surgery Stage of Anterior Debridement in the Treatment of Spinal Tuberculosis?

OBJECTIVE

In this retrospective comparative study, the efficacy and clinical outcomes of long posterior instrumentation, with or without laminectomy, were evaluated and the necessity of the second stage of anterior debridement in the treatment of spinal tuberculosis (TB) was discussed.

METHODS

This retrospective study included 41 patients who were diagnosed with spinal TB between January 2010 and June 2016. A total of 18 patients had received long posterior instrumentation, with or without laminectomy (group A), whereas the other 23 patients had posterior instrumentation plus anterior debridement and autogenous bone grafting (group B). The surgical information, clinical effectiveness, laboratory tests, and imaging results were compared between the 2 groups.

RESULTS

One patient in group B died. Sinus drainage and incomplete bone fusion were discovered 1 year postoperatively. TB symptoms were significantly improved after surgery compared with those before surgery (P < 0.05), and there was no significant difference in the treatment efficacy between the 2 groups at the final follow-ups (P > 0.05). Compared with those of group B, the surgical time, bed-rest time, and hospitalization time of group A were all significantly shorter (P < 0.05), whereas the times before abscesses disappeared, bone graft fusion, and erythrocyte sedimentation rate returning to normal were all significantly longer (P < 0.05).

CONCLUSIONS

Single-stage long posterior instrumentation, with or without laminectomy, is a safe, effective, and feasible method for the treatment of spinal TB. The second stage of anterior debridement surgery may not be necessary for every spinal TB treatment.