The efficacy of single posterior debridement, bone grafting and instrumentation for the treatment of thoracic spinal tuberculosis

[Current status of surgical treatment for angular kyphosis in spinal tuberculosis]

Objective

To review current status of surgical treatment for angular kyphosis in spinal tuberculosis and provide reference for clinical treatment.

Methods

The literature on the surgical treatment for angular kyphosis of spinal tuberculosis in recent years was extensively reviewed and summarized from the aspects of surgical indications, surgical contraindications, surgical approach, selection of osteotomy, and perioperative management.

Results

Angular kyphosis of spine is a common complication in patients with spinal tuberculosis. If kyphosis progresses gradually, it is easy to cause neurological damage, deterioration, and delayed paralysis, which requires surgical intervention. At present, surgical approaches for angular kyphosis of the spine include anterior approach, posterior approach, and combined anterior and posterior approaches. Anterior approach can be performed for patients with severe spinal cord compression and small kyphotic Cobb angle. Posterior approach can be used for patients with large kyphotic Cobb angle but not serious neurological impairment. A combined anterior and posterior approaches is an option for spinal canal decompression and orthosis. Osteotomy for kyphotic deformity include Smith-Peterson osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection(VCR), vertebral column decancellation (VCD), posterior vertebral column resection (PVCR), deformed complex vertebral osteotomy (DCVO), and Y-shaped osteotomy. SPO and PSO are osteotomy methods with relatively low surgical difficulty and low surgical risks, and can provide 15°-30° angular kyphosis correction effect. VCR or PVCR is a representative method of osteotomy and correction. The kyphosis correction can reach 50° and is suitable for patients with severe angular kyphosis. VCD, DCVO, and Y-shaped osteotomy are emerging surgical techniques in recent years. Compared with VCR, the surgical risks are lower and the treatment effects also improve to varying degrees. Postoperative recovery is also a very important part of the perioperative period and should be taken seriously.

Conclusion

There is no consensus on the choice of surgical treatment for angular kyphosis in spinal tuberculosis. Osteotomy surgery are invasive, which is a problem that colleagues have always been concerned about. It is best to choose a surgical method with less trauma while ensuring the effectiveness.

Development and validation of a diagnostic model to differentiate spinal tuberculosis from pyogenic spondylitis by combining multiple machine learning algorithms

This study focused on the development and validation of a diagnostic model to differentiate between spinal tuberculosis (STB) and pyogenic spondylitis (PS). We analyzed a total of 387 confirmed cases, out of which 241 were diagnosed with STB and 146 were diagnosed with PS. These cases were randomly divided into a training group (n = 271) and a validation group (n = 116). Within the training group, four machine learning (ML) algorithms (least absolute shrinkage and selection operator [LASSO], logistic regression analysis, random forest, and support vector machine recursive feature elimination [SVM-RFE]) were employed to identify distinctive variables. These specific variables were then utilized to construct a diagnostic model. The model's performance was subsequently assessed using the receiver operating characteristic (ROC) curves and the calibration curves. Finally, internal validation of the model was undertaken in the validation group. Our findings indicate that PS patients had an average platelet-to-neutrophil ratio (PNR) of 277.86, which was significantly higher than the STB patients' average of 69.88. The average age of PS patients was 54.71 years, older than the 48 years recorded for STB patients. Notably, the neutrophil-to-lymphocyte ratio (NLR) was higher in PS patients at 6.15, compared to the 3.46 NLR in STB patients. Additionally, the platelet volume distribution width (PDW) in PS patients was 0.2, compared to 0.15 in STB patients. Conversely, the mean platelet volume (MPV) was lower in PS patients at an average of 4.41, whereas STB patients averaged 8.31. Hemoglobin (HGB) levels were lower in PS patients at an average of 113.31 compared to STB patients' average of 121.64. Furthermore, the average red blood cell (RBC) count was 4.26 in PS patients, which was less than the 4.58 average observed in STB patients. After evaluation, seven key factors were identified using the four ML algorithms, forming the basis of our diagnostic model. The training and validation groups yielded area under the curve (AUC) values of 0.841 and 0.83, respectively. The calibration curves demonstrated a high alignment between the nomogram-predicted values and the actual measurements. The decision curve indicated optimal model performance with a threshold set between 2% and 88%. In conclusion, our model offers healthcare practitioners a reliable tool to efficiently and precisely differentiate between STB and PS, thereby facilitating swift and accurate diagnoses.

Comparison of Autografts and Biodegradable 3D-Printed Composite Scaffolds with Osteoconductive Properties for Tissue Regeneration in Bone Tuberculosis

Tuberculosis remains one of the major health problems worldwide. Besides the lungs, tuberculosis affects other organs, including bones and joints. In the case of bone tuberculosis, current treatment protocols include necrectomy in combination with conventional anti-tuberculosis therapy, followed by reconstruction of the resulting bone defects. In this study, we compared autografting and implantation with a biodegradable composite scaffold for bone-defect regeneration in a tuberculosis rabbit model. Porous three-dimensional composite materials were prepared by 3D printing and consisted of poly(ε-caprolactone) filled with nanocrystalline cellulose modified with poly(glutamic acid). In addition, rabbit mesenchymal stem cells were adhered to the surface of the composite scaffolds. The developed tuberculosis model was verified by immunological subcutaneous test, real-time polymerase chain reaction, biochemical markers and histomorphological study. Infected animals were randomly divided into three groups, representing the infection control and two experimental groups subjected to necrectomy, anti-tuberculosis treatment, and plastic surgery using autografts or 3D-composite scaffolds. The lifetime observation of the experimental animals and analysis of various biochemical markers at different time periods allowed the comparison of the state of the animals between the groups. Micro-computed tomography and histomorphological analysis enabled the evaluation of osteogenesis, inflammation and cellular changes between the groups, respectively.

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.

Comparing Bone Graft Techniques for Interbody Fusion through a Posterior Approach for Treating Mid-Thoracic Spinal Tuberculosis: A Retrospective Analysis

OBJECTIVE

Mid-thoracic spinal tuberculosis is prone to kyphotic deformities and neurologic impairment. Posterior approach can effectively restore the spinal stability by reconstructing the anterior and middle spinal columns. Titanium mesh cages (TMC), allogeneic bone (ALB), and autogenous bone (AUB) are three main bone graft struts. We aimed to compare the therapeutic efficacy of three bone graft struts, for anterior and middle column reconstruction through a posterior approach in cases of mid-thoracic spinal tuberculosis.

METHODS

Hundred and thirty seven patients with thoracic spinal tuberculosis who had undergone a posterior approach from June 2010 to December 2018 were enrolled. Of them, 46 patients were treated using a titanium mesh cage (TMC group), 44 with allogenic bone grafts (ALB group), and 47 using autogenous bone grafts (AUB group). The following were analyzed to evaluate clinical efficacy: visual analogue scale (VAS) values, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, kyphotic Cobb's angle, operation duration, intraoperative blood loss, improvement in American Spinal Injury Association (ASIA) grade and in the mental component summary (MCS) and physical component summary (PCS) of Short Form-36 (SF-36), duration of bone graft fusion. The data of the three groups were compared by way of variance analysis, followed by the LSD⁃t test to compare each group. A repeated measures ANOVA was used to analyze the dates of pre-, postoperative and final follow-up.

RESULTS

The follow-up duration was at least 3 years. All patients achieved a complete cure for spinal TB. Neurological performance and quality of life were remarkably improved at the final follow-up. The intraoperative blood loss, operation time and VAS values 1 day postoperatively for TMC group and ALB group were significantly lower than those in AUB group (P < 0.05). The duration of bone graft fusion in ALB group (18.1 ± 3.7 months) was longer than that in TMC group and AUB group (9.5 ± 2.8 and 9.2 ± 1.9 months) (P < 0.05). No significant intergroup differences were observed in terms of age or preoperative, 3-months postoperative, and final follow-up indices of ESR and CRP among the three groups (P > 0.05). At the final follow-up, the correction loss was mild (2.1 ± 0.9, 2.2 ± 1.0, 2.1 ± 0.8) and Cobb's angles of the three groups were 20.1 ± 2.9, 20.5 ± 3.2, 20.9 ± 3.4, respectively, which were remarkably rectified in comparison with the preoperative measurements (P < 0.05).

CONCLUSIONS

In terms of postoperative recovery and successful fusion rate of bone graft, it seems that posterior instrumentation, debridement, and interbody fusion with titanium mesh cages are more effective and appropriate surgical methods for mid-thoracic spinal tuberculosis.

Comparison of anterior or posterior approach in surgical treatment of thoracic and lumbar tuberculosis: a retrospective case-control study

BACKGROUND

With the widespread use of the posterior surgery, more and more surgeons chose posterior surgery to treat thoracic and lumbar tuberculosis. But others still believed that the anterior surgery is more conducive to eradicating the lesions, and easier to place larger bone pieces for bone graft fusion. We compared the clinical and radiological outcomes of anterior and posterior surgical approaches and presented our views.

METHODS

This study included 52 thoracic and lumbar tuberculosis patients at Sun Yat-sen Memorial Hospital from January 2010 to June 2018. All cases underwent radical debridement, nerve decompression, intervertebral bone graft fusion and internal fixation. Cases were divided into anterior group (24 cases) and posterior group (28 cases). Statistical analysis was used to compare the clinical effectiveness, radiological outcomes, complications and other related information.

RESULTS

Patients in the anterior group and the posterior group were followed up for an average of 27.4 and 22.3 months, respectively. There were no statistically significant differences between groups in the preoperative, postoperative and last follow-up VAS score, ASIA grade and Cobb angle of local kyphosis. Moreover, there were no statistically significant differences in the improvement of neurological function, loss of kyphotic correction, total incidence of complications, operative time, intraoperative blood loss and hospital stay between the two groups (P > 0.05). But there was greater correction of kyphosis, earlier bone fusion, lower incidence of poor wound healing, less interference with the normal spine and less internal fixation consumables and medical cost in the anterior group (P < 0.05).

CONCLUSIONS

Both anterior and posterior approaches are feasible for thoracic and lumbar tuberculosis. While for thoracic and lumbar tuberculosis patients with a single lesion limited in the anterior and middle columns of the spine without severe kyphosis, the anterior approach surgery may have greater advantages in kyphosis correction, bone fusion, wound healing, protection of the normal spine, and medical consumables and cost.

Comparison of Clinical Data Between Patients With Complications and Without Complications After Spinal Tuberculosis Surgery: A Propensity Score Matching Analysis

Purpose

This study used a propensity score matching (PSM) analysis to explore the risk factors of post-operative complications and compared the differences in clinical data between them following spinal tuberculosis surgery.

Methods

The clinical data of patients with spinal tuberculosis were collected in our hospital from June 2012 to June 2021, including general information, laboratory results, surgical information, and hospitalization costs. The data were divided into two groups: complication and without complication groups. The baseline data of the two groups were obtained using the PSM analysis. Univariate and multivariate logistic analyses were used to analyze the differences between the two groups.

Results

A total of 292 patients were included in the PSM analysis: 146 patients with complications and 146 patients without complications. The operation time, incision length, hospital stay, and albumin quantity in the complications group were 162 ± 74.1, 11.2 ± 4.76, 14.7 ± 9.34, and 1.71 ± 2.82, respectively, and those in the without complication group were 138 ± 60.5, 10.2 ± 3.56, 11.7 ± 7.44, and 0.740 ± 2.44, respectively. The laboratory costs, examination costs, guardianship costs, oxygen costs, and total costs in the complications group were higher than those in the without complication group. A significant difference was observed in the albumin quantity by logistic regression analysis (P < 0.05).

Conclusion

Several costs in the complication group were higher than in the without complication group. The albumin quantity may be an independent factor to predict post-operative complications of spinal tuberculosis by logistic regression analysis.