Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar interbody fusion (TLIF) and posterior instrumentation

Outcomes of Dorsolumbar and Lumbar Spinal Tuberculosis Treated by Minimally Invasive and Open Techniques: A Prospective Comparative Study

Purpose of Study

To compare the outcomes of minimally invasive and open techniques in the surgical management of dorsolumbar and lumbar spinal tuberculosis (STB).

Methods

Skeletally mature patients with active STB involving thoracolumbar and lumbar region confirmed by radiology (X-ray, MRI) and histopathological examination were included. Healed and mechanically stable STB, patients having severe hepatic and renal impairment, coexisting spinal conditions such as ankylosing spondylitis and rheumatoid arthritis, and patients unwilling to participate were excluded from the study. The patients were divided in to two groups, group A consisted of patients treated by MIS techniques and group B consisted of patients treated by open techniques. All the patients had a minimum follow-up of 24 months.

Results

A total of 42 patients were included in the study. MIS techniques were used in 18 patients and open techniques were used in 24 patients. On comparison between the two groups, blood loss (234 ml vs 742 ml), and immediate post-operative VAS score (5.26 vs 7.08) were significantly better in group A, whereas kyphotic correction (16° vs 33.25°) was significantly better in group B. Rest of the parameters such as duration of surgery, VAS score, ODI score and number of instrumented levels did not show significant difference between the two groups.

Conclusion

MIS stabilization when compared to open techniques is associated with significant improvement in immediate post-operative VAS scores. The MIS approaches at 2-year follow-up have functional results similar to open techniques. MIS is inferior to open techniques in kyphosis correction and may be associated with complications.

OLIF versus MI-TLIF for patients with degenerative lumbar disease: Is one procedure superior to the other? A systematic review and meta-analysis

PURPOSE

To compare the effectiveness and safety of oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative lumbar disease.

METHODS

We searched relevant studies in Embase, PubMed, Cochrane, and Web of Science databases comprehensively from inception to March 2022. The data were extracted from included studies, including operation indications, radiographic parameters, and clinical outcomes. Random or fixed-effects models were used in all meta-analyses according to the between-study heterogeneity.

RESULTS

In total, 30 studies, including 2,125 patients, were included in this meta-analysis. Our study found similar disk height, length of hospital stay, visual analog scale (VAS), and Oswestry disability index(ODI) between the two groups. However, the OLIF showed an advantage in restoring lumbar lordotic angle compared with MI-TLIF, with the pooled mean change of 17.73° and 2.61°, respectively. Additionally, the operative time and blood loss in the OLIF group appeared to be less compared with the MI-TLIF group. Regarding complications, the rates of the two groups were similar (OLIF 14.0% vs. MI-TLIF 10.0%), but the major complications that occurred in these two procedures differed significantly.

CONCLUSION

The results of disk height, length of hospital stay, VAS, and ODI between the OLIF and MI-TLIF groups were similar. And the OLIF was superior in restoring lumbar lordotic angle, operative time, and blood loss. However, the OLIF group's complication rate was higher, although not significantly, than that in the MI-TLIF group.

A comparison of three bone graft struts for interbody fusion using a posterior approach for lower lumbar spinal tuberculosis in adults: a midterm follow-up study

Background

This retrospective observational study was conducted to compare midterm outcomes of three bone graft struts for interbody fusion using a posterior approach in adults with lower lumbar spinal tuberculosis.

Methods

A total of 126 lower lumbar spinal tuberculosis patients were treated by one-stage posterior debridement, interbody fusion, and instrumentation. Forty-one patients (group A) were treated with autogenous bone graft for interbody fusion, 45 patients (group B) were treated with allogeneic bone grafting, and the remaining 40 (group C) patients were treated with titanium mesh cage. In addition, clinical and radiographic data were gathered and analyzed.

Results

At the final follow-up, all patients were completely cured. The operation period and intraoperative blood loss for groups B and C were significantly less than in group A (P = 0.000). Post-operation, neurological performance and quality of life were remarkably improved at the final follow-up. The preoperative lordosis angles of three groups were significantly improved, as evidenced by the values immediately after the operation or those at the final follow-up. The correction loss of the group C was lower than those of groups A and B (P = 0.000). All the patients obtained bone graft fusion, the fusion period of group B was longer than that of the other two groups (P = 0.000). No significant differences among the three groups in adjacent segment degeneration rates were found at the last visit (P = 0.922).

Conclusions

This midterm follow-up study established that one-stage posterior debridement, interbody fusion, and instrumentation, combined with medical therapy, can effectively treat lower lumbar spinal tuberculosis. In addition, the intervertebral titanium mesh cage bone graft can provide better outcomes with regard to maintaining lordosis and preventing collapse.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05539-8.

Surgical management of spontaneous thoracic and lumbar spondylodiscitis by fixation and debridement

Background:

Spondylodiscitis could be considered one of the most disturbing challenges that face neurosurgeons due to variety of management strategies. The lumbar region was highly affected then dorsal region with higher percentage for lesion in L4/5 (25%) followed by T11/12 and L5/S1 (15%). In our study, we discuss the efficacy of debridement and fixation in cases of spontaneous thoracic and lumbar spondylodiscitis.

Methods:

This retrospective study included 40 patients with spontaneous thoracic or lumbar spondylodiscitis indicated for surgical intervention in the period from March 2019 to February 2021. All patients were subjected to thorough history taking, neurological examination, and investigations. The patients were operated on through posterior approach by debridement and posterior transpedicular screws fixation and fusion.

Results:

Clinical assessment early postoperative revealed 75% of cases showed full motor power and 20% showed improvement in motor power, for sensory assessment, 85% showed improvement, the mean visual analog scale (VAS) score was of 3.65 ± 0.87. After 3 months postoperatively, 95% of cases were full motor power with sensory and autonomic (sphincteric) improvement. The mean VAS score was 2.5 ± 0.68. After 6 months postoperative, the clinical assessment revealed that 95% of cases were full motor power with sensory manifestation improvement, and 95% of them were continent. The mean VAS score was 1±0.85. Culture results showed that 65% of samples were negative culture, 15% had methicillin-resistant Staphylococcus aureus, and 10% had Escherichia coli with a single case of Pseudomonas and another one of fungal (Candida albicans). Postoperative 90% of cases showed improvement in erythrocyte sedimentation rate results and 95% of cases showed improvement in C-reactive protein results.

Conclusion:

Management of spontaneous thoracic and lumbar spondylodiscitis by surgical debridement and posterolateral open transpedicular fixation seems to be effective and safe method despite the presence of infection. We found that the clinical condition of our patients showed significant improvement with this addressed approach.

Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit

BACKGROUND

A combined anterior decompression and stabilization followed by posterior instrumented fusion promotes fusion of the affected segment of spine and prevents further progression of deformity. The objective of this study is to report on outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity who underwent single-stage anterior corpectomy and fusion and posterior decompression with instrumented fusion.

METHODS

A total of 49 patients (29 males, 20 females) with varying grades of neurological deficit due to tuberculosis of the spine (thoracic, thoracolumbar, and lumbar) were included in this prospective study. The diagnosis of tubercular infection was established after clinical, hematological, radiological, and histological specimens taken at surgery. All were treated with combined anterior and posterior decompression, debridement, and stabilization with direct autologous bone grafting or wrapped bone graft in mesh or expandable cages. Neurological status and visual analog scale (VAS) pain score were recorded at each visit. X-rays, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver function were evaluated at 3, 6, and 12 months after surgery and then once a year thereafter. Results were analyzed in terms of neurological recovery (Frankel grade), bony union time, and correction of kyphotic deformity.

RESULTS

The mean age was 37.8 years (range, 2-65 years). Mean preoperative VAS scores improved from 5.6 to 1.5. The average ESR and CRP returned to normal within 6 months in all patients. The mean time to fusion was 8.4 months for the whole group. The neurological deficit in 42 of 49 patients had excellent or good clinical outcome (P < .0001). A total of 10 of 17 patients improved from Frankel A and B to Frankel E (normal activity). Three patients each in the thoracic and thoracolumbar groups improved to Frankel D. Radiological measurements showed the mean kyphotic correction was 61%, 66%, and 67% in the thoracic, thoracolumbar, and lumbar/lumbosacral spine, respectively.

CONCLUSIONS

Combined single-stage anterior decompression and stabilization followed by posterior instrumented fusion is safe and effective in the treatment of tuberculous spondylitis with neurological deficit in the thoracic and lumbar spine. This procedure helps to correct and maintain the deformity, abscess clearance, spinal-cord decompression, and pain relief as well as return to normal motor function. Bony fusion prevents further progression of deformity.

LEVEL OF EVIDENCE

2.

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.

Revision Surgery for Postoperative Spondylodiscitis at Cage Level after Posterior Instrumented Fusion in the Lumbar Spine-Anterior Approach Is Not Absolutely Indicated

Spondylodiscitis at the cage level is rare but remains a challenge for spine surgeons. In this study, the safety and efficacy of revision surgery by a posterior approach to spondylodiscitis developed at the cage level were evaluated, and these data were compared to those of patients treated with revision surgeries using the traditional anterior plus posterior approach for their infections. Twenty-eight patients with postoperative spondylodiscitis underwent revision surgeries to salvage their infections, including 15 patients in the study group (posterior only) and 13 patients in the control group (combined anterior and posterior). Staphylococcus aureus was the most common pathogen in both groups. L4-L5 was the most common infection site in both groups. The operation time (229.5 vs. 449.5 min, p < 0.001) and blood loss (427.7 vs. 1106.9 mL, p < 0.001) were the only two data points that were statistically significantly different between the two groups. In conclusion, a single posterior approach with ipsilateral or contralateral transforaminal lumbar interbody debridement and fusion plus extending instrumentation was safe and effective for spondylodiscitis developed at the cage level. This strategy can decrease the operation time and blood loss.

Effects of Different Orientations of Cage Implantation on Lumbar Interbody Fusion

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF) via a fusion cage is widely carried out to treat degenerative lumbar spinal disease, and cage implantation plays a pivotal role in buttressing the vertebrae and promoting fusion. Clinically, the cage implantation is commonly placed in 2 different orientations: oblique and traverse. Therefore, this study aimed to explore the effects of different orientations of cage implantation on lumbar interbody fusion.

METHODS

From January 2016 to January 2018, a retrospective study of 98 patients with lumbar degenerative disease who were treated with lumbar interbody fusion with at least 2-year follow-up was performed. According to the different positions of cage implantation, the patients were divided into 2 groups: oblique group (OG) and traverse group (TG). The clinical and radiographic outcomes were compared preoperatively, postoperatively, and at last follow-up evaluation. Radiographic measurements included the height of intervertebral (HOI) disk, segment lordosis (SL), lumbar lordosis (LL), the distance between the posterior of cage and vertebrae postoperatively (D1), the distance at final follow-up (D2), and the distance of cage move (D3). Radiographic evaluation of fusion integrity was performed based on the Bridwell interbody fusion grading system at the final follow-up.

RESULTS

There was no significant difference between the 2 groups in terms of sex, age, surgical levels, operative time, intraoperative blood loss, time to ambulation, and length of hospital stay (P > 0.05). The HOI disk, SL, and LL in the 2 groups were noticeably improved postoperatively compared with preoperatively (P > 0.05), and there was no significant difference between the 2 groups (P > 0.05). However, at the final follow-up, HOI disk, SL, and LL in the TG were larger than those in the OG (P < 0.05). D1 and D2 in the TG were larger than those in the OG, and there was a significant difference between the 2 groups (P < 0.05). D3 in the OG was larger than that in the TG (P < 0.05). All patients achieved grade I fusion at the final evaluation.

CONCLUSIONS

The traverse cage implantation in TLIF had the same clinical effect as oblique cage implantation, but is superior in improving sagittal alignment. Therefore, we advise that the cage should be placed in traverse orientation in TLIF.

Posterior-only vs. combined posterior-anterior approaches in treating lumbar and lumbosacral spinal tuberculosis: a retrospective study with minimum 7-year follow-up

BACKGROUND

There is no comparative study with long-term follow-up between posterior-only and combined posterior-anterior approaches in treating lumbar spinal tuberculosis (LSTB) and lumbosacral spinal tuberculosis (LSSTB). This retrospective study aimed to compare and evaluate the long-term outcomes of these two surgical approaches in LSTB and LSSTB.

METHODS

Thirty patients with LSTB and 12 patients with LSSTB underwent posterior-only approach (group A); 26 patients with LSTB and 14 patients with LSSTB were managed with combined posterior-anterior approaches (group B). Analysis and comparison in clinical and radiographic outcomes between the two groups were performed.

RESULTS

The intra-operative bleeding amount, surgery time, and hospitalization days in group A were less than that in group B (P < 0.05). These patients were followed for a minimum of 7 years. All patients achieved completely healing within 2-year follow-up. Bony fusion was obtained in all patients. The visual analog scale, Japanese Orthopedic Association score, Oswestry Disability index, and Kirkaldy-Willis functional evaluation at the final visit demonstrated that all patients in both groups achieved satisfactory results. There was no significant difference in angle correction or maintaining correction between combined posterior-anterior approaches and posterior-only approach (P > 0.05). Complications occurred in both groups.

CONCLUSIONS

Both combined posterior-anterior approaches and posterior-only approach can achieve satisfactory clinical and radiological outcomes of long-term in treating LSTB and LSSTB, while posterior-only approach can safely and effectively achieve lesion debridement, decompression, and stability reconstruction and maintenance with the advantages of less invasive surgery, less bleeding, shorter surgery time, and hospital stay, and fewer complications. So, posterior-only approach seemed to be superior to the combined posterior-anterior one.

Minimally Invasive Surgery Combining Cortical Bone Trajectory Screws and Pedicle Screws to Treat Spondylodiskitis: Technical Notes and Preliminary Results

OBJECTIVE

Various surgical techniques for treating spondylodiskitis have been proposed, but the most appropriate surgical treatment remains controversial. In this study, we propose a new hybrid approach combining the use of cortical bone trajectory screws and pedicle screws with the technique of transforaminal lumbar interbody debridement and fusion. With this method, we can shorten the length of the segment that needs to be fixed, minimize the extent of surgical dissection, and reduce the risk of adjacent level degeneration.

METHODS

Patients with clinical and radiographic evidences of single-level lumbar spondylodiskitis seen between January and December of 2017 were included in the study. Demographic data, including age and sex, were recorded. The intraoperative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay were recorded.

RESULTS

The mean age of 15 patients was 62.8 years. The mean operative time was 135 minutes, and the mean blood loss was 260 mL. The culture rate was 80%. The mean Numeric Rating Scale score and Oswestry Disability Index score significantly improved from 6.60 to 2.47 and from 21.20 to 10.20, respectively. No major perioperative complications occurred.

CONCLUSIONS

With the proposed hybrid approach using cortical bone trajectory and pedicle screws with the transforaminal lumbar interbody debridement and fusion technique, the damaged anterior column can be debrided and reconstructed, and spinal stabilization can also be achieved.

Transforaminal Lumbar Interbody Fusion with Antibiotics Delivered by CaSO4 Drug Carrier System for Pyogenic Spondylodiscitis

BACKGROUND

Spondylodiscitis is a challenging spinal disorder that requires surgical treatment only as a last resort. The use of various procedures and instruments remains controversial. In this retrospective study, we reported the safety and efficacy of a CaSO₄ drug carrier system for the transforaminal lumbar interbody fusion (TLIF) procedure for lumbar pyogenic spondylodiscitis.

METHODS

Thirty-four patients with lumbar spondylodiscitis underwent TLIF. CaSO₄ beads carrying vancomycin and gentamycin were implanted in the trajectory of screws and disc spaces. We measured markers of inflammation, scores of neurologic recovery, and quality of life. The fusion status was assessed at final follow-up and the correction of local and total lordotic angle was calculated.

RESULTS

The patients were followed up for at least 12 months (range, 12-24 months). At 3 months follow-up, C-reactive protein levels and erythrocyte sedimentation rate returned to normal with no relapse. Nineteen patients with American Spinal Injury Association grade D preoperatively returned to American Spinal Injury Association grade E. The improvement on the visual analog scale and Oswestry Disability Index was 66.9% and 84.9%, respectively. At 12 months follow-up, 67.6% of patients achieved definitive union. The corrections of total and local lordotic angle were 10.02° ± 8.77° and 7.7° ± 8.75°, respectively. The rate of achievement of satisfactory Kirkaldy-Willis functional criteria was 85.3%.

CONCLUSIONS

The combined use of single-level TLIF with a CaSO₄ drug delivery system was safe and effective for treatment of pyogenic lumbar spondylodiscitis. The system promoted reduction of inflammation with limited fixed segments without a negative impact on fusion status. This procedure may be considered a novel choice for spondylodiscitis, with more efficacy and less invasion.

The use of CaSO4 drug delivery system in transforaminal lumbar interbody fusion for spinal brucellosis

OBJECTIVES

The incidence of human brucellosis has risen dramatically in China with few reports regarding the operation on spinal brucellosis. In this retrospective study we introduced CaSO₄drug delivery system into the TLIF surgical procedure and evaluated its clinical effectiveness and feasibility.

PATIENTS AND METHODS

36 patients with lumbar brucellosis were enrolled and treated by posterior transforaminal decompression, instrumentation and fusion. Prepared CaSO₄ beads carrying doxycycline were placed into the disc space and around pedicle screws. The activity of infection and pain-related function scales were recorded. Neurologic and functional recovery was evaluated using ASIA and Kirkaldy-Willis scale. Segmental and overall lordotic angles were measured and fusion status was assessed at final follow up.

RESULTS

The average follow-up period was 15.6 ± 3.73 months. The level of ESR and CRP returned to normal at 3 months post-op. 14 patients with ASIA grade D pre-op returned ASIA grade E with 3 months. The improvement of VAS and ODI was 82% and 85.8% at 3 months post-op. The corrections of segmental and overall lordotic angle were 5.98 ± 3.54° and 6.24 ± 7.93°. 69% of patients reached definitive union at 12 months after surgery. The satisfactory rate on Kirkaldy-Willis functional outcome criteria was 88.9%.

CONCLUSION

The use of CaSO₄ drug delivery system during single-stage TLIF for spinal brucellosis was safe and showed no negative impacts on fusion status and neurological function recovery. Our results are promising and the drug delivery system may be considered as a choice for future treatment in spinal brucellosis or other spondylodiscitis.

Single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis with associated neurological deficit: a multicentre retrospective study

BACKGROUND

A multicentre retrospective study was conducted to evaluate the safety and efficacy of single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis in patients with associated neurological deficit.

METHODS

Thoracolumbar junction (T12-L1) tuberculosis patients (n = 69) with neurological deficit who underwent single-stage posterior debridement, decompression and transpedicular screw fixation from January 2005 to January 2015 were included in the study. Antituberculosis therapy was performed both before and after surgery. The surgery duration and patient blood loss were evaluated, in addition to the change in pain visual analogue score (pVAS), kyphotic angle, Oswestry disability index (ODI) score and American Spinal Injury Association (ASIA) grade assessed preoperatively, immediate postoperatively and at the final follow-up visit.

RESULTS

The average blood loss was 354 ± 291 mL. The average kyphosis angle was corrected from 21 ± 9° preoperatively to 9 ± 4° postoperatively, with a mean decrease in pVAS and ODI scores of 3.4 and 16, respectively. The postoperative ASIA grading was grade A for five patients, grade C for 15 and grade D for 49 patients, which had improved to grade C for four patients, grade D for three patients and grade E for 62 patients at the final follow-up. The neurological deficit did not worsen in any of the patients.

CONCLUSIONS

Single-stage posterior debridement, decompression and transpedicular screw fixation is an effective treatment method in thoracolumbar junction (T12-L1) tuberculosis patients with neurological deficit, with good neurological recovery and no progression of kyphosis.

Management of Infected Transforaminal Lumbar Interbody Fusion Cage in Posterior Degenerative Lumbar Spine Surgery

BACKGROUND

The postoperative infection rates for transforaminal lumbar interbody fusion (TLIF) have ranged from <2% to 4%. However, no consensus has been reached on the treatment strategies. TLIF cage preservation or revision surgery for lumbar spine reconstruction are 2 possible treatments. We aimed to determine the most effective method for organ/space infection control.

METHODS

The data from 4923 patients who had undergone TLIF with cage and posterior pedicle-screw instrumentation for spondylolysis or degenerative spondylolisthesis from January 2008 to December 2015 were retrospectively analyzed. Of the 4923 patients, 32 (0.65%) had developed organ/space infection of the interbody cage and were divided into 2 groups: those whose interbody cage was removed for revision (group 1) and those who interbody cage was retained (group 2). We compared the initial management of both groups in terms of age, sex, elapsed time to diagnosis, changes in spinal lordotic angle, visual analog scale score, fusion status, and Kirkaldy-Willis functional outcomes.

RESULTS

The 32 patients with organ/space infection had a mean age of 66.3 years and a follow-up period of 23.8 months. Significant differences were observed in the mean elapsed time to diagnosis (P = 0.004), lordotic angle correction at the disease level (P = 0.03), and Kirkaldy-Wallis functional outcomes (P = 0.01). Of the 17 patients undergoing debridement for implant retention, 9 (52.9%) exhibited poor results.

CONCLUSIONS

The most important factor contributing to TLIF cage retention failure was epidural fibrosis of the previous transforaminal route and biofilm adhesion on interbody devices affecting infection clearance. Thus, we would recommend a combined anterior and posterior approach or the transforaminal route for radical debridement with cage removal and fusion to achieve better clinical outcomes.

Does Preserving or Restoring Lumbar Lordosis Have an Impact on Functional Outcomes in Tuberculosis of the Lumbosacral Region?

STUDY DESIGN

Single-center retrospective cohort analysis.

OBJECTIVES

To analyze the impact of loss of global lumbar lordosis (GLL) on functional outcomes in tuberculosis of the lumbar and lumbosacral spine and to define strategies to restore or preserve the physiological lumbar lordosis.

SUMMARY OF BACKGROUND DATA

In tuberculosis of lumbosacral spine, loss of lumbar lordosis (LL) leads to altered lumbosacral biomechanics. All available studies have assessed treatment outcomes with respect to physical well-being, neurologic improvement, bone healing, and changes in radiologic parameters. None have studied the correlation between functional outcomes and LL following treatment. We reviewed 63 patients with tuberculosis of lumbar and lumbosacral spine, with an attempt to analyze the impact of loss of GLL on functional outcomes and have defined strategies to restore the same.

METHODS

We retrospectively reviewed 63 patients with lumbar and lumbosacral tuberculosis, treated conservatively (n = 33) or surgically (n = 30) from March 2007 to July 2013. Average follow-up was 43.1±7.2 months. The correlation between posttreatment GLL and the functional outcome (Oswestry Disability Index), measured at 36 months' follow-up, was analyzed.

RESULTS

All patients showed good bone healing (at 8.4±1.5 months), significant improvement in neurology, VAS scores, ESR and CRP, p<0.001. Mean loss of GLL in the conservatively treated group was 6.4°±5.7°, whereas there was an average gain of 10.9°±9.9° of GLL with surgery. In all patients with minimal disability at the end of treatment, the final GLL was above 40°. In patients with severe disability and in a few with moderate disability, the posttreatment GLL was below 40°. Pearson's test showed a strong negative correlation between final posttreatment GLL and the degree of disability (r = -0.867, p<0.001).

CONCLUSIONS

Early disease with minimal loss of lordosis can be managed conservatively, whereas in advanced disease with gross hypolordosis/kyphosis, posterior stabilization with or without global spinal reconstruction is essential to regain LL. The management of lumbosacral tuberculosis should aim at preserving or restoring the normal LL to achieve good functional outcomes.

LEVEL OF EVIDENCE

Level III.

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 thoracolumbar spinal tuberculosis by posterior focus debridement and bone grafting and fixation combined with psoas abscess debridement and local chemotherapy via different approachs]

Objective

To compare the effectiveness of posterior and anterior psoas abscess debridement and local chemotherapy in abscess cavity combined with focus debridement, bone grafting, and fixation via posterior approach in treatment of thoracolumbar spinal tuberculosis, and explore the feasibility of psoas abscess debridement via posterior approach.

Methods

Between June 2012 and December 2015, the clinical data of 37 patients with thoracolumbar spine tuberculosis and psoas abscess were retrospectively analyzed. All the patients underwent posterior focus debridement, bone grafting, and internal fixation, and were divided into two groups according to different approaches to psoas abscess debridement. Twenty-one patients in group A underwent abscess debridement and local chemotherapy in abscess cavity via posterior approach; 16 patients in group B underwent abscess debridement and local chemotherapy in abscess cavity via anterior approach. No significant difference was found between two groups in gender, age, disease duration, involved segments, preoperative erythrocyte sedimentation rate (ESR), preoperative C-reactive protein (CRP), side of psoas abscess, maximum transverse diameter and sagittal diameter of psoas abscess, accompanying abscess, abscess cavity separation, preoperative Cobb angle of involved segments, preoperative American Spinal Injury Association (ASIA) classification ( P>0.05). The operation time, intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion were recorded and compared between 2 groups. The change of pre- and post-operative involved segments Cobb angle was observed. Neurological function was assessed according to ASIA classification.

Results

Except that the operation time of group B was significantly longer than that of group A ( t=-2.985, P=0.005), there was no significant difference in intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion between 2 groups ( P>0.05). All patients were followed up 18-47 months (mean, 31.1 months). No cerebrospinal fluid leakage occurred intra- and post-operation. Four patients in group A underwent second-stage operation of abscess debridement and local chemotherapy in abscess cavity via anterior approach. All patients got abscess absorption, meanwhile ESR and CRP level normalized at last follow-up. The involved segments Cobb angle improved significantly when compared with preoperative values in both 2 groups ( P<0.05); and there was no significant difference between 2 groups at last follow-up ( P>0.05). Nine patients with spinal cord injury had significant neurological recovery at last follow-up ( Z=-2.716, P=0.007).

Conclusion

Posterior focus debridement, bone grafting, and internal fixation combined with abscess debridement and local chemotherapy in abscess cavity is effective in treatment of thoracolumbar spinal tuberculosis, but in some cases anterior abscess debridement is still required.

A posterior versus anterior debridement in combination with bone graft and internal fixation for lumbar and thoracic tuberculosis

Background

Surgery treatment is usually required for spinal tuberculosis. The aim of this study was to compare the clinical efficacy and outcomes of anterior and posterior surgical approach in combination with debridement, bone grafting, and internal fixation.

Methods

All patients with thoracic and lumbar tuberculosis who underwent either the anterior or posterior surgery in combination with debridement, bone grafting, and internal fixation from August 2009 to August 2016 were reviewed retrospectively.

Results

A total of 186 patients were recruited in the analyses, 37 of whom received the anterior approach and 149 treated with the posterior approach. In the entire study population, there was no statistically significant difference between the groups in terms of kyphosis Cobb’s angle, VAS pain score, neurological status, operation duration, perioperative blood loss, and hospitalization days (p > 0.05). Good clinical outcomes were achieved in both treatment groups. In lumbar vertebra-affected patients, the average preoperative kyphosis Cobb’s angle was 8.7 ± 16.6° and − 5.6 ± 16.0° for the anterior and posterior groups, respectively, which were corrected to − 3.3 ± 13.2° and − 10.1 ± 13.8° after surgery. For thoracic vertebra-affected patients, the corrected kyphosis Cobb’s angle was 8.1 ± 9.7° and 10.3 ± 6.5°, respectively. After surgery, 32.4% of patients in the anterior group and 48.3% of patients in the posterior group claimed no pain (p = 0.24), while 83.8 and 85.9% recovered to Frankel grade E, respectively (p = 0.85).

Conclusions

The posterior debridement joint bone graft and internal fixation is an alternative procedure to treat lumbar and thoracic tuberculosis compared to the traditional anterior approach with similar clinical efficacy in terms of pain control, Cobb’s angle, and neurological function. The posterior approach is sufficient for lesion debridement.

One-stage posterior approaches for treatment of thoracic spinal infection: Transforaminal and costotransversectomy, compared with anterior approach with posterior instrumentation

Treating thoracic infective spondylodiscitis with anterior surgical approaches carry a relatively high risk of perioperative and postoperative complications. Posterior approaches have been reported to result in lower complication rates than anterior procedures, but more evidence is needed to demonstrate the safety and efficacy of 1-stage posterior approaches for treating infectious thoracic spondylodiscitis.Preoperative and postoperative clinical data, of 18 patients who underwent 2 types of 1-stage posterior procedures, costotransversectomy and transforaminal thoracic interbody debridement and fusion and 7 patients who underwent anterior debridement and reconstruction with posterior instrumentation, were retrospectively assessed.The clinical outcomes of patients treated with 1-stage posterior approaches were generally good, with good infection control, back pain relief, kyphotic angle correction, and either partial or solid union for fusion status. Furthermore, they achieved shorter surgical time, fewer postoperative complications, and shorter hospital stay than the patients underwent anterior debridement with posterior instrumentation.The results suggested that treating thoracic spondylodiscitis with a single-stage posterior approach might prevent postoperative complications and avoid respiratory problems associated with anterior approaches. Single-stage posterior approaches would be recommended for thoracic spine infection, especially for patients with medical comorbidities.

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis

Background

Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis.

Methods

From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria.

Results

The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months’ follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up.

Conclusions

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.

Single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis

PURPOSE

To review the outcome of single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis in 45 patients.

METHODS

Records of 16 men and 29 women aged 20 to 59 (mean, 34.1) years who underwent single-stage posterior instrumentation for active thoracic (n=27) or thoracolumbar (n=18) tuberculosis by a single surgeon and were followed up for a minimum of 5 years were reviewed. Neurological status was evaluated using the Frankel grading system. Pain was assessed using the visual analogue score (VAS). Disability status was assessed using the Oswestry Disability Index (ODI). Outcome was graded according to the Kim and Lee criteria. Kyphosis at presentation, preoperation (after one month of conservative therapy), immediate postoperation, and 5-year follow-up was measured on radiographs to determine the kyphosis progression, correction of deformity, postoperative loss of correction, and residual deformity.

RESULTS

Respectively for 27 and 18 patients with thoracic or thoracolumbar involvement, at 5 years the mean VAS score improved from 5.5 to 1.9 (p<0.001) and from 6.8 to 1.5 (p<0.001), whereas the mean ODI improved from 60.8 to 11.7 (p<0.001) and from 57.5 to 7.6 (p<0.001). The outcome was excellent in 17 and 11, good in 7 and 5, and fair in 3 and 2 patients, respectively. The mean kyphosis progression from presentation to preoperation was from 20.2º to 26.2º and from 10.3º to 14.1º, respectively, whereas the corresponding mean predicted kyphosis progression was from 15.5º to 48.1º and from 13.8º to 50.4º. The respective mean correction of deformity was -8.1º and -8.5º; the respective mean residual deformity was 4.1º and 6.8º; and the respective mean loss of correction at 5 years was 1.9 and 1.9. Two patients had a dural tear, and 3 patients had a transient root injury. Two diabetic patients had superficial wound infection. One patient had downward migration of one rod at 30 months but remained asymptomatic.

CONCLUSION

Single-stage posterior instrumentation combined with continued chemotherapy for a minimum 12 months is a viable option for early progressive thoracic and thoracolumbar tubercular kyphosis.

Surgery for spinal tuberculosis: a multi-center experience of 582 cases

BACKGROUND

Tuberculosis (TB) of the spine is a common site of osseous TB, accounting for 50%-60% of cases. Spinal TB still occurs in both developed and developing countries. The diagnosis of spinal TB is difficult and it commonly presents at an advanced stage. Delays in establishing diagnosis and management result in complications such as spinal cord compression and spinal deformity.

METHODS

A total of 582 patients with TB of the cervical, thoracic and lumbar spine with moderate to severe cord compression were studied. Variable degrees of neurological deficit with deformity were treated from January, 2003 to July, 2014. Thoracotomy along with anterolateral decompression and autogenous strut bone grafting with simultaneous fixation by screws and rods were performed in 113 cases. Posterior decompression, posterior interbody and posterolateral fusion by bone graft with stabilization by transpedicular screws and rods were done in the remaining 469 cases. Appropriate anti-TB drugs were given to all patients for 18-24 months. The follow-up period was 3 months to 10 years.

RESULTS

The average age was 32.5 years. All patients survived surgery. There were 7 cases of superficial infections (1.2%) whilst there were 4 cases (0.7%) of deep infections. Revision surgery was performed in 6 patients (1.0%). Implant failure occurred in 4 cases (0.7%) whilst malposition of screws occurred in 12 cases (2.1%). Perioperative bleeding complications were reported for 4 patients (0.7%). Neurological improvement occurred in all patients except for 2 cases (0.3%). Preoperatively, the majority of patients (n=221, 38%) were classified with Class A on the American Spinal Injury Association (ASIS) neurological impairment scale. This was significantly reduced postoperatively to 0.4%.

CONCLUSIONS

For patients with spinal TB anterior debridement, auto graft bone fusion, anterior or posterior fixation appears to be effective in arresting disease, correcting kyphotic deformity and maintaining correction until solid spinal fusion.

Impact on Neurological Recovery of Transforaminal Debridement and Interbody Fusion versus Transpedicular Decompression in Combination with Pedicle Screw Instrumentation for Treating Thoracic and Lumbar Spinal Tuberculosis

Study Design

Retrospective study.

Purpose

To compare the neurological outcome of transforaminal debridement and interbody fusion with transpedicular decompression for treatment of thoracic and lumbar spinal tuberculosis.

Overview of Literature

Few articles have addressed the impact of neurological recovery in patients with tuberculosis who were treated by two different operative methods via the posterior-only approach.

Methods

Clinical and radiographic results of one-stage posterior instrumented spinal fusion for treatment of tuberculous spondylodiscitis with neurological deficits were reviewed and analyzed from 2009 to 2013. The extensive (E) group consisted of patients who received transforaminal debridement and interbody fusion, whereas transpedicular decompression was performed on limited (L) group. Rapid recovery was improvement of at least one Frankel grade within 6 weeks after operation. Otherwise, it was slow recovery.

Results

All 39 patients had improved neurological signs. The median follow-up period was 24 months. Proportionately younger patients (under 65 years of age) received extensive surgery (15 of 18, 83.3% vs. 11 of 21, 52.4%; p=0.04). The mean operative time and blood loss in the group E were higher than in the group L (both p<0.01). With regard to type of procedure, especially at thoracic and thoracolumbar spine, patients who underwent extensive surgery had rapid neurological recovery significantly different from those of limited surgery (p=0.01; Relative Risk, 3.06; 95% Confidence Interval, 1.13 to 8.29).

Conclusions

Transforaminal debridement and interbody fusion provides more rapid neurological recovery in patients with thoracic and thoracolumbar spinal tuberculosis compared to transpedicular decompression.

Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults

Aim

Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients.

Patients and Methods

Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit.

Results

The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection.

Conclusions

Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. Take home message: With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834–9.

Surgical treatment for lumbar tuberculosis by posterior transforaminal lumbar debridement, interbody fusion, and instrumentation in the aged

Object

To evaluate the clinical efficacy and feasibility of single-stage posterior debridement, interbody fusion and posterior instrumentation for the treatment of lumbar tuberculosis in the aged and to discuss the surgical strategies of this intervention.

Methods

From January 2006 to January 2012, 28 elderly patients who suffered from lumbar tuberculosis underwent one-stage posterior debridement, interbody fusion and posterior instrumentation. Radiographic data which included correction of local kyphosis, loss of correction and bone fusion were carefully collected pre and postoperatively to evaluate the efficacy of surgery. Perioperative and postoperative complications were also registered. All patients were asked to fill out Oswestry Disability Index questionnaire before the surgery and at the last follow-up.

Results

All patients (12M/16F) were followed for at least 24 months. The average kyphotic angle decreased to 11.3° ± 7.0° postoperatively from 26.4° ± 5.7° preoperatively. Meanwhile, average loss of 2.0° ± 1.5° was observed at last visit. Bone fusion occurred at 4–6 months. Neither mortalities nor any neurological complications were found in the series. 16 cases who suffered neurologic insults before surgery, the majority of patients recovered after surgery. The mean Oswestry Disability Index was significantly improved from 28.6 ± 4.9 before surgery to 10.4 ± 3.8 at last visit.

Conclusions

The outcomes of follow-up showed that single-stage posterior debridement, interbody fusion and instrumentation is an effective method for the treatment of lumbar tuberculosis in the aged.

One-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children

OBJECTIVE

The purpose of this study is to investigate the clinical efficacy and feasibility of one-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children.

METHODS

From December 2007 to May 2012, 13 patients (six males and seven females) suffering from lumbar spinal tuberculosis with kyphosis were admitted. All patients were treated with one-stage posterior focus debridement, fusion, and instrumentation. Then, the clinical efficacy was estimated by statistical analysis based on the data about Frankel grade, the Cobb angle of kyphosis, and erythrocyte sedimentation rate (ESR), which were collected at certain time.

RESULTS

The age of all patients ranged from 5 to 13 years (average, 8.8 years). Operation time ranged from 120 to 190 min (average, 165 min). Intraoperative blood loss ranged from 200 to 800 ml (average, 460 ml). All patients were followed up for 24 to 57 months postoperatively (average, 33.5 months). The Cobb angle was changed significantly between preoperation and postoperation (P < 0.05), and there was no significant loss at the last follow-up. The preoperation ESR (62.5 ± 15.7) returned to normal (16.6 ± 8.1) within 3 months postoperatively in all patients (P < 0.05). Bone fusion was achieved within 3-5 months (average, 3.5 months). In the 13 cases, no postoperative severe complications occurred and neurologic function improved in various degrees.

CONCLUSION

The outcomes of follow-up showed that one-stage posterior focus debridement, fusion, and instrumentation can be an effective treatment method for the lumbar spinal tuberculosis with kyphosis in children.

Treatment of lumbosacral spinal tuberculosis by one-stage anterior debridement and fusion combined with dual screw-rod anterior instrumentation underneath the iliac vessel

BACKGROUND

There has been no consensus regarding what is the optimal means of treating lumbosacral segment tuberculosis. The aim of this study was to evaluate the clinical outcomes of our newly developed one-stage anterior debridement and fusion combined with dual screw-rod construct anterior instrument underneath the iliac vessels for lumbosacral spinal tuberculosis.

METHODS

We retrospectively reviewed 22 patients with lumbosacral spinal tuberculosis who underwent one-stage anterior debridement and fusion combined with dual screw-rod anterior instrument underneath the iliac vessels between January 2004 and June 2013. We assessed the visual analogue scale (VAS), erythrocyte sedimentation rates (ESR), neurological performance, kyphotic angles, fusion rates, and computed tomographic angiography (CTA) before and after surgery.

RESULTS

All patients were followed-up for a mean of 46.59 months. There were no instances of spinal tuberculosis recurrence. The mean VAS scores and ESR decreased significantly from the preoperative levels both postoperatively and at the final follow-up (all P <0.001). The mean kyphotic angle significantly increased from the mean preoperative angle both postoperatively and at the final follow-up (both P <0.001). All patients had bone fusion at a mean of five months after surgery. No postoperative vascular complications were observed.

CONCLUSIONS

Our findings suggest that anterior radical debridement, fusion combined with dual screw-rod anterior instrument underneath the iliac vessels can be an effective and safe treatment option for lumbosacral segment tuberculosis.

Subscapularis Transthoracic Versus Posterolateral Approaches in the Surgical Management of Upper Thoracic Tuberculosis: A Prospective, Randomized Controlled Study

The objective of the present study was to evaluate the clinical, radiological, and functional outcomes of a subscapularis transthoracic surgical approach and a posterolateral surgical approach with debridement, bone graft fusion, and internal fixation for the treatment of upper thoracic tuberculosis.There is currently debate over the best surgical approach for the treatment of upper thoracic tuberculosis. Traditionally, the subscapularis transthoracic approach has been preferred; however, the posterolateral approach has gained popularity in the past few years.A prospective, consecutive cohort of 43 upper thoracic tuberculosis patients with a mean age of 39 years (range: 20-52 years) was followed up for a minimum of 12 months (range: 12-60 months). Patients were randomly divided into 2 groups. Group A (n = 21) was treated by the subscapularis transthoracic approach and group B (n = 22) was treated by the posterolateral approach. All cases were evaluated for clinical, radiological, and functional outcomes. Intraoperative blood loss, operative duration, intraoperative and postoperative complications, hospital stay, the cure rate, fusion time, and the Frankel scale were used for clinical and functional evaluation, whereas the kyphosis angle was used for radiological evaluation.Grafted bones were fused by 10 months in all cases. There was no statistically significant difference between groups before surgery in terms of gender, age, segmental tuberculosis, erythrocyte sedimentation rate (ESR), Frankel scale, or Cobb's angle (P > 0.05). The average operative duration for Group B was lower than that of Group A. There were no significant differences in intraoperative blood loss, intraoperative and postoperative complications, hospital stay, grafted bone fusion time, or cure rate between groups (P > 0.05). The Cobb's angle correction rate for group B (68.5%) was significantly better than that of group A (30.9%). The neurological score showed significant postoperative improvement in both groups, with no significant difference between the groups.The subscapularis transthoracic approach and the posterolateral approach with debridement, bone graft fusion, and internal fixation are both sufficient and satisfactory for the surgical treatment of upper thoracic tuberculosis. However, the posterolateral approach is superior to the subscapularis transthoracic approach in terms of surgical trauma, operative time, and kyphosis correction.

A Retrospective Study of 39 Patients Treated With Anterior Approach of Thoracic and Lumbar Spondylodiscitis: Clinical Manifestations, Anterior Surgical Treatment, and Outcome

The aim of this study is to report our 39 patients treated with anterior debridement and autologous iliac bone grafting with or without anterior instrumentation, which is the presumed treatment of choice for thoracic or lumbar spondylodiscitis.Our patients underwent surgical treatment of spondylodiscitis using anterior debridement and autologous iliac bone grafting with or without anterior instrumentation and were analyzed with a mean follow-up of 8 years (range, 2-11 years). Kaneda 2-rod system instrumentation was used in 12 patients, in total. Clinical outcomes were assessed by the Frankel grade. Radiographic fusion was characterized based on 3-dimensional computed tomography.Of the whole group, 20 patients suffered from tuberculous spondylodiscitis and 19 suffered from hematogenous spondylodiscitis. Pathogens responsible for pyogenic infection included Staphylococcus aureus (4 patients), Pseudomonas aeruginosa (3 patients), and Brucella melitensis (1 patient). Fifteen patients had thoracic involvement, 20 had lumbar involvement, and 4 had thoracolumbar junction involvement. Preoperative neurological deficits were noted in 13 of the 39 patients. In terms of Frankel grade, 8 patients have improved, 4 have remained the same, and 1 patient has worsened during the follow-up period. Imaging-documented fusion was achieved in 23 of 27 patients in the graft group (85% fusion rate) and 11 of 12 patients in the graft + Kaneda instrumentation group (91% fusion rate).There was no instrumentation failure, loosening, or graft-related complication such as slippage or fracture of the graft. This approach demonstrated a good recovery rate of neurological functions and a high fusion rate.

Surgical treatment for mono-segmental lumbar tuberculosis by single-stage posterior debridement, compact bone grafting and posterior single-segment fixation

PURPOSE

To evaluate the efficacy and safety of single-stage posterior debridement, compact bone grafting and posterior single-segment fixation for the treatment of mono-segmental lumbar tuberculosis.

METHODS

We enrolled 32 patients with mono-segmental lumbar tuberculosis from January 2005 to April 2011. The severity of damage to the vertebral bodies is not more than 2/3 height. All the patients were treated by single-stage posterior debridement, compact bone grafting and posterior single-segment fixation.

RESULTS

Patients were followed 21-63 months (43.5±9.5 months). The average Cobb angle decreased to 5.3±3.0° postoperatively from 22.1±6.1° preoperatively. Meanwhile, average 1.8±1.0° loss was observed at last visit. Fusion occurred at 3-9 months (mean 5.1 months). All patients with preoperative neurologic deficit recovered in different degree. 1 with grade B recovered to grade D; 2 with grade C recovered to grade E; 18 with grade D recovered to grade E. No mortality occurred. One patient experienced anti-tuberculosis drug-induced liver dysfunction which was managed successfully with modified anti-TB treatment and hepato-protective treatment. The Oswestry Disability Index decreased from 40.1±4.0 preoperatively to 13.7±3.1 postoperatively.

CONCLUSIONS

Single-stage posterior debridement, compact bone grafting and posterior single-segment fixation is an effective method for the treatment of mono-segmental lumbar tuberculosis.

Surgical management for thoracic spinal tuberculosis posterior only versus anterior video-assisted thoracoscopic surgery

STUDY DESIGN

A comparable retrospective study.

OBJECT

To compare the clinical outcomes of surgical treatment by posterior only and anterior video-assisted thoracoscopic surgery for thoracic spinal tuberculosis (TSTB).

METHOD

145 patients with TSTB treated by two different surgical procedures in our institution from June 2001 to June 2014 were studied. All cases were retrospectively analyzed and divided into two groups according to the given treatments: 75 cases (32F/43M) in group A performed single-stage posterior debridement, transforaminal thoracic interbody fusion and instrumentation, and 70 cases (30F/40M) in group B underwent anterior video-assisted thoracoscopic surgery (VATS). Clinical and radiographic results in the two groups were analyzed and compared.

RESULTS

Patients in group A and B were followed up for an average of 4.6±1.8, 4.4±1.2 years, respectively. There was no statistically significant difference between groups in terms of the operation time, blood loss, bony fusion, neurological recovery and the correction angle of kyphotic deformity (P>0.05). Fewer pulmonary complications were observed in group A. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the anterior VATS and posterior approaches can effectively treat thoracic tuberculosis. Nevertheless, the posterior approach procedure obtained less morbidity and complications than the other.

One-stage lumbopelvic fixation in the treatment of lumbosacral junction tuberculosis

PURPOSE

To investigate the clinical efficacy and feasibility of surgical treatment for lumbosacral junction tuberculosis by one-stage posterior debridement, interbody fusion, lumbopelvic fixation, and postural drainage.

METHODS

A total of 15 cases with lumbosacral junction tuberculosis treated by one-stage posterior debridement, interbody fusion, lumbopelvic fixation, and postural drainage in our center from January 2005 to October 2011 were studied. Lumbosacral angle, visual analog scale (VAS), and neurological performance were assessed before and after surgery.

RESULTS

All patients were followed for 28-56 months post-operation (average, 40.7 ± 7.7 months). No severe complications occurred. Bone fusion occurred in all patients at a mean of 8.4 months (range 6-12 months) after surgery. The mean lumbosacral angle was significantly increased from the mean preoperative angle (20.9° ± 1.8°) both post-operatively (26.5° ± 1.6°) and at final follow-up (25.3° ± 1.4°) (both P < 0.05). All patients had significant post-operative improvement in neurological performance and VAS scores.

CONCLUSIONS

Our results suggest that one-stage posterior debridement, interbody fusion, lumbopelvic fixation, and postural drainage can be an effective and feasible treatment option for lumbosacral junction tuberculosis, offering fewer complications and a better quality of life.

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by spinal epidural abscess (SEA) is a predictor of clinical outcome

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of this study was to investigate the question whether surgical treatment of patients with spondylodiscitis and neurological deficits caused by a spinal epidural abscess (SEA) is a predictor of clinical outcome.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis with an accompanying SEA is a serious medical condition that is associated with potentially high risk for long-term neurological morbidity. In the literature, up to 75% of patients suffer from neurological deficits related to SEA in spondylodiscitis. Independent of treatment, residual neurology persists at a high rate.

METHODS

A retrospective analysis of 135 patients admitted to our department due to a diagnosis of spondylodiscitis was performed. Presence of SEA was evaluated based on computed tomography and magnetic resonance imaging. Neurological status was documented on admission and at discharge according to the Frankel Score. In addition, our patient population was separated into group I without neurological deficits (Frankel E) and group II with abnormal Frankel A-D. Surgical and nonsurgical therapy was retrospectively evaluated. Data were statistically analyzed using the 2-sided Fisher exact test.

RESULTS

On admission, 102 patients were graded as Frankel E in group I. In group II, 15 were Frankel D, 8 Frankel C, 8 Frankel B, and 2 Frankel A. After treatment, 105 patients were Frankel E, 19 Frankel D, 4 Frankel C, 3 Frankel B, and none Frankel A. Four patients died because of severe comorbidities. In group II, 13 of 33 patients had a SEA. Twelve patients showed improvement in Frankel grade, 1 remained unchanged. Of the 20 patients in group II without a SEA, 11 improved and 9 remained unchanged. Twenty-eight of the 33 patients in group II were treated surgically. Patients in both groups with improved neurology showed an upgrade by 1 or 2 Frankel scores. There was no deterioration of neurology. The correlation between surgically treated patients with SEA in comparison with patients without SEA is considered to be statistically significant.

CONCLUSION

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by SEA is a predictor of clinical outcome.

Transforaminal lumbar interbody debridement and fusion for the treatment of infective spondylodiscitis in the lumbar spine

PURPOSE

To determine the safety and efficacy of using a single posterior approach with transforaminal lumbar interbody debridement and fusion (TLIDF) plus pedicle screws fixation in treating infective spondylodiscitis in the lumbar spine.

METHODS

Between January 2009 and June 2011, 28 patients with infective spondylodiscitis who underwent TLIDF, using autogenous graft and posterior pedicle screws instrumentation, met the indications for surgery, and completed more than 18 months of follow-up, were included. Clinical outcomes were assessed using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and Kirkaldy-Willis functional outcome criteria. Infection status was evaluated using C-reactive protein levels, erythrocyte sedimentation rate, and clinical symptoms. The interbody fusion status and sagittal alignment of the infected segments were assessed using radiographic studies.

RESULTS

Intra-operative culture rate was 82.1 %. The most common pathogen was methicillin-resistant Staphylococcus aureus. One post-operative deep wound infection with septic implant loosening and one instance of early aseptic implant loosening were noted. Implants in both patients were subsequently removed. Two infections recurred within 3 months post-operatively, with both subsiding within 3 months after extended antibiotic treatment. VAS and ODI values were significantly improved. The interbody fusion rate was 82.1 % and the lordotic angle of the infected segments and the lumbar spine were corrected by 9.7° and 14.3°, respectively at the last follow-up.

CONCLUSIONS

A single posterior approach with TLIDF and pedicle screws instrumentation for lumbar infective spondylodiscitis provided a satisfactory clinical outcome, adequate infection control and good fusion rate, and this strategy avoids the risks of anterior or staging surgeries.

Surgical treatment of lumbar spondylodiscitis: a comparison of two methods

PURPOSE

This study evaluates two basic hypotheses: (1) the risk of an isolated dorsal approach to ventral lumbar spondylodiscitis based on clinical and radiographic results and (2) the risk of anterior radical debridement due to using a titanium implant in the site of bone infection.

METHODS

Group A consisting of 23 patients was treated only by a dorsal transmuscular approach and group B consisting of eight patients was treated by two-stage posteroanterior surgery. Both evaluated groups were assessed before surgery, six weeks and one year after surgery with the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) and Kirkaldy-Willis functional criteria. To evaluate the sagittal balance restoration, measurement by the Cobb modified angle of the affected segment was performed.

RESULTS

Differences (p < 0.001) in group A were found between JOA values before surgery (average 9.30) and at six weeks after surgery (average 11.82) and 12 months after surgery (13.27) and VAS differences before surgery (average 7.39), six weeks after surgery (average 3.82) and 12 months after surgery (average 2.36) in group A. According to the Kirkaldy-Willis functional criteria, 11 patients were evaluated as excellent, nine patients as good and two patients as poor. The values of the JOA score in group B showed an improvement compared with the JOA values before surgery (average 9.38) at six weeks after surgery (average 11.75) and 12 months after surgery (average 13.63), and the VAS score before surgery (average 7.38) was found to have improved six weeks after surgery (average 4.63) and 12 months after surgery (average 2.25). The functional evaluation according to the Kirkaldy-Willis functional criteria assessed three patients as excellent, four patients as good and one patient as fair. Radiographic examinations of group A revealed the following findings before surgery (average 1.75), six months after surgery (average -3.73) and 12 months after surgery (average -0.79) and in group B before surgery (average 3.71), six weeks after surgery (average -8.21) and 12 months after surgery (average -6.45).

CONCLUSIONS

The results demonstrate the minimum serious surgical complications and greater loss of sagittal balance without clinical correlation in group A. We did not find any relapse or persistence of the infection in the post-operative period in group B.

The clinical outcomes of surgical treatment of noncontiguous spinal tuberculosis: a retrospective study in 23 cases

Study design

A retrospective clinical study.

Objective

To evaluate the clinical efficacy of the surgical treatment of noncontiguous spinal tuberculosis (NSTB), and to discuss its therapeutic strategies.

Methods

We performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Apart from 4 patients being treated conservatively, the remainder received surgery by posterior transforaminal debridement, interbody fusion with instrumentation, posterior instrumentation and anterior debridement with fusion in a single or two-stage operation. The clinical outcomes were evaluated before and after treatment in terms of hematologic and radiographic examinations, bone fusion and neurologic status. The Oswestry Disability Index score was determined before treatment and at the last follow-up visit.

Results

23 patients (15 M/8F), averaged 44.6±14.2 years old (range, 19 to 70 yd), who received surgical treatment, were followed up after surgery for a mean of 52.5±19.5 months (range, 24 to 72 months). The kyphotic angle was changed significantly between pre- and postoperation (P<0.05). The mean amount of correction was 12.6±7.2 degrees, with a small loss of correction at last follow-up. All patients achieved solid bone fusion. No patients with neurological deficit deteriorated postoperatively. Neither mortalities nor any major complications were found. There was a significant difference of Oswestry Disability Index scores between preoperation and the final follow-up.

Conclusion

The outcomes of follow-up showed that posterior and posterior-anterior surgical treatment methods were both viable surgical options for NSTB. Posterior transforaminal debridement, interbody fusion and posterior instrumentation, as a less invasive technique, was feasible and effective to treat specific tubercular foci.

[Dorsolateral access and interbody spinal fusion in spondylodiscitis of the thoracolumbar spine (TLIF technique)]

SURGICAL GOAL: Resolve infection and achieve primary stability of instrumentation and permanent fusion of the affected spinal segment by means of debridement of the focus of infection. Defect-filling using autologous/allograft bone or a spacer, as well as immobilization by means of dorsal instrumentation.

INDICATION

Acute and chronic thoracolumbar spondylodiscitis.

CONTRAINDICATIONS

Purely epidural abscesses requiring only decompression (fenestration). Defects whose size make a ventral approach necessary.

SURGICAL TECHNIQUE

Classic dorsal approach to the thoracolumbar spine. Pedicle placed using screws depending on the size of the spinal defect for mono-, bi-, or multisegmental spinal fusion. Exposure performed at the level of the infected spinal disc or vertebral body on the more strongly affected side. Focus of infection removed. Depending on the degree of infection, defect filling is carried out using autologous bone or cancellous allograft, followed by rod assembly.

POSTOPERATIVE MANAGEMENT

Back brace-free follow-up treatment, physiotherapy and back training. Antibiotic administration until inflammation values fall within the normal range, or for at least 14 days.

RESULTS

Successful fusion of affected segments, including resolution of infection, is reported in over 90% of cases described in the literature. The revision rate among our mostly multimorbid patient group with an average age of 66 years was 16%. Of 39 of the 114 (34%) patients with preoperative neurological deficits, 26 (66%) demonstrated postoperative regression. Nine patients (23%) showed no improvement, whilst exacerbation of existing neurological deficits was seen in four patients (11%). Staphylococcus was the major pathogen in 34% of cases.

Should we cross the cross-links?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To assess critically if cross-links are necessary adjuvants in posterior spinal constructs.

SUMMARY OF BACKGROUND DATA

Although numerous biomechanical studies are available in the literature, there has been no clinical study that has evaluated the need for cross-links in clinical situations.

METHODS

The spinal constructs of patients of varied etiology who underwent surgery between July 2007 and July 2011 without the usage of cross-links were evaluated. The immediate postoperative erect radiographs were compared with the erect radiographs at the last follow-up by 2 independent observers (spine fellows not involved in the management of the patients) critically for any rotational instability using the Nash-Moe technique of assessment of vertebral rotation as well as for any "parallelogram effect." The intraobserver and interobserver reliability was analyzed.

RESULTS

There were 208 cases included in the study during the study period that satisfied the criteria. The total number of motion segments fused was 707 ranging from 1 to 15 involving various etiologies. The average follow-up was 15 months (12-36 mo). Barring one patient with a thoracolumbar fracture with rotational instability (AO [Arbeitsgemeinschaft für Osteosynthesefragen] type C) who had undergone a short-segment fixation, none of the cases demonstrated any rotational instability in the follow-up radiographs. Interestingly, the rotational instability (parallelogram effect) in that patient got corrected spontaneously once anterior reconstruction was performed. The intraobserver reliability was 100% and the interobserver reliability was 92.83%. This variability was in assessing the grade of vertebral rotation only; none of the levels had a change in rotation irrespective of variation in grade assessment in the final postoperative radiograph.

CONCLUSION

This study concludes that use of cross-links in clinical practice may be avoidable. The derivations from biomechanical studies do not translate into clinical advantages. Eliminating the usage of cross-links reduces the operative time as well as the overall total hospital costs (a single cross-link may cost anywhere between $1500 and $2000 and surgeons tend to use single or multiple cross-links). Additionally, prominence of implants, corrosion, infection, implant failure, and pseudarthrosis are the other complications attributed to cross-links in the literature that can be eliminated by preventing their incorporation in spinal constructs.

LEVEL OF EVIDENCE

N/A.

One-stage posterior surgical treatment for lumbosacral tuberculosis with major vertebral body loss and kyphosis

The treatment goals of tuberculous spondylitis are to eradicate infection and to prevent or treat instability, deformity, and neurologic deficit. The purpose of this study was to evaluate the clinical outcomes following chemotherapy with 1-stage posterior debridement, correction, and instrumentation and fusion for the treatment of lumbosacral tuberculosis with major vertebral body loss and kyphosis. Fourteen patients with lumbosacral tuberculosis with major vertebral body loss and kyphosis underwent 1-stage posterior surgery. Clinical assessments included low back ache, Oswestry Disability Index, Scoliosis Research Society-22 scores, neurologic deficit, erythrocyte sedimentation rate, and C-reactive protein level. Radiographic parameters included kyphosis angle, anteroposterior translation, local scoliosis, lumbar lordosis, pelvic parameters, sagittal offset, and fusion. Thorough debridement was performed. Patients were followed for an average of 39.3 months. Constitutional symptoms, low back ache, and functional outcome improved in all patients postoperatively. At final follow-up, Frankel Grade improved by 0 to 2 grades, mean kyphosis angle improvement was 44.3°, and satisfactory spinopelvic and sagittal balance were achieved. Spinal posterolateral fusion was obtained in all patients and no fixation loosening was found at 2-year follow-up. Differences existed between the pre- and postoperative radiographic parameters (P<.05). Correction loss at last follow-up was not statistically significant (P>.05). No surgical complications or infection recurrence occurred. Tuberculosis can be cured and effective correction of kyphosis can be achieved for lumbosacral tuberculosis with major vertebral body loss and kyphosis by performing 1-stage posterior surgery and chemotherapy.

One-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis

PURPOSE

Retrospective analysis of the clinical study efficacy and feasibility of one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis.

METHOD

A total of 21 patients with lumbosacral tuberculosis (TB) collected from January 2004 to January 2010, underwent one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation. In addition, the clinical efficacy was evaluated based on the data on the lumbo-sacral angle, neuro-logical status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at specific time points.

RESULTS

All cases were followed up for 16-36 months (average 24.9 ± 6.44 months). 18 patients suffered from evident neurological deficits preoperatively, of which 16 patients returned to normal at the final follow-up. Two patients with neurological dysfunction aggravated postoperative, experienced significant partial neurological recovery. With an effective and standard anti-TB chemotherapy treated, the values of ESR and CRP returned to normal levels 3-month later postoperative and maintained till the final follow-up. Preoperative lumbosacral angle was 20.89 ± 2.32° and returned 29.62 ± 1.41° postoperative. During long-term follow-up, there was only 1-3° lumbosacral angle loss. There was a significant difference between preoperative and postoperative lumbosacral angles.

CONCLUSION

With effective and standard anti-TB chemotherapy, one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation for lumbosacral tuberculosis can effectively relieve pain symptoms, improve neurological function, and reconstruct the spinal stability.

Spinal infection: state of the art and management algorithm

INTRODUCTION

Spinal infection is a rare pathology although a concerning rising incidence has been observed in recent years. This increase might reflect a progressively more susceptible population but also the availability of increased diagnostic accuracy. Yet, even with improved diagnosis tools and procedures, the delay in diagnosis remains an important issue. This review aims to highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

METHODS

Appropriate literature on spinal infection was selected using databases from the US National Library of Medicine and the National Institutes of Health.

RESULTS

Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment.

CONCLUSIONS

A methodological assessment could lead to diagnosis effectiveness of spinal infection. Towards this, we present a management algorithm based on literature findings.

Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases

(1) To present the indications of single stage all posterior surgery in thoracic and lumbar tuberculosis. (2) To evaluate the results of single stage all posterior surgery. We analysed 67 patients who underwent single stage all posterior surgery with follow-up of 31.37 months. We performed the following operative procedures depending upon level and case requirements. (Group A) Instrumentation alone for instability. (Group B) Transpedicular decompression and instrumentation for neurological compression in thoracic and thoracolumbar spine. (Group C) Transforaminal approach for access to anterior column in lumbar spine in addition to posterior instrumentation. (Group D) Pedicle subtraction osteotomy and instrumentation for deformity correction. (Group E) Posterior decompression alone for isolated posterior epidural compression. (Group F) Reconstruction of anterior column by all posterior approach. Thirty-eight had neurological deficit whereas 29 were Frankel E. In 12 cases, anterior reconstruction was done. In the remaining 55 cases, we relied on vertebral reconstitution under chemotherapy. Operative time was 150.5 min and blood loss was 514.18 ml. Of 38 patients with deficit, 34 improved. There was radiological fusion in all patients. Pre- and post-operative Cobb's measurements were 9.95 and 8.1, respectively, in thoracic and thoracolumbar spine and -9.39 and -11.42, respectively, in lumbar spine. Of 55 cases where anterior reconstruction was not done, only 3 had progression of Cobb's >10°. Posterior approach can achieve adequate decompression of offending middle column and if required, even anterior reconstruction. Posterior approach is versatile, with many surgical options depending on the level and case requirements.

One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series

PURPOSE

The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time.

METHODS

Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B.

RESULTS

The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which became normal (9.0 ± 2.8 mm/h) within 3 months in all patients.

CONCLUSIONS

Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries.

Outcomes of different surgical procedures in the treatment of spinal tuberculosis in adults

OBJECTIVE

To investigate surgical methods and outcomes in the treatment of spinal tuberculosis (TB) in adults.

SUBJECTS AND METHODS

One hundred and eighty-one patients (average age 39 years) without multiple-level noncontiguous spinal TB were followed up for 22-72 months. The patients were divided into four groups according to surgical procedure on the basis of the position and extension of the foci: group A (74 cases): anterior radical debridement and strut grafting with instrumentation; group B (83 cases): posterior instrumentation and bone grafting with anterior radical debridement and strut grafting in a single- or two-stage procedure; group C (10 cases): extrapleural anterolateral decompression and strut grafting with posterior instrumentation in thoracic or thoracolumbar spine, and group D (27 cases): single-stage transforaminal decompression and posterior instrumentation and fusion.

RESULTS

There was a significant decrease (p < 0.05) in mean preoperative (81%) Oswestry's Disability Index. Except for 24 patients with lumbosacral TB who were only instrumented posteriorly, kyphosis degrees were corrected by a mean of 11.5° in the anterior instrumentation group and 12.6° in the posterior instrumentation group (p < 0.01). The correction loss was 6.8° in the anterior instrumentation group and 6.1° in the posterior instrumentation group at the last follow-up (p < 0.01).

CONCLUSION

The four surgical procedures obtained good results for correction and maintenance of the correction, clearance of the foci, decompression of the spinal cord and pain relief in the treatment of spinal TB in adults, providing that the operative indication is accurately identified. However, the posterior approach was superior to anterior instrumentation for correcting deformity and maintaining the correction.