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

Efficacy and Clinical Outcomes of Minimally Invasive Direct Thoracic Interbody Fusion: A Retrospective Analysis

INTRODUCTION

A unique surgical approach - the minimally invasive direct interbody fusion (MIS-DTIF) - was previously introduced in our proof-of-concept study, which included four patients who underwent thoracic interbody fusion below the scapula at the T6/7 vertebral level. However, due to the novelty of this method, a report of associated operative parameters such as pain, function, and clinical outcomes from an expanded patient cohort was needed to assess the validity of our results.

MATERIALS AND METHODS

Following IRB approval, data were analyzed retrospectively from electronic health records between 2014 and 2021. Inclusion criteria were patients ≥18 years old who underwent minimally invasive thoracic interbody fusion using the MIS-DTIF technique for at least one vertebral level. The primary outcomes included demographic/radiographic features (e.g., age). Secondary outcomes included perioperative clinical features (e.g., preoperative and ≥1-year final follow-up (FFU)). Tertiary outcomes included perioperative complications. Both preoperative and FFU patient-reported pain and functional outcomes (ODI scores) were analyzed using t-tests to establish significance.  Results: A total of 13 patients who underwent MIS-DTIF surgery were observed, with eight male patients and five female patients. The average age was 49.2 years, with an average BMI of 30.5 kg/m². Of the surgeries included, the majority (69.23%) were 1-level thoracic vertebrae fusions - with 2-level fusions and ≥ 3-level fusions accounting for 15.38% and 15.38% of cases, respectively. The mean operative time was 58.9 ± 19.9 minutes, with an average fluoroscopy time of 285.7 ± 126.8 seconds and an average actual blood loss volume of 109.0 ± 79.0 mL. The average hospital length of stay was 1.1 (±1.7) days, and no clinically significant perioperative complications were observed in this patient cohort. The average follow-up period was 12.1 ± 9.6 months, with preoperative and FFU back pain visual analog scale (VAS) scores showing highly significant improvement (p<0.001). In addition to pain reduction, quality of life improvements was noted, with significant differences in some of the ODI domains between preoperative and FFU scores (p<0.05), as well as the overall total score between preoperative and FFU ODI assessment (p<0.001) - both of which reflect increased patient function and decreased disability.

CONCLUSION

This study provides further evidence for the safety and efficacy of the MIS-DTIF approach for surgical management of symptomatically refractory patients with thoracic disc herniation or stenosis owing to degenerative disc disease or compression fractures. Additionally, the data gathered suggests that this minimally invasive procedure offers many clinical benefits, including less tissue damage, decreased intraoperative blood loss, shortened surgery time, and shortened hospital length of stay. Finally, in addition to significant pain intensity improvement, this study showed that treated patients highly benefited from 'sleeping' and 'return-to-work' domains and other ODI functional domains in activities of daily living (ADLs). More clinical studies are recommended in larger patient cohorts to ascertain the findings reported in this study.

Efficacy analysis of one-stage posterior-only surgical treatment for thoracic spinal tuberculosis in the T4-6 segments with minimum 5-year follow-up

In recent years, with the in-depth research on spinal tuberculosis, posterior surgery alone has been praised highly by more and more surgeons due to the better correction of kyphosis, better maintenance of spinal physiological curvature, smaller surgical trauma and fewer surgical complications. However, there is currently lack of relevant reports about the efficacy of posterior surgery alone in the treatment of tuberculosis in the T4–6 segments. This study aimed to evaluate the clinical study efficacy and feasibility of one-stage posterior-only surgical treatment for thoracic spinal tuberculosis in the T4–6 segments. 67 patients with tuberculosis in T4–6 segments who underwent one-stage posterior-only surgery were included in this study. The clinical efficacy was evaluated using statistical analysis based on the data about erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Oswestry Dability Index (ODI) score, Visual Analogue Scale (VAS) score and Cobb angle before surgery, after surgery and at the last follow-up. All patients completed fusion during the follow-up period of 6–9 months. ESR and CRP were returned to normal for all patients at 6 months follow-up. In the meanwhile, among the 27 patients combined with neurological impairment, neurological functions of 22 cases (81.48%) recovered completely at the last follow-up (P < 0.05). Cobb angle of the kyphosis was improved from preoperative 34.8 ± 10.9° to postoperative 9.6 ± 2.8°, maintaining at 11.3 ± 3.2° at the last follow-up, The ODI and VAS scores were improved by 77.10% and 81.70%, respectively. This 5-year follow-up study shows that better clinical efficacy can be achieved for tuberculosis in T4–6 segments using one-stage posterior-only approach by costotransverse debridement in combination with bone graft and internal fixation. The posterior surgical method cannot only effectively accomplish debridement, obtain satisfactory clinical results, but also well correct kyphotic deformity and maintain it.

Comparison of anterior, posterior, and anterior combined with posterior surgical treatment of thoracic and lumbar spinal tuberculosis: a systematic review

Background

This study was performed to compare different surgical approaches in the treatment of spinal tuberculosis.

Methods

We conducted a literature search to identify and analyze papers published from January 1966 to April 2018 relevant to comparison of the anterior, posterior, and anterior combined with posterior approaches in the treatment of spinal tuberculosis of the thoracic and lumbar regions.

Results

Twenty-five studies involving 2295 patients were identified in this systematic review. The operative time was significantly longer in the anterior combined with posterior approach than in the other two approaches. Blood loss was significantly greater in the anterior combined with posterior approach (1125.0 ± 275.5 mL) than in the posterior approach (710.4 ± 192.4 mL). The difference in correction of the kyphosis angle among the three procedures was not significant. The overall surgical and transthoracic complications were significantly lower in the posterior approach. The clinical outcome of all patients improved, but there was no significant difference among the three procedures.

Conclusions

Blood loss, overall surgical and transthoracic complications, and the operative time are different among the three approaches. Therefore, different factors must be carefully assessed in deciding among the three procedures.

Tuberculous Spondylolisthesis: A Reappraisal of the Clinicoradiologic Spectrum and Surgical Treatment Paradigm

INTRODUCTION

Spinal tuberculosis (TB) is a common infectious disease prevalent in developing countries and an increasing issue in developed countries. The association of tuberculosis with spondylolisthesis is rarely reported in literature. The aim of our review is to analyze the clinical features and radiologic characteristics of TB spondylolisthesis and to provide a concise update on its surgical management, based on the literature.

METHODS

A systematic review was performed after conducting a thorough search of the PubMed database. Articles were selected systematically and reviewed completely and relevant data were summarized and discussed.

RESULTS

Nineteen articles were selected for the review. The most common clinical manifestation was focal back pain, followed by motor deficit. Most patients had grade 2 listhesis and associated tubercular abscess. The anterior as well as the posterior surgical approach have their own advantages and the choice of approach depends on the location of disease, ease of access, achievement of spinal stability, and avoidance of spread of contiguous infection. Although a posterior approach and fixation using pedicular screws and rods along with debridement of pus or granulation tissue is the favored approach in dorsolumbar TB, an anterior approach, corpectomy, and fusion are preferred in cervical TB.

CONCLUSIONS

Treatment of TB spondylolisthesis encompasses a wide spectrum of surgical options. However, the mainstay of treatment is chemotherapy. The indications for which surgical management may have an upper hand over medical management are spinal cord compression, significant instability, large tubercular abscess, painful vertebral lesions, kyphosis, and infection by multidrug-resistant TB or extreme drug-resistant TB, when medical management alone does not help. Surgery is effective in these situations by achieving radical debridement, permanent stability, prevention of further neurologic deterioration, and early recovery. Even although conservative management may help in certain cases, a posterior approach, decompression, and fusion are preferred for unstable dorsolumbar disease, whereas an anterior approach is preferred for cervical disease. Combined approaches can be considered in pediatric spinal TB for the correction of kyphotic deformity and its consequent maintenance.

Trends in Spinal Surgery for Pott's Disease (2000-2016): An Overview and Bibliometric Study

STUDY DESIGN

Systematic review.

OBJECTIVES

(1) What are the surgical indications? Have they changed over time since the year 2000? (2) What is the current surgical approaches of choice? Have they changed over time since the year 2000? Do they vary by geographical region? (3) What are the most common outcome measures following surgery?

METHODS

Electronic databases and reference lists of key articles were searched from database inception from January 1, 2000 to December 31, 2016 to identify studies specifically evaluating surgical indications, current surgical approaches, and outcome measures for spinal tuberculosis.

RESULTS

Six randomized controlled trials were identified from our search (1 excluded: no surgical arm identified after review) Neurological deficit, instability and deformity were common indications identified. Surgical approach included predominantly anterior for cervical spine and posterior for thoracic and lumbar spine. Combined approach was preferred in pediatric cases. Degree of deformity correction, neurological outcomes, and fusion formed the main bases of assessing surgical outcomes.

CONCLUSIONS

Majority of the current literature is from South Asia. The presence of neurological compromise, deformity, and instability were the primary criteria for surgical intervention. The preferred approach varied with the anatomical region of the spine in adults. Outcome measures predominantly involved deformity correction, neurological deficit, and fusion.

Minimally Invasive Direct Thoracic Interbody Fusion (MIS-DTIF): Technical Notes of a Single Surgeon Study

Background

Minimally invasive direct thoracic interbody fusion (MIS-DTIF) is a new single surgeon procedure for fusion of the thoracic vertebrae below the scapula (T6/7) to the thoracolumbar junction. In this proof of concept study, we describe the surgical technique for MIS-DTIF and report our experience and the perioperative outcomes of the first four patients who underwent this procedure.

Study design/setting

In this study we attempt to establish the safety and efficacy of MIS-DTIF. We have performed MIS-DTIF on six spinal levels in four patients with degenerative disk disease or disk herniation. We recorded surgery time, blood loss, fluoroscopy time, complications, and patient-reported pain.

Methods

Throughout the MIS-DTIF procedure, the surgeon is aided by biplanar fluoroscopic imaging and electrophysiological monitoring. The surgeon approaches the spine with a series of gentle tissue dilations and inserts a working tube that establishes a direct connection from the outside of the skin to the disk space. Through this working tube, the surgeon performs a discectomy and inserts an interbody graft or cage. The procedure is completed with minimally invasive (MI) posterior pedicle screw fixation.

Results

For the single level patients the mean blood loss was 90 ml, surgery time 43 minutes, fluoroscopy time 293 seconds, and hospital stay two days. For the two-level surgeries, the mean blood loss was 27 ml, surgery time 61 minutes, fluoroscopy time 321 seconds, and hospital stay three days. We did not encounter any clinically significant complications. Thirty days post-surgery, the patients reported a statistically significant reduction of 5.3 points on a 10-point sliding pain scale.

Conclusions

MIS-DTIF with pedicle screw fixation is a safe and clinically effective procedure for fusions of the thoracic spine. The procedure is technically straightforward and overcomes many of the limitations of the current minimally invasive (MI) approaches to the thoracic spine. MIS-DTIF has the potential to improve patient outcomes and reduce costs relative to the current standard of care. We are currently expanding this study to a larger cohort and recording long term outcomes and costs.