The posterior-only surgical approach in the treatment of tuberculosis of the spine

Learning curve and complication analysis of oblique lateral interbody fusion in cases with single-segment lumbar tuberculosis: a retrospective single-center consecutive study

OBJECTIVE

Oblique lateral interbody fusion (OLIF) is becoming widely used in patients with single-segment spinal tuberculosis (STB). The learning curve and complications associated with OLIF for the treatment of STB are still unknown. This study aims to figure out the learning curve and associated complications experience of OLIF for the treatment of STB.

METHODS

Between September 2018 and August 2023, 61 STB patients underwent OLIF plus percutaneous pedicle screw fixation (PPSF) were consecutively included in this research. Cumulative sum analysis (CUSUM) was applied to establish the learning curve of OLIF and determine the cut-off case number. All cases were divided into learning and experienced groups based on the cut-off case number. Clinical characteristics and relating surgical complications were compared and analyzed between the two groups.

RESULTS

The best-fitting curve was quadratic. The fitting equation was CUSUM (min) = 95.83 + 34.16x - 0.611 x 2 (x means operation case). The cut-off operation case number was 27 cases. The presence of significant differences particularly in the duration of operation, operative blood loss, overall incidence, and severity of postoperative complications was noteworthy between the two groups.

CONCLUSION

A total of 27 cases is the minimum number to master OLIF combined with PPSF for the treatment of patients with single-segment STB. When surgeons master this operation, the operative time, operative blood loss, overall incidence, and severity of postoperative complications will improve.

Disparities in the Clinical Profile of Spinal Tuberculosis in Africa: A Scoping Review of Management and Outcome

BACKGROUND

Spinal tuberculosis (STB) is a significant contributor to nontraumatic myelopathy. There is a rising burden in Africa, in parallel with the high prevalence of human immunodeficiency virus. We conducted a scoping review to highlight the disparities in the management and outcomes of STB in Africa.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping review guidelines. AJOL, Embase, MEDLINE, Google Scholar, and Cochrane CENTRAL databases were searched to identify all relevant peer-reviewed articles published on the management of STB in African centers, excluding abstract-only articles, literature reviews, and meta-analyses.

RESULTS

Sixty studies were eligible for inclusion, comprising data from 3416 patients aged 8 months to 89 years (median, 32 years). Thoracic and lumbar segments were the most commonly affected vertebral regions (thoracic = 42.7%; lumbar = 35.9%). The most common clinical features were back pain and neurological deficits. Lack of essential laboratory and imaging diagnostic infrastructure was a common problem. Patients received antitubercular therapy (ATT) for varying durations, and only 18.3% underwent surgery. A favorable outcome was achieved in 51.6% of patients, 20.3% developed a permanent disability, and the mortality rate was 2.1%. Treatment outcome was adversely affected by a high rate of late presentation and treatment default.

CONCLUSIONS

ATT remains the mainstay of treatment; however, the duration of treatment varied widely among studies. Further research is required to explore the feasibility and efficacy of short-course ATT in treating STB in the African population.

Predictive Value of Vertebral Bone Destruction Classification Based on Computed Tomography in Diagnosing on Adult Spinal Tuberculosis

OBJECTIVE

Although magnetic resonance imaging (MRI) is well-established for evaluation of spinal tuberculosis (TB), the importance of computed tomography (CT) should not be overlooked. The purpose of this study was to determine the characteristics of spinal TB and the relationship between spinal TB and the bone lesion pattern seen on three-dimensional CT images.

METHODS

One hundred and sixty-one subjects were divided into a TB-positive group and a TB-negative group based on laboratory (X-pert mycobacterium tuberculosis/ rifampin) results and then subdivided further according to whether the bone lesion pattern seen on three-dimensional CT images was fragmentary, osteolytic, sclerotic, or had no evidence of bone destruction. The diagnostic value of the bone lesion pattern was compared between the TB-positive and TB-negative groups.

RESULTS

Ninety-nine of the 161 patients were TB-positive and 62 were TB-negative. Fifty-six (34.8%) of the 161 patients had fragmentary/osteolytic lesions, seventy-four (45.9%) had absolute osteolytic lesions, 13 (8.1%) had osteosclerotic lesions, and 18 (11.2%) had no evidence of bone destruction. The fragmentary/osteolytic lesion pattern was strongly predictive of spinal TB (odds ratio 3.33), and when combined with 3 MRI findings (thin abscess wall, more than one half of the vertebral body destroyed, and subligamentous spread) had an even stronger diagnostic value (odds ratio 15.58).

CONCLUSIONS

The absolute osteolytic pattern was the most common of the bone lesion patterns. The fragmentary/osteolytic pattern is highly suggestive of spinal TB, especially when combined with MRI findings of a thin abscess wall, destruction of more than one half of the vertebral body, and subligamentous spread.

Effectiveness and safety analysis of titanium mesh grafting versus bone grafting in the treatment of spinal Tuberculosis: a systematic review and meta-analysis

BACKGROUND

To systematically assess the safety and effectiveness of titanium mesh grafting compared with bone grafting in the treatment of spinal tuberculosis.

METHODS

Electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, were searched from their inception until April 2023. The outcome indicators for patients treated with titanium mesh grafting or bone grafting for spinal tuberculosis include surgical duration, intraoperative blood loss, graft fusion time, American Spinal Injury Association (ASIA) Spinal Cord Injury Grade E assessment, VAS score, lumbar pain score, post-graft kyphotic angle, and postoperative complications. The Newcastle-Ottawa Scale (NOS) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used for quality assessment and evidence grading of clinical studies. Funnel plots and Begg's test were employed for bias assessment.

RESULTS

A total of 8 studies were finally included, comprising 523 patients, with 267 cases of titanium mesh fixation and 256 cases of bone grafting. The meta-analysis showed no significant statistical differences in surgical duration (Weighted Mean Difference (WMD) = -7.20, 95% Confidence Interval (CI): -28.06 to 13.67, P = 0.499), intraoperative blood loss (WMD = 16.22, 95% CI: -40.62 to 73.06, P = 0.576), graft fusion time (WMD = 0.97, 95% CI: -0.88 to 2.81, P = 0.304), ASIA Spinal Cord Injury Grade E assessment (Relative Risk (RR) = 1.03, 95% CI: 0.97 to 1.09, P = 0.346), and overall complications (RR = 0.87, 95% CI: 0.49 to 1.55, P = 0.643). Differences in VAS score, ODI lumbar pain score, and post-graft kyphotic angle between the titanium mesh grafting group and the bone grafting group were not significant within the 95% CI range. The rate of postoperative implant subsidence was slightly lower in bone grafting than in titanium mesh grafting (RR = 9.30, 95% CI: 1.05 to 82.22, P = 0.045).

CONCLUSIONS

Both bone grafting and titanium mesh grafting are effective and safe for the surgery, with no significant statistical differences in the results. Considering the limitations of the present study, large-scale randomized controlled trials are warranted to further verify the reliability of this finding.

A comparison of the biomechanical properties of three different lumbar internal fixation methods in the treatment of lumbosacral spinal tuberculosis: finite element analysis

There are various internal fixation methods in treating lumbosacral spinal tuberculosis. The study compared the stability and stress distribution in surrounding tissues/implants, such as discs, endplates and screw-rod internal fixation system, etc. when applying three different lumbar internal fixation methods to treat lumbosacral spinal tuberculosis. A finite element model was constructed and validated. The spinal stability was restored using three methods: a titanium cage with lateral double screw-rod fixation (group 1), autologous bone with posterior double screw-rod fixation (group 2), and a titanium cage with posterior double screw-rod fixation (group 3). For comparison, group 4 represented the intact L3-S1 spine. Finally, a load was applied, and the ranges of motion and Von Mises stresses in the cortical endplates, screw-rod internal fixation system and cortical bone around the screws in the different groups were recorded and analyzed. All six ranges of motion (flexion, extension, left/right lateral bending, left/right rotation) of the surgical segment were substantially lower in groups 1 (0.53° ~ 1.41°), 2 (0.68° ~ 1.54°) and 3 (0.55° ~ 0.64°) than in group 4 (4.48° ~ 10.12°). The maximum stress in the screw-rod internal fixation system was clearly higher in group 2 than in groups 1 and 3 under flexion, left/right lateral bending, and left/right rotation. However, in extension, group 1 had the highest maximum stress in the screw-rod internal fixation system. Group 2 had the lowest peak stresses in the cortical endplates in all directions. The peak stresses in the cortical bone around the screws were higher in group 1 and group 2 than in group 3 in all directions. Thus, titanium cage with posterior double screw-rod fixation has more advantages in immediate reconstruction of lumbosacral spinal stability and prevention of screw loosening.

Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis

BACKGROUND

The incidence of lumbar tuberculosis is high worldwide, and effective treatment is a continuing problem.

AIM

To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.

METHODS

The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), visual analogue scale (VAS) score, oswestry disability index (ODI) and American Spinal Injury Association (ASIA) grade were recorded and analysed pre- and postoperatively.

RESULTS

The CRP level and ESR returned to normal, and the VAS score and ODI were decreased at 3 mo postoperatively, with significant differences compared with the preoperative values (P < 0.01). Neurological dysfunction was relieved, and the ASIA grade increased, with no adverse events.

CONCLUSION

The multitrack, multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 Granular Bone Grafts and Transverse Process Bone Grafts for Single-Segmental Thoracic Tuberculosis: A Retrospective Single-Center Comparative Study

Background: To compare the clinical efficacy of granular bone grafts and transverse process bone grafts for single-segmental thoracic tuberculosis (TB). Methods: The clinical records of 52 patients who were diagnosed with single-segmental thoracic TB and treated by one stage posterior debridement, bone graft fusion, and internal fixation in our department from 2015 to 2018 were retrospectively analyzed. Among them, 25 cases were in the granular bone graft group and 27 cases in the transverse processes bone graft group. Outcomes including the visual analog scale (VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), neurological function, operative time, operative blood loss, hospital stay, Cobb angle, bone graft fusion time, and postoperative complications were all recorded and analyzed. Results: There were no significant differences in operative time, operative blood loss, and hospital stay between the two groups (P > 0.05). With an average follow-up of 18-33 months, all patients in the two groups showed significant improvement in VAS score, ESR, CRP, and neurological function compared with preoperative measurements (P < 0.05), however, no significant differences were found for the last follow-up (P > 0.05). The two groups showed similar Cobb angle correction (P > 0.05), but the granular bone graft group had a larger Cobb angle loss than the transverse processes bone graft group (P < 0.05). The bone graft fusion time of the granular bone graft group was shorter than that of the transverse processes bone graft group (P < 0.05). No significant difference was found in the postoperative complications rate between the two groups (P > 0.05). Conclusion: Granular bone grafts and transverse process bone grafts may achieve comparable clinical efficacy for single-segmental thoracic TB, but the former method had a shorter bone fusion time.

Unilateral Limited Laminectomy for Debridement to Treat Localized Short-Segment Lumbosacral Spinal Tuberculosis: A Retrospective Case Series

Objective

This study aimed to investigate the clinical effects of surgically treating lumbosacral tuberculosis with a modified posterior unilateral limited laminectomy method for debridement.

Methods

This retrospective study enrolled a total of 26 patients who were administered in our institution from January 2010 to December 2016, diagnosed with lumbosacral tuberculosis at the L5/S1 level, and underwent one‐stage posterior unilateral limited laminectomy as surgical treatment for debridement, allograft of cortical bone grafting, and fixation. The erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) level, visual analog scale (VAS) score, Oswestry Disability Index (ODI), and lumbosacral angle (LA, Cobb's method) were statistically compared, and the American Spinal Injury Association Impairment (ASIA) Scale was compared between the preoperative and postoperative time points to evaluate the clinical outcomes.

Results

All 26 patients were observed during the follow‐up period, and the mean follow‐up time was 1.3 ± 0.42 years. The mean age was 56 ± 7.4 years old. The average operation time was 118.1 ± 17.5 min, and the mean bleeding volume was 513.0 ± 79.6 mL. There were no intraoperative complications or tuberculous sinus, and two cases experienced hypostatic pneumonia during hospitalization, which resolved with responsive antibiotics and symptomatic supportive treatment. At the final follow‐up, there was no recurrence of tuberculosis, and the ESR (11.8 ± 1.8 mm/h) and CRP (3.0 ± 1.0 mg/L) levels in all patients had returned to normal. The patients with neurologic deficits had improved, and the mean ODI was 79.9 ± 10.6 (87–62) preoperatively and significantly decreased to 20.5 ± 5.7 (11–29) at the final follow‐up (P < 0.01). ASIA scale scores were improved by 1~2 grades at the last follow‐up. The patients' pain levels were significantly alleviated; the mean VAS score declined to 1.2 ± 0.4 (0–2.5) at the final follow‐up compared to 7.5 ± 1.6 (6.5–8.5) preoperatively (P < 0.01). All patients achieved bony graft fusion at an average time of 6.8 ± 1.2 months. Physiological lumbar lordosis was significantly improved, and the mean LA before operation was 17.6° ± 2.1°, which was significantly different from the postoperative LA (29.3° ± 7.4°, P < 0.01) at the final follow up. The LA (27.1° ± 5.5°, P = 0.15) slightly rebounded but without significance compared to the postoperative level.

Conclusion

Only posterior approach by unilateral limited laminectomy for debridement could be served as an effective and safe method to treat short‐segment lumbosacral tuberculosis without extensive anterior sacral and gravitation abscesses.

Arthroscopic Ankle Arthrodesis for End-Stage Tuberculosis of the Ankle: A 2-Year Follow-Up

Surgical treatment for end-stage ankle joint tuberculosis (TB) has rarely been reported. This study followed cases treated by arthroscopic arthrodesis for ankle joint TB to evaluate its efficacy and safety in the clinic. Patients who underwent arthroscopic ankle arthrodesis for ankle joint TB between April 11, 2010, and December 31, 2016, were followed. Their diagnoses were confirmed by bacterial culture or pathological examination. During arthroscopy, tissue samples were first obtained to further confirm the diagnosis. Then the necrotic tissue, hyperplasia of synovial tissue, and exfoliated cartilage were removed. Ankle joint arthrodesis was performed if the area of articular cartilage damage was >2 cm². Continued nutritional support and standardized anti-TB drug treatment were given after surgery. Follow-up measurements included visual analogue scale score, American Orthopaedic Foot and Ankle Society score, erythrocyte sedimentation rate, and radiographic imaging. All 9 patients in this study, with an average age of 54 (range 37 to 68) years, were followed. The mean follow-up duration was 55.44 ± 31.15 (range 24 to 96) months. There were significant differences in the visual analogue scale scores, American Orthopaedic Foot and Ankle Society scores, and erythrocyte sedimentation rate between before treatment and 18 months postoperatively (p < .05). All patients (100%) showed union at 18 ± 4 weeks. Arthroscopic treatment for ankle joint TB has the advantages of minor trauma and low complications. It can be used to accurately obtain samples from specific areas of TB for further diagnosis. According to the degree of articular cartilage damage, the surgeon can determine whether to perform arthrodesis. Thorough debridement of necrotic tissue and residual articular cartilage on the fusion surface can improve the rate of ankle fusion.

Early surgical intervention for active thoracic spinal tuberculosis patients with paraparesis and paraplegia

Background

To explore the therapeutic effect of early surgical intervention for active thoracic spinal tuberculosis (TB) patients with paraparesis and paraplegia.

Methods

Data on 118 active thoracic spinal TB patients with paraparesis and paraplegia who had undergone surgery at an early stage (within three weeks of paraparesis and paraplegia) from January 2008 to December 2014 were retrospectively analyzed. The operation duration, blood loss, perioperative complication rate, VAS score, ASIA grade and NASCIS score of neurological status rating, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), kyphotic Cobb’s angle, and duration of bone graft fusion were analyzed to evaluate the therapeutic effects of surgery.

Results

The mean operating time was 194.2 minutes, and the mean blood loss was 871.2 ml. The perioperative complication rate was 5.9 %. The mean preoperative VAS score was 5.3, which significantly decreased to 3.2 after the operation and continued decreasing to 1.1 at follow up (P<0.05). All cases achieved an increase of at least one ASIA grade after operation. The rate of full neurological recovery for paraplegia (ASIA grade A and B) was 18.0 % and was significantly lower than the rate (100 %) for paraparesis (ASIA grade C and D) (P<0.05). On the NASCIS scale, the difference in the neurological improvement rate between paraplegia (22.2 % ± 14.1 % in sensation and 52.2 % ± 25.8 % in movement) and paraparesis (26.7 % ± 7.5 % in sensation and 59.4 % ± 7.3 % in movement) was remarkable (P<0.05). Mean preoperative ESR and CRP were 73.1 mm /h and 82.4 mg/L, respectively, which showed a significant increase after operation (P>0.05), then gradually decreased to 11.5 ± 1.8 mm/h and 2.6 ± 0.82 mg/L, respectively, at final follow up (P<0.05). The mean preoperative kyphotic Cobb’s angle was 21.9º, which significantly decreased to 6.5º after operation (P<0.05) while kyphotic correction was not lost during follow up (P>0.05). The mean duration of bone graft fusion was 8.6 ± 1.3 months.

Conclusions

Early surgical intervention may be beneficial for active thoracic spinal TB patients with paraparesis and paraplegia, with surgical intervention being more beneficial for recovery from paraparesis than paraplegia.

Oblique lateral interbody fusion combined percutaneous pedicle screw fixation in the surgical treatment of single-segment lumbar tuberculosis: A single-center retrospective comparative study

OBJECTIVE

To evaluate the clinical efficacy of oblique lateral interbody fusion combined posterior percutaneous pedicle screw fixation in the treatment of single segment lumbar tuberculosis.

METHODS

Patients who underwent surgical treatment for single segment lumbar tuberculosis from 2015 to 2018 in our department were retrospectively included in this study. The included patients were divided into two groups, namely oblique lateral interbody fusion combined percutaneous pedicle screw fixation (OLIF) group and traditional posterior transforaminal or transpedicular approach debridement and pedicle screws fixation (PTA) group, according to the surgical methods. Outcomes including operative time, operative blood loss, hospital stay, visual analogue scale (VAS) score, Oswestry disability index (ODI), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), Cobb angle correction and loss, bone fusion time, ASIA grade and complications were all recorded and compared.

RESULTS

A total of 60 patients were included in this study, involving 23 patients in the OLIF group and 37 patients in the PTA group. The OLIF group had less operative time, blood loss and shorter hospital stay compared with the PTA group (P < 0.05). Both the two groups achieved significant improvements in ESR, CRP and ASIA grade at the last follow-up (P < 0.05), but no significant differences were found between them (P>0.05). There were no significant differences in Cobb angle correction and loss between the two groups (P > 0.05), but the bone graft fusion time of the OLIF group was significantly shorter than the PTA group (P < 0.05). The two groups achieved similar improvement in VAS score and ODI at 12 months postoperative and the last follow-up, however, OLIF group had a lower VAS score and ODI at 1 month, 3 months and 6 months postoperative (P < 0.05). No significant difference was found in complications between the two groups (P > 0.05) and all patients were cured after active treatment.

CONCLUSIONS

Both OLIF and PTA can achieve satisfactory clinical efficacy in the surgical treatment of single segment lumbar TB, but OLIF has the advantages of less surgical trauma, faster postoperative recovery and shorter bone fusion time.

Low sensitivity of histopathological examination of peri-implant tissue samples in diagnosing postoperative spinal implant infection

AIMS

To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII).

METHODS

This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study.

RESULTS

PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci.

CONCLUSION

Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899-903.

The efficacy of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis

Background

The bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis has not been explained in detail. We aimed to analyze the efficacy of bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis.

Methods

We treated 32 thoracic or thoracolumbar tuberculosis patients by one-stage posterior debridement, allograft bone graft using titanium mesh, posterior instrumentation, and fusion from May 2011 to September 2015. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were analyzed preoperatively, postoperatively, and at final follow-up. The Cobb angles were recorded to evaluate the kyphosis correction and the loss of correction. The bony fusion was evaluated by X-ray and computed tomography images, and the bony fusion classifications were recorded.

Results

All patients had pain relief. The erythrocyte sedimentation rate, C-response protein, and hepatorenal function were normal at final follow-up. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were improved in all the patients. All patients achieved bone fusion. Twenty-eight patients achieved complete fusion (Grade I), whereas only four patients achieved partial fusion (Grade II). The preoperative Cobb angle was 33.6 ± 9.3°. The Cobb angle was reduced to 10.6 ± 2.6° postoperatively and was found to be 11.4 ± 3.1° at the final follow-up. The mean angle correction was 23.0 ± 8.9°, and the correction rate was 66.2 ± 12.2%. The mean angle lost was 0.8 ± 0.9°, and the lost rate was 5.8 ± 5.4% at the final follow-up.

Conclusions

Allograft bone using titanium mesh in the posterior-only surgical treatment is effective for patients with thoracic and thoracolumbar spinal tuberculosis. It can correct kyphosis, and most patients can achieve complete bony fusion.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis - a long-term retrospective study of 106 cases

Background

Minimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy.

Methods

A total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI).

Results

The mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination.

Conclusion

MIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

Transforaminal debridement with a posterior-only approach involving placement of an interbody bone graft combined with diseased vertebral fixation for the treatment of thoracic and lumbar tuberculosis: Minimum 5-year follow-up

The aim of this study was to evaluate the clinical and imaging results of transforaminal debridement with a posterior-only approach involving placement of an interbody bone graft combined with diseased vertebral fixation for the treatment of thoracic and lumbar tuberculosis (TB) with a minimum 5-year follow-up.Sixty-five patients who presented with active thoracic and lumbar TB between October 2006 and August 2013 were retrospectively analyzed: 20 were thoracic TB (group A), 17 were thoracolumbar TB (group B), and 28 were lumbar TB (group C). The patient data, operating time, blood loss, Visual Analog Scale score, Oswestry Disability Index score, correction of kyphosis, recovery of neurological function, and complications were recorded and analyzed.The patients were followed for 68.7 ± 17.8 months. The preoperative average Cobb angles of kyphosis in patients in groups A, B, and C significantly decreased from 28.2 ± 11.9°, 30.5 ± 16.9°, and 10.9 ± 8.8° before surgery to 8.0 ± 5.4°, 5.0 ± 4.1°, and -4.4 ± 1.6° (- indicates lordosis) after surgery, respectively. At the final follow-up time, the Cobb angles were 9.2 ± 6.1°, 6.8 ± 10.0°, and -3.7 ± 2.0°, respectively. The postoperative Cobb angles of kyphosis were significantly improved in all groups (P < .05). The correction loss angles were larger in groups A and B than in group C (P > .05). The operating time, blood loss, and complications were not significantly different between the groups (P > .05). Three (4.6%) patients developed unhealed TB during postoperative anti-TB treatment, and 6 patients (9.2%) with TB relapsed after healing from surgery.The posterior-only approach for the surgical treatment of thoracic and lumbar TB achieved satisfactory outcomes over long-term follow-up. The implantation of pedicle screws in diseased vertebrae reduced the range of fixation, but patients with thoracic and thoracolumbar TB should undergo fixation to at least 1 adjacent normal segment. There were some cases of recurrence after TB healed, and long-term follow-up is therefore necessary.

Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults

Background

The surgical procedures for mid-thoracic spinal tuberculosis mainly include anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion. Until now, the surgical choice is still controversial. This study aims to compare the clinical efficacy of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic (T5–9) spinal tuberculosis in adult patients.

Methods

Eighty-seven cases with mid-thoracic spinal tuberculosis were treated with anterior transthoracic debridement and fusion (Group A, n = 39) and posterior transpedicular debridement and fusion (Group B, n = 48) from January 2007 to June 2014. Parameters including the operation time, blood loss, time of ESR and CRP decreasing to the normal level, time of abscess disappearance, time of bone graft fusion, rate of surgical complications, Visual Analog Scale (VAS) score, kyphosis angle and SF-36 scale were compared between two groups to evaluate their therapeutic effects.

Results

All patients were followed up for 5–10 years with the mean of 6.2 ± 1.1 years. No significant differences were observed regarding the gender composition ratio, age, course of disease, number of lesion segments, and preoperative indexes of ESR, CRP, VAS score, kyphosis angle and SF-36 scale between the two groups. Besides, no significant differences were observed regarding VAS score, kyphosis angle and SF-36 scale between the two groups in the 5th postoperative year (P > 0.05). However, the operation time (158.2 ± 10.7 min vs. 183.7 ± 14.1 min), blood loss (517.9 ± 76.5 ml vs.714.6 ± 57.4 ml), time of ESR (2.3 ± 1.1 months vs.3.1 ± 1.4 months) and CRP (1.1 ± 0.3 months vs.1.2 ± 0.6 months) decreasing to the normal level, time of abscess disappearance (2.7 ± 1.6 months vs.4.9 ± 1.9 months), and time of bone graft fusion (6.6 ± 0.8 months vs.8.0 ± 9.6 months) in Group A were less than those in Group B (P < 0.05).

Conclusions

Both anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion have a low risk of surgical complications and provide good quality of life for the patients with mid-thoracic (T5–9) spinal tuberculosis followed up in the mid-term. Moreover, the anterior procedure leads to early resolution of the disease and faster fusion.

Could Nonstructural Interbody Fusion Be an Alternative Surgical Technique for Treatment of Single Segment Thoracic and Lumbar Spinal Tuberculosis via a Posterior- Only Approach?

OBJECTIVE

To compare and evaluate the efficacy and safety of nonstructural versus structural interbody fusion, using a combination of autograft and allograft bone for treatment of single segment thoracic and lumbar spinal tuberculosis (TB) via a posterior-only approach.

METHODS

We retrospectively analyzed 37 patients who were surgically treated in our department for thoracic and lumbar spinal TB between March 2015 and March 2018 and met our inclusion criteria. Eighteen of these 37 patients underwent nonstructural interbody fusion (group A), whereas the other 19 underwent structural interbody fusion with the aid of titanium mesh cages (group B). We compared and analyzed visual analog scale scores, erythrocyte sedimentation rate, blood loss, operation time, bone fusion rates, and correction angles.

RESULTS

The average duration of follow-up was 20.33 ± 4.73 months (range, 12-26 months) in group A and 19.63 ± 4.63 months (range, 12-26 months), in group B. All patients showed significant improvement in neurologic function by 1 or 2 grades. Bone fusion was achieved in all patients, with no statistically significant difference between the 2 groups (P > 0.05). However, there were significant between-group differences in operation time (mean, 196.28 ± 43.49 minutes [range, 128-300 minutes] in group A vs. 223.26 ± 46.34 minutes [range, 150-300 minutes] in group B; P < 0.05) and estimated blood loss (mean, 474.44 ± 224.37 mL [range, 200-900 mL] in group A vs. 585.79 ± 378.82 mL [range, 200-1500] in group B; P < 0.05).

CONCLUSION

The 2 surgical techniques may well have achieved similar results in terms of decreasing bone fusion time, improving neurologic function, and correcting kyphotic angles. However, the nonstructural interbody fusion technique exhibited less blood loss and faster operation time, and thus could serve as an alternative surgical technique for treatment of single-segment thoracic and lumbar spinal TB.

Unexpected positive cultures in presumed aseptic revision spine surgery using sonication

AIMS

During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients.

PATIENTS AND METHODS

All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (sd 20.4) and there were 104 female patients.

RESULTS

Sonication cultures were positive in 75 cases (45.2%). Hardware failure was the most common indication for revision surgery and revealed a positive sonication culture in 26/75 cases (35%) followed by adjacent segment disease (ASD) in 23/75 cases (30%). Cutibacterium acnes and Staphylococcus epidermidis were the most commonly isolated microorganisms, observed in 45% and 31% of cases, respectively. C. acnes was isolated in 65.2% of cases when the indication for revision surgery was ASD.

CONCLUSION

Infection must always be considered as a possibility in the setting of spinal revision surgery, especially in the case of hardware failure, regardless of the lack of clinical signs. Sonication should be routinely used to isolate microorganisms adherent to implants. Cite this article: Bone Joint J 2019;101-B:621-624.