Objective To investigate the short-term effectiveness of the anterior and middle columns in thoracolumbar tuberculosis reconstructed with whole autogenous spinous process-laminar bone through posterior approach. Methods The retrospective study included 78 patients with thoracolumbar tuberculosis who underwent posterior approach surgery and anterior and middle column bone graft reconstruction between January 2012 and May 2023. Based on the type of autogenous bone graft used, patients were divided into group A (whole autogenous spinous process-laminar bone graft, 38 cases) and group B (autogenous structural iliac bone graft, 40 cases). There was no significant difference of baseline data, such as age, gender, disease duration, involved segment of spinal tuberculosis, and preoperative erythrocyte sedimentation rate (ESR), C reactive protein (CRP), Oswestry disability index (ODI), visual analogue scale (VAS) score, the American Spinal Injury Association (ASIA) grade, segmental kyphotic angle, and intervertebral height between the two groups (P>0.05). The operation time, intraoperative blood loss, postoperative drainage, hospital stays, ESR, CRP, VAS score, ODI, bone fusion time, ASIA grade for neurological status valuation, postoperative complications, change of segmental kyphotic angle, change of intervertebral height were recorded and compared between the two groups. Results The operation time in group A was significantly shorter than that in group B (P<0.05); there was no significant difference in intraoperative blood loss, postoperative drainage, and hospital stays between the two groups (P>0.05). All patients in the two groups were followed up 14-110 months (mean, 64.1 months); there was no significant difference in the follow-up time between the two groups (P>0.05). The ESR, CRP, ODI, and VAS score at each time point after operation in both groups significantly improved when compared with those before operation, and further improved with the extension of time, the differences were significant (P<0.05). There was no significant difference between the two groups (P>0.05) except that the VAS score of group A was significantly better than that of group B at 3 days after operation (P<0.05). There was no significant difference in fusion time between the two groups (P>0.05). The neurological function of most patients improved after operation, and there was no significant difference in ASIA grade between the two groups at last follow-up (P>0.05). There was no significant difference in segmental kyphosis angle and intervertebral height between the two groups at each time point (P>0.05), and no significant difference in segmental kyphosis angle, intervertebral height correction and loss were found between the two groups (P>0.05). In group A, there was 1 case of incision fat liquefaction and 1 case of incision infection; in group B, there was 1 case of deep venous thrombosis, 2 cases of pleural effusion, and 10 cases of pain in bone harvesting area; in both groups, there were 2 cases of gout caused by hyperuricemia. There was a significant difference in the incidence of pain in bone harvesting area between the two groups (P<0.05), and there was no significant difference in the incidence of other complications between the two groups (P>0.05). ConclusionWhole autogenous spinous process-laminar bone grafting is equivalent to structural iliac bone graft in reconstruction of the anterior and middle columns in thoracolumbar tuberculosis through posterior approach, effectively supporting the stability of the anterior and middle columns of the spine, while resulting in shorter operation time and less postoperative pain in bone harvesting area.
Objective To summarize the effect of one-stage anterior debridement of infection in function reconstruction of anterior and middle column for the treatment of thoracolumbar spinal tuberculosis. Methods From January 2001 to January 2007, 65 patients with thoracolumbar spinal tuberculosis were treated with one-stage anterior debridement, decompression, autogenous bone grafts and internal fixation. There were 43 males and 22 females with an average age of 40.2 years (range, 19-64 years), including 18 cases of thoracic tuberculosis (T4-10), 44 cases of thoracolumbar tuberculosis (T11-L2) and 3 cases of lumbar tuberculosis (L3-5). The disease course was 3 months to 10 years (median 10 months). One segment was involved in 7 cases, two segments in 54 cases and three segments in 4 cases. In 14 cases with spinalcord injury, there were 5 cases of grade C and 9 cases of grade D according to Frankel classification. The kyphotic Cobb angle was 20-65° (41° on average). Results The operative time was 120-210 minutes (170 minutes on average), and the blood loss was 300-1 500 mL (600 mL on average). Fifty-eight patients were followed up for 1-6 years (23 months on average). Abscess occurred in 2 cases at 40 days and 3 months, and healed after symptomatic management. The other incisions achieved heal ing by first intention. The X-ray films showed bony fusion 4-12 months (6 months on average) after operation. No tuberculosis recurred. At 12 months after operation, pain disappeared, and there were 7 cases of grade D and 7 cases of grade E according to Frankel classification. The kyphotic Cobb angle was 0-33° (24° on average), showing statistically significant difference (P lt; 0.05) when compared with preoperation. Conclusion Early reconstruction of load-bearing function and stabil ity of anterior and middle column in the treatment of spinal tuberculosis is great significant. The appl ication of one-stage anterior surgery with debridement, decompression, autogenous bone grafts and internal fixation in the operative treatment of thoracolumbar tuberculosis is safe and effective after a rigorous anti-tuberculosis treatment.
目的:探讨后路内固定治疗脊柱结核的必要性及适应证。方法:2002年1月~2008年12月采用后路器械固定、融合结合前路彻底病灶清除、植骨治疗脊柱结核17例。病变位于胸椎3例,胸腰段2例,腰椎4例,腰骶椎8例;累及2个节段7例,3个节段7例,4个节段3例;有3例伴窦道形成;9例伴不同程度的脊髓和(或)神经根受压症状;术前后凸成角10°~72°,平均31°。所有患者均一期手术。结果:术后随访6个月~5年,平均3.1年,术后切口均Ⅰ期愈合,后凸成角7°~58°,平均16°,椎间植骨平均在5个月融合,植骨融合率95.6%,优良率达89.6%,无一例复发。结论:后路器械固定结合前路彻底病灶清除、植骨治疗脊柱结核主要适用于多个节段受累、腰骶段及伴窦道者,利于恢复脊柱的稳定性、提高植骨融合率、纠正和预防后凸畸形。
【摘要】 目的 探讨低位下颈椎前方入路联合胸骨柄劈开术治疗颈胸段脊柱结核的手术方式及术后疗效。 方法 2002年3月-2009年7月收治颈胸段脊柱结核16例，男11例，女5例；年龄18~52岁，平均38岁。其中位于颈6-胸1者2例，颈7-胸1者5例，胸1-2者4例，胸2-3者3例，胸1-3者2例。神经功能Frankel分级为：B级4例，C级7例，D级3例，E级2例。手术行低位下颈椎前方入路联合胸骨柄劈开术，术中彻底清除结核肉芽组织、脓液、死骨并进行脊髓减压，取自体髂骨块植骨重建中前柱、前方钛板内固定。术后佩戴头颈胸支具6个月，正规抗痨18个月。术前后凸Cobb角为25~60°，平均为37.5°。 结果 全部患者均获得随访，随访时间2~8年，平均3年。均获得骨性融合，融合时间为5～8个月，无螺钉松动、脱落及钢板断裂等并发症发生。神经功能恢复按Frankel分级，平均改善3.6个级别；结核病变无复发，术后后凸Cobb角明显改善，为15～35°，平均22.6°，末次随访后凸角无明显丢失。1例术后出现暂时性声音嘶哑，术后1个月恢复。 结论 低位下颈椎前方入路联合胸骨柄劈开术治疗颈胸段脊柱结核，病灶显露充分，植骨内固定，重建脊柱稳定性，矫正后凸畸形可靠。【Abstract】 Objective To explore the clinical characteristics of cervico-thoracic junction spinal tuberculosis (CTJST) and to observe the therapeutic effect of lower anterior cervical approach combined with presternum-splitting approach on CTJST. Methods The clinical data of 16 patients with cervicothoracic junction spinal tuberculosis from Match 2002 to July 2008 were retrospectively analyzed. According to the Frankel grades, four patients were in grade B, seven were in grade C, three were in grade D, and two were in grade E. There were 11 males and five females with a average age of 38 years ranging from 18 to 52 years. All patients underwent radical excision of epidural granulation tissue/abscess and necrotic bone, whilst a proper tricortical iliac crest autograft and anterior titanium plate were placed to reconstruct the anteromedian spinal column, followed by chemotherapy for 18 months and immobilization in a brace for six months. The mean Cobb angle was 37.5° (ranged from 25° to 60°) before surgery. Results All patients were followed up for two to eight years (three years on average), and got complete bone fusion within five to eight months postoperatively. There were no pull out and breakage of screws or plates.Spinal cord functional recovery improved on average 3.6 degree according Frankel standard, without recurrence of the disease or loss of Cobb angle till the last follow up. There was a statistically significant improvement in the Cobb angles from 22.6° to 37.5° (Plt;0.01) in average. However, two patients appeared transient hoarse voice after surgery, and the symptoms were alleviated one month after the operation. Conclusion Lower anterior cervical approach combined with presternum-splitting approach for CTJST may provide adequate exposure to the lesion, keep the bone graft with internal fixation and spinal stability, and correct the kyphosis.
ObjectiveTo investigate the reasons for failure to treat thoracolumbar tuberculosis by anterior internal fixation and its countermeasures. MethodsA total of 485 patients with thoracolumbar spinal tuberculosis underwent anterior focus clearance and fixation from January 2005 to January 2012. Eighteen of them failed with a rate of 3.71%. Screws were pulled out in two patients. Vertebra cutted by screws occurred in three patients. In another three patients, screws dropped into the intervertebral disc. Tuberculosis relapsed in 10 patients (5 accompanied with spinal deformity, 2 with pure malunion, 2 with abscess formation, and 1 with sequestra). Twelve of the patients underwent two-stage posterior pedicle screw internal fixation and anterior focus clearance and autogenous bone grafts fusion. Four were treated by shifting antituberculosis drugs and staying in bed. Two were cured by multiple abscesses puncture and antituberculosis injection. ResultsThese patients were followed up for 15~30 months. Twelve cases of spinal tuberculosis were completely cured and 6 cases of them got clinical cure. However, 3 cases of them had scoliosis deformity followed and 1 had kyphosis. No tuberculosis relapse, cold abscess or sinus formation, or pedicle screw internal fixation failure occurred again. ConclusionAlthough there are many complications of anterior internal fixation for spinal tuberculosis, anterior internal fixation is still a perfect choice if we can make an appropriate choice of operation and strengthen the management after operation.
Objective To review the progress of surgical treatment for the thoracolumbar spinal tuberculosis. Methods The related literature of surgical treatment for the thoracolumbar spinal tuberculosis was reviewed and analyzed from the aspects such as surgical approach, fixed segments, fusion ranges, bone graft, and bone graft material research progress. Results Most scholars prefer anterior or combined posterior approach for surgical treatment of thoracic and lumbar tuberculosis because it possessed advantage of precise effectiveness. In recent years, a simple posterior surgery achieved satisfactory effectiveness. The fixation segments are mainly composed of short segments or intervertebral fixation. The interbody fusion is better for the bone graft fusion range and manner, and the bone graft materials is most satisfied with autologous iliac Cage or titanium Cage filled with autologous cancellous bone. Conclusion The perfect strategy for treating the thoracolumbar spinal tuberculosis has not yet been developed, and the personalized therapy for different patients warrants further study.
Objective To explore the effectiveness and related issues in the treatment of multiple segments of thoracolumbar tuberculosis through posterior unilateral debridement with bone graft and internal fixation. Methods The clinical data of 29 patients with multiple segments of thoracolumbar tuberculosis who met the selection criteria were retrospective analyzed between January 2012 and July 2015. There were 17 males and 12 females, with age of 21-62 years (mean, 37.4 years). Lesions contained 3-8 vertebral segments, including 3 segments in 6 cases, 4-6 segments in 17 cases, and 7-8 segments in 6 cases. The center lesions located at thoracic spine in 8 cases, lumbar spine in 10 cases, and thoracolumbar segment in 6 cases, and thoracic lumbar skip lesions in 5 cases. The complications included vertebral abscess in 7 cases, psoas major abscess in 6 cases, sacral spine muscle abscess in 7 cases, iliac fossa and the buttocks abscess in 1 case, spinal canal abscess in 2 cases. Preoperative neurological function was assessed according to the American Spinal Injury Association (ASIA) classification: 1 case of grade B, 3 cases of grade C, 8 cases of grade D, and 17 cases of grade E. The disease duration was 6-48 months (mean, 19.3 months). All the patients were treated with posterior unilateral transpedicular or transarticular debridement with bone graft fusion and internal fixation under general anesthesia. Pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), and sagittal Cobb angle were recorded and compared. Bridwell classification standard was used to evaluate bone graft fusion. According to the number and the center of the lesion, the necessity to placement of titanium mesh cage was analyzed. Results All the patients were followed up 18-30 months (mean, 24 months). Cerebrospinal fluid leakage occurred in 3 cases, intercostal neuralgia in 2 cases, wound unhealed and fistula formation in 1 case, and ofiliac fossa abscess recurred in 1 case, and all recovered after symptomatic treatment. During follow-up, no fracture or loosing of internal fixation was found and all the lesions were cured at last follow-up. According to Bridwell classification standard, bone graft achieved bony fusion during 4-9 months after operation. The VAS score, ODI, and Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative ones (P<0.05). At last follow-up, the neural function of all patients improved significantly when compared with preoperative one (Z= –3.101, P=0.002). The ratio of no placement of titanium mesh cage was significantly higher in patients with more than 6 lesion segments (6/6, 100%) than in patients with less than 6 lesion segments (4/23, 17.4%) (χ2=14.374, P=0.000). And the ratio of placement of titanium mesh cage was not significantly different between the patients with the different locations of center focus (χ2=0.294, P=0.863). Conclusion For treating multiple segments of thoracolumbar tuberculosis, the method of posterior unilateral debridement with bone graft and internal fixation can decrease the damage of posterior spinal structures and surgical trauma.
Objective To compare the clinical efficacy between one-stage combined posterior and anterior approaches (PA-approach) and simple posterior approach (P-approach) for lower lumbar tuberculosis so as to provide some clinical reference for different surgical procedures of lower lumbar tuberculosis. Methods A retrospective analysis was made on the clinical data of 48 patients with lower lumbar tuberculosis treated between January 2010 and November 2014. Of them, 28 patients underwent debridement, bone graft, and instrumentation by PA-approach (PA-approach group), and 20 patients underwent debridement, interbody fusion, and instrumentation by P-approach (P-approach group). There was no significant difference in gender, age, course of the disease, and destructive segment between 2 groups (P>0.05). The operation time, blood loss, bed rest time, visual analogue scale (VAS) and complication were recorded and compared between 2 groups; American Spinal Injury Association (ASIA) grade was used to evaluate the nerve function, Bridwell classification and CT fusion criteria to assess bone fusion, erythrocyte sedimentation rate (ESR) to evaluate the tuberculosis control, and Oswestry disability index (ODI) to estimate lumbar function. Results The operation time, blood loss, and the bed rest time of the P-approach group were significantly less than those of the PA-approach group (P<0.05). Iliac vessels rupture was observed in 1 case of the PA-approach group and sinus tract formed in 2 cases of the P-approach group. The patients were followed up 13-35 months (mean, 15.7 months) in the PA-approach group and 15-37 months (mean, 16.3 months) in the P-approach group. At last follow-up, common toxic symptom of tuberculosis disappeared and the ASIA scale was improved to grade E. The VAS score and ESR at 1 year after operation and last follow-up, and ODI at last follow-up were significantly improved when compared with preoperative ones in 2 groups (P<0.05), but there was no significant difference between the 2 groups (P>0.05). During follow-up, no internal fixation broken, loosening, or pulling was found. Bridwell bone fusion rates were 89.29% (25/28) and 80.00% (16/20) respectively, and CT fusion rates were 96.43% (27/28) and 90.00% (18/20) respectively, showing no significant difference between the 2 groups (P>0.05). Conclusion Both one-stage PA-approach and simple P-approach could obtain good clinical efficacy. The PA-approach should be selected for patients with anterior-vertebral destroy, presacral or psoas major muscles abscess, and multiple vertebral body destroy, while P-approach should be selected for patient who could gain a good debridement evaluated by imaging before operation, especially for patients with middle-vertebral body destroy, block the iliac blood vessels and old patients.
Objective To review current status of surgical treatment for angular kyphosis in spinal tuberculosis and provide reference for clinical treatment. Methods The literature on the surgical treatment for angular kyphosis of spinal tuberculosis in recent years was extensively reviewed and summarized from the aspects of surgical indications, surgical contraindications, surgical approach, selection of osteotomy, and perioperative management. Results Angular kyphosis of spine is a common complication in patients with spinal tuberculosis. If kyphosis progresses gradually, it is easy to cause neurological damage, deterioration, and delayed paralysis, which requires surgical intervention. At present, surgical approaches for angular kyphosis of the spine include anterior approach, posterior approach, and combined anterior and posterior approaches. Anterior approach can be performed for patients with severe spinal cord compression and small kyphotic Cobb angle. Posterior approach can be used for patients with large kyphotic Cobb angle but not serious neurological impairment. A combined anterior and posterior approaches is an option for spinal canal decompression and orthosis. Osteotomy for kyphotic deformity include Smith-Peterson osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection(VCR), vertebral column decancellation (VCD), posterior vertebral column resection (PVCR), deformed complex vertebral osteotomy (DCVO), and Y-shaped osteotomy. SPO and PSO are osteotomy methods with relatively low surgical difficulty and low surgical risks, and can provide 15°-30° angular kyphosis correction effect. VCR or PVCR is a representative method of osteotomy and correction. The kyphosis correction can reach 50° and is suitable for patients with severe angular kyphosis. VCD, DCVO, and Y-shaped osteotomy are emerging surgical techniques in recent years. Compared with VCR, the surgical risks are lower and the treatment effects also improve to varying degrees. Postoperative recovery is also a very important part of the perioperative period and should be taken seriously. Conclusion There is no consensus on the choice of surgical treatment for angular kyphosis in spinal tuberculosis. Osteotomy surgery are invasive, which is a problem that colleagues have always been concerned about. It is best to choose a surgical method with less trauma while ensuring the effectiveness.