The Prospective Study Of The Comparison In The Treatment For Thoracolumbar Tuberculosis With Anterior Vs. Posterior Debridement Strategy

BackgroundSpine tuberculosis is the most common extra pulmonary tuberculosis and takes up50%of all bone and joint tuberculosis. Thoracolumbar region is the common sight for spinetuberculosis. It will cause severe deformity, neurological dysfunction and even paralysisand pose a severe negative impact on human health. Now the mild cases can be treated withmedicine, but for the severe cases, surgical intervention should be applied with medicine inorder to prevent and cure the complications.Spine tuberculosis usually takes place in vertebral body, especially the anterior andmiddle column. The debridement with anterior approach achieved satisfactory in formertime, so debridement and fusion with anterior approach, combined with anterior or posteriorinternal fixation is regarded as the classical operation for spine tuberculosis. With thedevelopment of posterior approach of spine surgery, the debridement with posteriorapproach is also applied. However, it is still controversial because surgeons can not achievedirect visualization in the debridement with posterior approach. So the surgery withposterior approach is also regarded as with high difficulties and risk.PurposeA prospective study to compare the clinical outcomes, radiological changes, andbacteriological test from post-op drainage of debridement, fusion and internal fixation withanterior and posterior approaches and to evaluate the debridement effect, safety, validityand the technique characteristics of the two kind of operations. This study can provide ahigh-level evidence for clinical doctors.Material and MethodsA total of63cases of thoracolumbar tuberculosis from Feb2011to Apr2013wereinvolved in this study. Follow-up data were acquired from59cases and the follow-up rate is93.6%.33cases were applied debridement with posterior approach(group A) and all the patients were treated with debridement, interbody fusion and fixation with posteriorapproach. Of them,20cases were male and13cases were female and at a mean age of37.9year-old.10cases were combined with kyphosis and average kyphosis angle were33.7°.13cases were combined with neurological dysfunction,2cases with ASIA grade B,2caseswith grade C and9cases with grade D.26cases were applied with debridement withanterior approach(group B) and all the patients were treated with debridement, interbodyfusion and fixation with anterior approach. Of them,9males and17females were at a meanage of36.4year-old.7cases were combined with kyphosis and average kyphosis anglewere26.3°.8cases were combined with neurological dysfunction, with a ASIA grade B.The operation duration, blood loss, recovery effect and complication rate of bothgroups were compared. We also compared the correction and maintain effect of both groupsfrom radiological images and VAS, ODI and SF-36score were applied to compare thesurgical outcomes of the two approaches.Post-op drainage were collected after2and4days of surgery from both groups and thedrainage were applied acid fast staining, PCR, identification of Mycobacterium tuberculosisand culture of Mycobacterium tuberculosis. We analysed the bacteriological results fromthe patients underwent anterior approach and posterior approach surgery.ResultsAll the cases have been followed-up for at least one year and the average follow-uptime is15.5months(12-27months). The surgical duration, blood loss of the patients whounderwent posterior approach surgery(group A) is higher than that in the patients underwentapproach surgery(group B)(P<0.05) but there is no difference in the complicationoccurrence. The average correction angle is23.6°in group A and it is higher than that ingroup B(16.7°) but without statistical difference(P>0.05). The loss of angle in the finalfollow-up is higher in group B but without statistical difference, either(P>0.05). There is nostatistical difference in VAS score, ODI score between group A and group B in pre-op,post-op and final follow-up. There is no statistical difference in SF-36in both groups inpre-op and one month after operation(P>0.05), but at the final follow-up, there is statisticaldifference(P<0.05).33cases and23cases of drainage were collected from patients in group A and group B,respectively. There are10positive cases in group A and5positive cases group B of48h PCR and11and3in96h PCR. There are2positive cases in each group in the identificationof Mycobacterium tuberculosis and3positive cases in each group in the culture ofMycobacterium tuberculosis. The acid fast staining in both group in48h and96h were allnegative. There is no statistical difference in the positive rate in all the experimentaltest(P>0.05). There are total15positive cases in group A and9positive cases in groupB(positive result in any tests) and there is no statistical difference(P>0.05). There is alsono statistical difference in the recurrence rate, sinus formation rate.ConclusionThere is equal effect of anterior approach and posterior approach in the debridement oflesion in anterior and middle column in the treatment of thoracolumbar tuberculosis andboth strategy can acquire equal clinical outcomes. Compared with anterior approach, thereis simpler anatomical structure and less trauma of posterior approach and it is better at thecorrection of severe deformity. However, the operation difficulty, learning curve, surgicalduration and blood loss are much higher in posterior approach. There may exists activeMycobacterium tuberculosis with both approaches but it will not affect the cure oftuberculosis with effective anti-tuberculosis treatment.