| BackgroundPosterior only surgery has been used to treat thoracic and lumbar tuberculosis for many years,but there is still controversy.PurposeA prospective study was conducted to compare the etiological results of the surgical area and the cure rate of spinal tuberculosis after anterior and posterior surgery.A retrospective study was conducted to observe the clinical efficacy and imaging changes of posterior only approach in the treatment of thoracic and lumbar tuberculosis with different characteristics.To evaluate the efficacy,safety,technical characteristics and long-term follow-up outcomes of posterior only approach surgery.Materials and Methods1)Sixty-five patients with active thoracic and lumbar tuberculosis between October 2006 and August 2013 were retrospectively analyzed.Twenty patients with thoracic tuberculosis(Group A),including 11 males and 9 females,the average age was 35.6±11.1 years,7 patients with more than 3 vertebral involved,1 with lumbago major or iliac fossa abscess,9 with neurological impairment,and 15 with kyphosis.Seventeen with thoracolumbar tuberculosis(Group B),including 9 males and 8 females,the av erage age was 33.9±12.5 years,2 patients with more than 3 vertebral involved,1 with lumbago major or iliac fossa abscess,6 with neurological impairment,and 10 with kyphosis.And 28 with lumbar tuberculosis(Group C),including 11 males and 17 females,the average age was 39.5±12.3 years,2 patients with more than 3 vertebral involved,9 with lumbago major or iliac fossa abscess,15 with neurological impairment,and 4 with kyphosis.Patients data,operative time,blood loss,visual analog scale,Oswestry disability index,correction of kyphosis,recovery of neurological and complications were recorded and analyzed.2)A total of 105 patients were enrolled in this prospective study from February 2011 to September 2015.Patients were divided into two groups: Group A(51 patients,posterior approach surgery),there were 27 males and 24 females,with an average age of 36.5±13.9 years,and an average number of lesion segments of 1.3±0.7,among which 19 cases were associated with neurological impairment.Group B(54 patients,anterior approach surgery).19 males and 35 females,with an average age of 37.6±13.2 years,and an average number of lesion segments of 1.2±0.6,among which 29 cases were associated with neurological impairment.Intraoperative TB samples were sent for Mycobacterium Tuberculosis Culture(MTBC).Drainage fluid was postoperatively collected for Polymerase Chain Reaction(PCR),Acid-Fast Strains(AFS),MTBC and DNA Molecular Detection(DNAMD)analyses.Compare the drainage liquid positive rate of two groups and estimate relationship between the positive results of drainage fluid and the lesions region.In addition,the clinical outcomes including the bony fusion,relapse rate,complications and neurological status were collected.3)Seventy-nine patients with active lumbar tuberculosis between February 2012 and December 2015 were retrospectively analyzed.They were divided into two groups according to the type of surgery.Forty-three patients in group A underwent posterior only approach transforaminal debridement,interbody bone graft,combined with internal fixation.Among them,21 cases were male and 22 female,16 cases were combined with lumbago major or iliac fossa abscess,20 cases with neurological impairment,and 10 cases with kyphosis.Thirty-six patients in group B underwent anterior only approach debridement,interbody bone graft and internal fixation.Among them,there were 13 males and 23 females,15 were associated with lumbago major or iliac fossa abscess,17 with neurological impairment,and 10 with kyphosis.Operative time,blood loss,complications,tuberculosis healing,improvement of nerve function,correction of segmental kyphosis and reconstruction of lumbar lordosis were compared between the two groups.4)Sixteen patients developed consecutive multi-segment thoracic and lumbar tuberculosis with kyphosis between September 2012 and November 2015 were retrospectively analyzed.According to the surgical approach,it was divided into two groups.Group A was the posterior only surgery group,with 11 cases,including 4 males and 7 females.The average age was 33.9±13.0 years,and the average segments of lesions involved was 3.1±1.0.Group B was the anterior only surgery group,with 5 cases,including 3 males and 2 females,with an average age of 57.6±11.1 years,and the average segments of lesions involving was 2.2±0.4.The cure rate of tuberculosis,operation time,blood loss,correction of spinal deformity,complications,improvement of neurological function,VAS and ODI scores were compared between the two groups.Results1)Patients were followed for 68.7±17.8 months.Patients with multiple segments(More than one segment)involved or with kyphosis in group A(35%,75%)and B(11.8%,58.8%)are more than these in group C(7.1%,14.3%).Patients with psoas or iliac abscess in group B(35.3%)and C(32.1%)are more than these in group A(5%).The operation time and blood loss of group A was 281.3±101.3min,910.0±594.6ml,that of group B was 310.2±149.1min,705.9.5±908.6ml.The operative time,blood loss and complications were no statistically difference between each group(P>0.05).The preoperative VAS and OID scores of group A,B,C were 3.3±1.2,28.3±20.6%,3.9±1.1,23.0±12.8%,and 3.6±0.8,21.1±11.5%,respectively.At the last follow-up time the VAS and ODI scores of group A,B,C were 0.7±0.7,5.2%±6.0%,0.8±0.6,7.5%±7.8%,0.7±0.9,4.9%±10.3%.After the operation,VAS and ODI were significantly improved in 3 groups at the final follow-up time.The preoperative average cobb angle of patients with kyphosis in group A,B and C was 28.2±11.9°,30.5±16.9° and 10.9±8.8°,which was significantly decreased to 8.0±5.4°,5.0±4.1° and-4.4±1.6°(-means lordosis)after the surgery,respectively.At the final follow-up time,the cobb angle was 9.2±6.1°,6.8±10.0° and-3.7±2.0°,respectively.The correction loss angle of group A and B is more than that of group C(P>0.05).Six patients(9.2%)in 65 with tuberculosis relapse after them has been healed.There was no statistical difference in the incidence of complications between the three groups(P>0.05).At final follow-up time,all patients with neurological impairment were improved at least one level in ASIA impairment scale.2)There was no significant difference in the positive rate of AFS,PCR,DNAMD,MTBC,or Any Positive Rate(APR)of drainage liquid between the two groups(P > 0.05).In both groups,the MTBC-positive rate of postoperative drainage fluid was significantly lower than that of the intraoperative sample(P< 0.01).There was no significant relationship between APR and the lesion region(P> 0.05).All the patients had at least 2 years of follow-up,with an average of 34.4±15.8 months.There were 4 patients in group A and 2 patients in group B who had recurrent spine TB,and the rest of the patients had fusion in the surgical area.There was no significant difference in the incidence of TB recurrence or other complications between the two groups(P> 0.05).All the patients with neurological dysfunction had improved after surgery.3)All operations were successfully without serious complications.There was no significant difference in operation time,blood loss and complication rate between group A and group B(P>0.05).All patients were followed up for at least 1 year,with an average of 24.9±11.2 months(12-61 months).Two patients in group A developed tuberculosis recurrence and they were cured by secondary surgery,and the others were cured in the first stage.Bone graft fusion was performed,and no complications such as loosening or fracture of internal fixation occurred.The preoperative average kyphosis angle of patients with kyphosis in group A,B was 34.38±23.46°,24.73°±10.05°,which was significantly decreased to-0.78°±10.01°,3.58°±6.54°(-means lordosis)after the surgery,respectively.At the final follow-up time,the cobb angle was 1.16°±11.09,6.63±7.64°,respectively.There were statistically significant differences between preoperative and postoperative in two groups(P<0.05),the correction angle of group A was larger than that of group B(P<0.05).The average lumbar lordosis angle of patents with kyphosis in group A was statistically different between preoperative and postoperative(P<0.05),while there was no statistically difference in group B(P>0.05).At the last follow-up,patients with neurological impairment recovered to ASIA grade E in both groups.4)The operation time of group A was 455.0±104.3min,the operation time of group B was 306.4±22.0min,the operation time of group A was greater than that of group B(P<0.05).The blood loss in group A was 1845.5±868.8ml,while that in group B was 1360.0±532.0ml.There was no significant difference between the two groups(P>0.05).All patients were followed up for at least 2 years after surgery,with an average follow-up time of 36.8 12.4m(24-61m).All patients were cured of tuberculosis without loosening of internal fixation.Complications occurred in 4 patients in group A(36.4%)and 3 patients in group B(60.0%),with no statistical difference between the two groups(P>0.05).The preoperative average cobb angle of kyphosis and scoliosis in group A,B was 37.0±17.5°,6.7±5.5° and 25.0±6.7°、2.4±1.0°,which was significantly decreased to 3.2±13.8°,1.7±1.4° and 6.5±2.6°,3.1±3.2°.At the final follow-up time,the cobb angle was 5.3±11.8°,1.0±0.6° and 9.5±3.7°,3.8±2.7°,respectively.There was significant differences between preoperative,postoperative kyphosis and scoliosis angle in both group,while postoperative and final follow-up were not statistically significant(P>0.05).The average kyphosis corrective angle of group A and B was 33.8±17.6 °,18.5±4.8 °.The correction of kyphosis in group A was greater than that in group B,with statistical difference(P<0.05).The average kyphosis loss angle of group A and B was 2.1±2.9 °,3.0±1.6 °.There is no statistical difference between the two groups(P > 0.05).The VAS and ODI were significantly different between preoperative and postoperative in two groups(P<0.05).At the end of the last follow-up,cases with nerve damage in group A and group B were significantly improved(P<0.05),and there was no statistical difference between the two groups(P >0.05).Conclusions1)Posterior only approach surgery treatment of thoracic and lumbar tuberculosis could obtain satisfactory outcomes at long-term follow-up time.The implant of pedicle screws in diseased vertebra could reduce the range of fixation,but the cases with thoracic and thoracolumbar tuberculosis should be fixed to at least one adjacent normal segment.There were some recurrence cases after the tuberculosis was healed and long-term follow-up is necessary.2)Compared with anterior approach surgery,posterior approach surgery had equal effectiveness of debridement.The two kinds of surgery can effectively clear the lesions surrounding the spine and heal thoracic and lumbar TB.3)Anterior and posterior approach surgery to the treatment of lumbar tuberculosis can obtain good clinical efficacy,and posterior approaches are more advantageous in correcting deformity and reconstructing the lumbar lordosis.4)For consecutive multi-segment thoracic and lumbar tuberculosis with kyphosis cases,anterior or posterior only approach can achieve satisfactory clinical efficacy,and is a safe and effective surgical.Posterior surgery is superior to anterior surgery in correction of kyphosis deformity,and can avoid some complications related to anterior surgery.Therefore,posterior surgery is recommended,but the operation time is longer due to cumbersome operation. |
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