Clinical Efficacy Of Three Different Surgical Approaches In The Treatment Of Spinal Junction Tuberculosis

Background:Due to the increase in the number of global immigrants,HIV patients and the spread of drug-resistant strains in recent decades,global tuberculosis(TB)prevention and treatment are facing new challenges.At present,the number of TB patients from China is the second largest in the world,accounting for 17% of TB patients worldwide,and the situation of TB control is serious.Spine TB,as a common extrapulmonary TB,is the most common and severe form of bone and joint TB.The disease not only imposes a heavy burden on the quality of life of patients,but also increases the social and economic burden of patients.Spinal junction TB,located in special areas of the spine,occur in the stress transition areas of the spine and have high risks of progressing to kyphosis and paraplegia.However,few studies have been reported at present.Spinal junction TB contain cranio-cervical junction TB,cervicothoracic junction TB,thoracolumbar junction TB and lumbosacral junction TB.And thoracolumbar junction TB is the most common,while cranio-cervical junction TB is rare.So far,there are no guidelines for the treatment of spinal junction TB.It is generally believed that mild to moderate spinal junction TB can be cured by conservative treatment,which is composed of antituberculosis chemotherapy,systemic nutritional support and partial immobilization.Surgical intervention is needed for TB patients with spinal instability,neurological injury,massive paravertebral abscess,severe kyphosis and drug-resistant TB.Surgery can be simply classified as anterior approach surgery,posterior approach surgery and anterior-posterior combined approach surgery,and each has its own indications,advantages and disadvantages.The local anatomical structure,mechanical characteristics,and lesion range of each spinal junction TB showed different characteristics.There is no unified consensus and standard for surgical treatment of spinal junction TB.The decision-making of the operating surgeon is seriously affected for few relevant studies can be referred.In this research,the clinical efficacy of three different surgical approaches in the treatment of spinal junction TB has been studied,the indications of each surgical approach have been explored.We aimed to offer help for medical peers choosing the appropriate individualized surgical treatment strategy and provide reference for clinical surgical treatment and scientific research of spinal junction TB.Part ?: Clinical efficacy of three different surgical approaches for the treatment of cervicothoracic junction TB.Purpose:To estimate the clinical efficacy of three different surgical approaches for the treatment of cervicothoracic junction TB.Methods:A retrospective study was performed on 65 patients with cervicothoracic junction TB who underwent surgical treatment in our hospital from September 2004 to September 2019.Based on the differences of surgical approaches,three groups contained: group A,anterior approach,35 cases;group B,posterior approach,18 cases;group C,combined anterior and posterior approach,12 cases.In the three groups,36 cases with preoperative neurological injury were counted.The Cobb angle,VAS,ASIA,NDI,JOA and other indicators of each group at preoperative and postoperative were statistically analyzed to estimate the efficacy of each group.Results:The average age,follow-up period and hospitalization time were 37.1±16.6 y,15.7±13.2 mon and 21.4±9.7 d in group A,26.4±12.9 y,21.8±13.0 mon and 28.4±8.2 d in group B,and 31.3±15.9 y,23.4±12.8 mon and 26.3±6.8 d in group C,respectively.There were no statistically significant differences among three groups(P>0.05).The mean operation time and intraoperative blood loss were 244.4±117.6 min and 373.4±433.7 ml in group A,218.0±47.0 min and 222.2±134.2 ml in group B,374.8±43.6 min and 741.7±281.1ml in group C,respectively.Group C had the largest blood loss and the longest operation time among the three groups,and there were statistically significantly differences with group A\B(P<0.05).ESR at preoperative and the last follow-up were 42.9±23.5 mm/h and9.7±5.6 mm/h in group A,45.9±29.1 mm/h and 5.7±3.1 mm/h in Group B,61.3±27.2 mm/h and 6.3 ± 3.4 mm/h in Group C,respectively.In each group,ESR at the last follow-up was statistically improved compared with that at preoperative(P<0.05).The Cobb angles at the preoperative,postoperative,and last follow-up in each group were as follows: 15.7±10.6°,10.4±9.3°,and 11.0±7.7° in group A;19.8±7.7°,10.0±3.1°,and 11.0±3.2° in group B;13.8±5.3°,7.6±2.9°,and 8.3±2.8° in group C,respectively.The Cobb angle in each group improved significantly at postoperative and at last follow-up compared with that at preoperative in each group(P<0.05).Most of the patients in each group with preoperative neurological injury had different degrees of improvement at the last follow-up.Postoperative and last follow-up VAS score compared with preoperative values in each group were statistically decreased(P<0.05).Similarly,the JOA and NDI values of each group at postoperative and final follow-up were significantly improved compared with those at preoperative(P<0.05).Part ?: Clinical efficacy of three different surgical approaches for the treatment of thoracolumbar junction TB.Purpose:To estimate the clinical outcomes of three different surgical approaches for the treatment of thoracolumbar junction TB.Methods:A retrospective study was performed on 122 patients with thoracolumbar junction TB who underwent surgical treatment in our hospital from September 2004 to September 2019.Based on the differences of surgical approaches,three groups contained: group A,anterior approach,37 cases;group B,posterior approach,57 cases;group C,combined anterior and posterior approach,28 cases.In the three groups,46 cases with preoperative neurological injury were counted.The Cobb angle,VAS,ASIA and other indicators of each group at preoperative and postoperative were statistically analyzed to estimate the efficacy of each group.Results:The average age,follow-up period and hospitalization time of each group were35.5±13.6 y,20.3±13.0 mon and 22.4±4.7 d in group A,42.5±15.6 y,18.8±13.7 mon and19.8±8.3 d in group B,and 35.7±14.2 y,23.4±10.6 mon and 27.5±10.9 d in group C,respectively.The average operation time were 332.7±91.6 min in group A,319.4±137.0 min in group B,434.8±121.4 min in group C,respectively.Group C had longer operation time than group A\B(P<0.05).The average intraoperative blood loss was 923.8±421.3 ml in group A,967.5±813.5 ml in group B,1157.1±994.6 ml in group C,respectively.ESR at preoperative and the last follow-up were 53.9±25.0 mm/h and 9.5±5.6 mm/h in group A,46.1±27.6 mm/h and 12.4±11.9 mm/h in Group B,49.2±27.0 mm/h and 11.6±10.6 mm/h in Group C,respectively.In each group,ESR at the last follow-up was significantly improved compared with that at preoperative(P<0.05).The Cobb angles at preoperative,postoperative,and the last follow-up in each group were as follows: 22.8±8.8°,14.9±5.3°,and 18.3±6.3° in group A;21.5±10.8°,7.4±4.9°,and 10.3±5.4° in group B;23.4±14.7°,9.7±6.0°,and 12.8±7.6° in group C,respectively.The Cobb angle in each group improved significantly after surgery and at the last follow-up compared with that before surgery in each group(P<0.05).Most of the patients in each group with preoperative neurological injury had different degrees of improvement at the last follow-up.Postoperative and last follow-up VAS score among three groups compared with preoperative values were significantly decreased,and the differences were statistically significant(P<0.05).Part ?: Clinical efficacy of three different surgical approaches for the treatment of lumbosacral junction TB.Purpose:To estimate the clinical outcomes of three different surgical approaches for the treatment of lumbosacral junction TB.Methods:A retrospective study was performed on 72 patients with lumbosacral junction TB who underwent surgical treatment in our hospital from April 2004 to April 2020.Based on the differences of surgical approaches,three groups contained: group A,anterior approach,34cases;group B,posterior approach,25 cases;group C,combined anterior and posterior approach,13 cases.In the three groups,19 cases with preoperative neurological injury were counted.The Cobb angle,VAS,ASIA and other indicators of each group at preoperative and postoperative were statistically analyzed to estimate the efficacy of each group.Results:The average age,follow-up period and hospitalization time in each group were37.4±13.3 y,16.6±14.8 mon and 16.6±4.3 d in group A,42.7±15.2 y,23.1±25.1 mon and26.3±6.8 d in group B,and 33.5±13.5 y,20.3±11.4 mon and 23.6±7.6 d in group C,respectively.The mean operation time and blood loss were 181.2±77.2 min and375.3±271.4 ml in group A,320.0±169.1 min and 910.0±861.9 ml in group B,454.1±154.3min and 1046.2±598.1 ml in group C,respectively.Group A had less blood loss and shorter operation time than group B\C(P<0.05).ESR at preoperative and the last follow-up were48.1±28.2 mm/h and 13.3±16.3 mm/h in group A,39.6±25.3 mm/h and 21.0±22.5 mm/h in Group B,52.8±32.3 mm/h and 21.0±28.9 mm/h in Group C,respectively.In each group,ESR at the last follow-up was significantly improved compared with that at preoperative(P<0.05).The lumbosacral angles at preoperative,postoperative,and the last follow-up in each group were respectively as follows: 34.4±11.6°,36.7±6.5°,and 36.1±8.1° in group A;31.3±12.6°,34.6±7.8°,and 33.5±8.5° in group B;25.8±8.2°,34.3±6.8°,and 32.7±5.6° in group C.The Cobb angles(L1-S1)at preoperative,postoperative,and the last follow-up in each group were respectively as follows: 45.0±14.7°,48.5±13.2°,and 47.6±12.5° in group A;40.2±16.2°,45.0±12.4°,and 43.7±13.7° in group B;31.8±15.6°,37.2±13.6°,and36.5±13.2° in group C.The lumbosacral angle and the Cobb angle(L1-S1)improved significantly after surgery and at the last follow-up compared with that before surgery in each group(P<0.05).Most of the patients in each group with preoperativ e neurological injury had different degrees of improvement at the last follow-up.Postoperative and the last follow-up VAS score compared with preoperative values were significantly decreased,and the differences were statistically significant(P<0.05).Conclusions:1.Anterior,posterior and anterior-posterior combined surgical approaches are effective in the treatment of cervicothoracic junction TB.Posterior approach should be used selectively for its narrow indication.Anterior-posterior combined surgical approach has longer operation time,larger blood loss,greater trauma and higher surgical skills requirements,so it is necessary to strictly control its indications.The anterior approach has excellent efficacy and wide indications.2.For thoracolumbar junction TB,all of the three surgical approaches can remove the focus,decompress the spinal cord and nerve root,stabilize the spine,correct kyphosis deformity and maintain the correction.Posterior approach has the advantages of less trauma,shorter operation time,shorter hospital duration and wider indications.For patients with anterior huge abscess,multi-segmental lesions and severe kyphosis,anterior-posterior combined approach is recommended.3.Anterior approach for the treatment of lumbosacral junction TB has many advantages,such as less trauma,shorter operation time,less blood loss and shorter hospital duration.For the patients with severe kyphosis or severe damage in anterior and middle column,anterior-posterior combined approach is recommended.Posterior surgery is available for patients with lesions located in the posterior column without anterior abscess.4.Any surgical approach alone cannot treat all spinal junction TB.Each approach has its suitable indications.An individualized treatment plan should be developed on the basis of reasonable anti-tuberculosis drug treatment.The choice of surgical approach should be fully based on the scope of the lesion,the basic condition of the patient,and the familiar approach of the surgeon.