Lumbosacral Tuberculosis And Skipped Multi-segmental Spinal Tuberculosis Treatment Strategy Selection And Clinical Retrospective Study

BackgroundThe annual incidence of tuberculosis in China is about 1.3 million, accounting for 14.3 percent of global incidence, ranking second in the world, the incidence of extrapulmonary tuberculosis rates are also high. The incidence of spinal tuberculosis ranks the first among bone and joint tuberculosis, typical spinal tuberculosis were massively reported and had more mature surgical treatment strategies, however, tuberculosis at special parts or with special types of often troublesome to clinical diagnosis and treatment. This study focused on the clinical treatment strategies of lumbosacral tuberculosis and skipped multi-segmental spinal tuberculosis.Due to the anatomy complexity and high mechanical stability requirements of lumbosacral tuberculosis, anterior debridement and posterior surgical fixation were commonly adopted for surgery, bringing great trauma to the patients. The design of special internal fixation devices for stage-one anterior inner fixation is based on the iliac vessels contorts lumbosacral spine anatomical shape and endplate damage specification caused by tuberculosis. We previously designed an anatomical lumbosacral anterior fixation device(ARCH) to adapt spinal tuberculosis characteristics, which make one-stage anterior surgery possible and also lead to academic debate to compare the effectiveness and safety of the two surgical methods.Spinal tuberculosis with two or more spine lesions separated by normal vertebrae is called skipped multi-segmental spinal tuberculosis(SMSST). SMSS can easily be missed because of the limitation of auxiliary examination, large differences reported in the literature(1.1%-71.4%); Kyphosis and paraplegia are in higher risk in SMSST compare to adjacent spinal tuberculosis. Most SMSST require surgery, surgical approach including anterior, posterior and combination. However, due to the complex factors such as skipped lesions, neurological damage, abscess location and scope, how to choose the appropriate surgical approach is a problem for surgeons. No standard treatment for reference and reports in literature are rare. ObjectiveThis study was designed to evaluate the current treatment and clinical efficacy of lumbosacral tuberculosis and skipped multi-segmental spinal tuberculosis through clinical retrospective study, to explore reasonable choice of surgical strategy. MethodsA total of 32 cases of lumbosacral tuberculosis from June 2005 to April 2013 were included in this study. Group division: ARCH steel plate group, 18 patients(7 males, 11 females, aged 15 to 68 years, mean 36 years), using one-stage anterior thorough debridement internal fixation of bone graft fusion(ARCH); AP group, 14 patients(6 males, 8 females, aged 18 to 72 years, mean 44 years) using one-stage anterior debridement, posterior pedicle bone graft fusion and internal fixation. Through clinical observation, laboratory tests and imaging studies to assess the clinical efficacy. A total of 24 cases of skipped multi-segmental spinal tuberculosis From January 1999 to December 2013 were included in this study. SMSST patients, A group(simple anterior group) 10 cases, AP group(combination group) 4 cases, P group(simple posterior group) 10 cases, 13 males, 11 females, aged 15 to 69 years, Clinical observation and imaging studies were adopted to assess the clinical efficacy. Results32 cases of lumbosacral tuberculosis patients in the ARCH steel plate group and AP group were effectively followed-up for more than one year, original lower back pain, neurological symptoms were significantly alleviated at the end of the follow-up. Both ESR and CRP levels restored to normal six months after surgery. X and CT confirmed bone healing after 3-9 months. Injury of iliac vessels or inferior vena, ureter, symptomatic deep vein thrombosis, erectile dysfunction, retrograde ejaculation and other complications were not detected. Lumbosacral angle between the ARCH group and AP group, physiological lumbar lordosis and other imaging measurements were not statistically significant in the last follow-up. ATCH group was better than the AP group in operative time, blood loss and hospital stay. 24 cases of skipped multi-segmental spinal tuberculosi patients with an average follow-up time of 18.6 months, kyphosis and nerve function have improved significantly. Bony fusion occurred 6-12 months after operation. One case of tuberculosis patients relapse in the AP group, 24 patients were cured. ConclusionAnterior debridement, fusion, within ARCH titanium plate inner fixation can effectively treat lumbosacral tuberculosis; risk of intraoperative vascular injury, ureter and autonomic nerve injury are controllable; Compared to conventional surgery methods, operation time was shortened, blood loss was reduce, and functional recovery of spinal was promoted.Three surgical approach in treating SMSST are safe and effective for decompression, fusion, and kyphosis correction, individualized surgical treatment should be based on different characteristics of the lesion(vertebral lesion number, position, vertebral destruction whether the extent and the remaining vertebrae may be fixed, deformity, neurological symptoms, abscess), the general condition of the patient and surgical experience.