Efficacy comparison between one-stage combined posterior and anterior approaches and simple posterior approach for lower lumbar tuberculosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIAO Yehui ¹ , YE Rupei ² , LI Guangzhou ¹ , TANG Qiang ¹ , WANG Gaoju ¹ ,  ZHONG Dejun ¹ , WANG Qing ¹

1. Department of Spinal Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China;
2. Department of Pathology, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China;

Corresponding?author：

ZHONG Dejun, Email: zdj_1974@163.com

Keywords：

Spinal tuberculosis; lower lumbar vertebrae; surgery approach; clinical efficacy

DOI：

10.7507/1002-1892.201609083

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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.

Citation： LIAO Yehui, YE Rupei, LI Guangzhou, TANG Qiang, WANG Gaoju, ZHONG Dejun, WANG Qing. Efficacy comparison between one-stage combined posterior and anterior approaches and simple posterior approach for lower lumbar tuberculosis. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(5): 534-540. doi: 10.7507/1002-1892.201609083 Copy

1.	?Rajasekaran S, Kanna RM, Shetty AP. History of spine surgery for tuberculous spondylodiscitis. Unfallchirurg, 2015, 118 Suppl 1: 19-27.
2.	Yang P, Zang Q, Kang J, et al. Comparison of clinical efficacy and safety among three surgical approaches for the treatment of spinal tuberculosis: a meta-analysis. Eur Spine J, 2016, 25(12): 3862-3874.
3.	Wang Z, Yuan H, Geng G, et al. Posterior mono-segmental fixation, combined with anterior debridement and strut graft, for treatment of the mono-segmental lumbar spine tuberculosis. Int Orthop, 2012, 36(2): 325-329.
4.	Zhang HQ, Lin MZ, Li JS, et al. One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg, 2013, 133(3): 333-341.
5.	陳林, 覃建樸, 敖俊, 等. 一期后路保留部分關節突開窗病灶清除短節段椎弓根螺釘內固定治療腰骶椎結核. 中國修復重建外科雜志, 2016, 30(7): 849-854.
6.	Tang MX, Zhang HQ, Wang YX, et al. Treatment of spinal tuberculosis by debridement, interbody fusion and internal fixation via posterior approach only. Orthop Surg, 2016, 8(1): 89-93.
7.	張宏其, 郭強, 郭超峰, 等. 單純后路、單純前路或前后聯合入路治療成人腰椎結核的中期療效比較. 中華骨科雜志, 2016, 36(11): 651-661.
8.	Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
9.	Nakshima H, Yukawa Y, Ito K, et al. Extension CT scan: its suitability for fusion after posterior lumbar interbody fusion. Eur Spine J, 2011, 20(9): 1496-1502.
10.	Hodgson AR, Stock FE. Anterior spinal fusion a preliminary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. Br J Surg, 1956, 44(185): 266-275.
11.	王自立. 脊柱結核的病灶清除與融合固定問題. 中國脊柱脊髓雜志, 2006, 16(12): 888-889.
12.	瞿東濱, 金大地. 正確認識脊柱結核病灶清除術. 中國脊柱脊髓雜志, 2008, 18(8): 565-567.
13.	宋躍明. 如何理解脊柱結核病灶徹底清除? 中國脊柱脊髓雜志, 2010, 20(10): 798.
14.	施建黨, 王騫, 王自立. 胸、腰椎結核融合及內固定范圍的合理選擇. 中華骨科雜志, 2016, 36(11): 745-752.
15.	Singh S, Kumaraswamy V, Sharma N, et al. Evaluation of role of anterior debridement and decompression of spinal cord and instrumentation in treatment of tubercular spondylitis. Asian Spine J, 2012, 6(3): 183-193.
16.	Xu Z, Wang X, Shen X, et al. Two one-stage posterior approaches for treating thoracic and lumbar spinal tuberculosis: A retrospective case-control study. Exp Ther Med, 2015, 9(6): 2269-2274.
17.	武啟軍, 王自立, 戈朝暉, 等. 脊柱單節段前中柱切除后不同節段椎弓根螺釘內固定的穩定性測試. 中國脊柱脊髓雜志, 2010, 20(4): 267-271.
18.	Soh J, Lee JC, Shin BJ. Analysis of risk factors for adjacent segment degeneration occurring more than 5 years after fusion with pedicle screw fixation for degenerative lumbar spine. Asian Spine J, 2013, 7(4): 273-281.
19.	朱明海, 梁國輝, 蔡小利, 等. 后路脊柱固定聯合雙側經腹膜外病灶清除術治療腰骶椎結核. 中國修復重建外科雜志, 2008, 22(5): 539-542.
20.	劉樹平, 劉躍洪, 徐巍, 等. 一期前路病灶清除植骨后路內固定治療下腰椎結核. 中國修復重建外科雜志, 2008, 22(10): 1274-1276.
21.	唐永超, 梁德, 江曉兵, 等. 一期經后路固定聯合側前方入路病灶清除植骨融合術治療老年下腰椎結核. 中國修復重建外科雜志, 2013, 27(3): 382-383.

1. ?Rajasekaran S, Kanna RM, Shetty AP. History of spine surgery for tuberculous spondylodiscitis. Unfallchirurg, 2015, 118 Suppl 1: 19-27.
2. Yang P, Zang Q, Kang J, et al. Comparison of clinical efficacy and safety among three surgical approaches for the treatment of spinal tuberculosis: a meta-analysis. Eur Spine J, 2016, 25(12): 3862-3874.
3. Wang Z, Yuan H, Geng G, et al. Posterior mono-segmental fixation, combined with anterior debridement and strut graft, for treatment of the mono-segmental lumbar spine tuberculosis. Int Orthop, 2012, 36(2): 325-329.
4. Zhang HQ, Lin MZ, Li JS, et al. One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg, 2013, 133(3): 333-341.
5. 陳林, 覃建樸, 敖俊, 等. 一期后路保留部分關節突開窗病灶清除短節段椎弓根螺釘內固定治療腰骶椎結核. 中國修復重建外科雜志, 2016, 30(7): 849-854.
6. Tang MX, Zhang HQ, Wang YX, et al. Treatment of spinal tuberculosis by debridement, interbody fusion and internal fixation via posterior approach only. Orthop Surg, 2016, 8(1): 89-93.
7. 張宏其, 郭強, 郭超峰, 等. 單純后路、單純前路或前后聯合入路治療成人腰椎結核的中期療效比較. 中華骨科雜志, 2016, 36(11): 651-661.
8. Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
9. Nakshima H, Yukawa Y, Ito K, et al. Extension CT scan: its suitability for fusion after posterior lumbar interbody fusion. Eur Spine J, 2011, 20(9): 1496-1502.
10. Hodgson AR, Stock FE. Anterior spinal fusion a preliminary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. Br J Surg, 1956, 44(185): 266-275.
11. 王自立. 脊柱結核的病灶清除與融合固定問題. 中國脊柱脊髓雜志, 2006, 16(12): 888-889.
12. 瞿東濱, 金大地. 正確認識脊柱結核病灶清除術. 中國脊柱脊髓雜志, 2008, 18(8): 565-567.
13. 宋躍明. 如何理解脊柱結核病灶徹底清除? 中國脊柱脊髓雜志, 2010, 20(10): 798.
14. 施建黨, 王騫, 王自立. 胸、腰椎結核融合及內固定范圍的合理選擇. 中華骨科雜志, 2016, 36(11): 745-752.
15. Singh S, Kumaraswamy V, Sharma N, et al. Evaluation of role of anterior debridement and decompression of spinal cord and instrumentation in treatment of tubercular spondylitis. Asian Spine J, 2012, 6(3): 183-193.
16. Xu Z, Wang X, Shen X, et al. Two one-stage posterior approaches for treating thoracic and lumbar spinal tuberculosis: A retrospective case-control study. Exp Ther Med, 2015, 9(6): 2269-2274.
17. 武啟軍, 王自立, 戈朝暉, 等. 脊柱單節段前中柱切除后不同節段椎弓根螺釘內固定的穩定性測試. 中國脊柱脊髓雜志, 2010, 20(4): 267-271.
18. Soh J, Lee JC, Shin BJ. Analysis of risk factors for adjacent segment degeneration occurring more than 5 years after fusion with pedicle screw fixation for degenerative lumbar spine. Asian Spine J, 2013, 7(4): 273-281.
19. 朱明海, 梁國輝, 蔡小利, 等. 后路脊柱固定聯合雙側經腹膜外病灶清除術治療腰骶椎結核. 中國修復重建外科雜志, 2008, 22(5): 539-542.
20. 劉樹平, 劉躍洪, 徐巍, 等. 一期前路病灶清除植骨后路內固定治療下腰椎結核. 中國修復重建外科雜志, 2008, 22(10): 1274-1276.
21. 唐永超, 梁德, 江曉兵, 等. 一期經后路固定聯合側前方入路病灶清除植骨融合術治療老年下腰椎結核. 中國修復重建外科雜志, 2013, 27(3): 382-383.

Chinese Journal of Reparative and Reconstructive Surgery

Efficacy comparison between one-stage combined posterior and anterior approaches and simple posterior approach for lower lumbar tuberculosis

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