Treatment of multiple segments of thoracolumbar tuberculosis using posterior unilateral debridement with bone graft and internal fixation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Zenghui , ZHU Yong , LUO Wei , DU Xing , LI Jianxiao ,  OU Yunsheng , QUAN Zhengxue

Department of Orthopedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, P.R.China;

Corresponding?author：

OU Yunsheng, Email: ouyunsheng2001@163.com

Keywords：

Multiple segmental spinal tuberculosis; unilateral debridement; posterior approach; internal fixation

DOI：

10.7507/1002-1892.201703104

Video：

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Objective To explore the effectiveness and related issues in the treatment of multiple segments of thoracolumbar tuberculosis through posterior unilateral debridement with bone graft and internal fixation. Methods The clinical data of 29 patients with multiple segments of thoracolumbar tuberculosis who met the selection criteria were retrospective analyzed between January 2012 and July 2015. There were 17 males and 12 females, with age of 21-62 years (mean, 37.4 years). Lesions contained 3-8 vertebral segments, including 3 segments in 6 cases, 4-6 segments in 17 cases, and 7-8 segments in 6 cases. The center lesions located at thoracic spine in 8 cases, lumbar spine in 10 cases, and thoracolumbar segment in 6 cases, and thoracic lumbar skip lesions in 5 cases. The complications included vertebral abscess in 7 cases, psoas major abscess in 6 cases, sacral spine muscle abscess in 7 cases, iliac fossa and the buttocks abscess in 1 case, spinal canal abscess in 2 cases. Preoperative neurological function was assessed according to the American Spinal Injury Association (ASIA) classification: 1 case of grade B, 3 cases of grade C, 8 cases of grade D, and 17 cases of grade E. The disease duration was 6-48 months (mean, 19.3 months). All the patients were treated with posterior unilateral transpedicular or transarticular debridement with bone graft fusion and internal fixation under general anesthesia. Pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), and sagittal Cobb angle were recorded and compared. Bridwell classification standard was used to evaluate bone graft fusion. According to the number and the center of the lesion, the necessity to placement of titanium mesh cage was analyzed. Results All the patients were followed up 18-30 months (mean, 24 months). Cerebrospinal fluid leakage occurred in 3 cases, intercostal neuralgia in 2 cases, wound unhealed and fistula formation in 1 case, and ofiliac fossa abscess recurred in 1 case, and all recovered after symptomatic treatment. During follow-up, no fracture or loosing of internal fixation was found and all the lesions were cured at last follow-up. According to Bridwell classification standard, bone graft achieved bony fusion during 4-9 months after operation. The VAS score, ODI, and Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative ones (P<0.05). At last follow-up, the neural function of all patients improved significantly when compared with preoperative one (Z= –3.101, P=0.002). The ratio of no placement of titanium mesh cage was significantly higher in patients with more than 6 lesion segments (6/6, 100%) than in patients with less than 6 lesion segments (4/23, 17.4%) (χ²=14.374, P=0.000). And the ratio of placement of titanium mesh cage was not significantly different between the patients with the different locations of center focus (χ²=0.294, P=0.863). Conclusion For treating multiple segments of thoracolumbar tuberculosis, the method of posterior unilateral debridement with bone graft and internal fixation can decrease the damage of posterior spinal structures and surgical trauma.

Citation： ZHAO Zenghui, ZHU Yong, LUO Wei, DU Xing, LI Jianxiao, OU Yunsheng, QUAN Zhengxue. Treatment of multiple segments of thoracolumbar tuberculosis using posterior unilateral debridement with bone graft and internal fixation. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(9): 1073-1079. doi: 10.7507/1002-1892.201703104 Copy

1.	Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg (Br), 2010, 92(7): 905-913.
2.	Jain A, Jain AK, Kiyawat V. Evaluation of Outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis. Asian Spine J, 2017, 11(1): 31-36.
3.	Wang XB, Li J, Lü GH, et al. Single-stage posterior instrumentation and anterior debridement foractive tuberculosis of the thoracic and lumbar spine with kyphotic deformity. Int Orthop, 2012, 36(2): 373-380.
4.	Hassan K, Elmorshidy E. Anterior versus posterior approach in surgical treatment of tuberculousspondylodiscitis of thoracic and lumbar spine. Eur Spine J, 2016, 25(4): 1056-1063.
5.	Wang LJ, Zhang HQ, Tang MX, et al. Comparison of Three Surgical Approaches for Thoracic Spinal Tuberculosis in Adult: Minimum 5-Year Follow-Up. Spine (Phila Pa 1976), 2017, 42(11): 808-817.
6.	Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografs in the thoracic and lumbar spine. Do the 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.
7.	Moon MS, Kim SS, Moon H. (i)Tuberculosis of the spine:current views in diagnosis, management, and setting a globalstandard. Orthop Trauma, 2013, 27(4): 185-194.
8.	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.
9.	Pu X, Zhou Q, He Q, et al. A posterior versus anterior surgical approach in combination with debridement,interbody autografting and instrumentation for thoracic and lumbar tuberculosis. Int Orthop, 2012, 36(2): 307-313.
10.	Tuli SM. Tuberculosis of the skeletal system. 4th ed. Delhi: Jaypee Publishers, 2010: 215.
11.	Güven O, Kumano K, Yal?in S, et al. A singlestage posterior approach and rigid fixation for preventing Kyphosisin the treatment of spinal tuberculosis. Spine (Phila Pa 1976), 1994, 199: 1039-1043.
12.	Kumar MN, Joseph B, Manur R. Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosiswithout anterior instrumentation and without anterior or posteriorbone grafting. Eur Spine J, 2013, 22(3): 624-632.
13.	Qian J, Rijiepu A, Zhu B, et al.Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis. Int Orthop, 2016, 40(10): 2081-2088.
14.	王清, 徐楊博, 韓福剛, 等. 多節段脊柱結核的診斷與治療. 瀘州醫學院學報, 2006, 29(3): 234-237.
15.	施建黨, 王自立, 馬小民. 病灶清除植骨內固定治療相鄰多椎體脊柱結核.中國脊柱脊髓雜志, 2010, 20(2): 98-102.
16.	張西峰, 王巖, 肖嵩華, 等. 經皮穿刺置管沖洗引流持續局部化療治療活動期多椎體脊柱結核. 中國脊柱脊髓雜志, 2007, 17(11): 842-844.
17.	張強, 洪標輝, 李小海, 等. 一期前路植骨融合內固定治療相鄰多椎體結核.中華骨科雜志, 2006, 26(3): 179-182.
18.	Shen X, Huang X, Xiao S, et al. Surgical treatment of selected patients with multilevel contiguous thoracolumbar spinal tuberculosis by only posterior instrumentation without any bone fusion. Int J Clin Exp Med, 2015, 8(10): 18611-18619.
19.	Fukuta S, Miyamoto K, Masuda T, et al. Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine (Phila Pa 1976), 2003, 28(15): E302-308.
20.	吳鵬, 歐云生, 劉德龍, 等. 后路經單側椎弓根病灶清除植骨內固定治療胸腰椎結核的療效分析. 中國修復重建外科雜志, 2015, 29(10): 1259-1264.
21.	XH Yin, SH Liu, JS Li, et al. The role of costotransverse radical debridement, fusion and postural drainage in the surgical treatment of multisegmental thoracic spinal tuberculosis: a minimum 5-year follow-up. Eur Spine J, 2016, 25(4): 1047-1055.
22.	McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976), 1994, 19(15): 1741-1744.
23.	Zhou Y, Song Z, Luo J, et al.The efficacy oflocal continuous chemotherapy and postural drainage in combination with one-stage posterior surgery for the treatment of lumbar spinal tuberculosis. BMC Musculoskelet Disord, 2016, 17: 66.

1. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg (Br), 2010, 92(7): 905-913.
2. Jain A, Jain AK, Kiyawat V. Evaluation of Outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis. Asian Spine J, 2017, 11(1): 31-36.
3. Wang XB, Li J, Lü GH, et al. Single-stage posterior instrumentation and anterior debridement foractive tuberculosis of the thoracic and lumbar spine with kyphotic deformity. Int Orthop, 2012, 36(2): 373-380.
4. Hassan K, Elmorshidy E. Anterior versus posterior approach in surgical treatment of tuberculousspondylodiscitis of thoracic and lumbar spine. Eur Spine J, 2016, 25(4): 1056-1063.
5. Wang LJ, Zhang HQ, Tang MX, et al. Comparison of Three Surgical Approaches for Thoracic Spinal Tuberculosis in Adult: Minimum 5-Year Follow-Up. Spine (Phila Pa 1976), 2017, 42(11): 808-817.
6. Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografs in the thoracic and lumbar spine. Do the 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.
7. Moon MS, Kim SS, Moon H. (i)Tuberculosis of the spine:current views in diagnosis, management, and setting a globalstandard. Orthop Trauma, 2013, 27(4): 185-194.
8. 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.
9. Pu X, Zhou Q, He Q, et al. A posterior versus anterior surgical approach in combination with debridement,interbody autografting and instrumentation for thoracic and lumbar tuberculosis. Int Orthop, 2012, 36(2): 307-313.
10. Tuli SM. Tuberculosis of the skeletal system. 4th ed. Delhi: Jaypee Publishers, 2010: 215.
11. Güven O, Kumano K, Yal?in S, et al. A singlestage posterior approach and rigid fixation for preventing Kyphosisin the treatment of spinal tuberculosis. Spine (Phila Pa 1976), 1994, 199: 1039-1043.
12. Kumar MN, Joseph B, Manur R. Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosiswithout anterior instrumentation and without anterior or posteriorbone grafting. Eur Spine J, 2013, 22(3): 624-632.
13. Qian J, Rijiepu A, Zhu B, et al.Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis. Int Orthop, 2016, 40(10): 2081-2088.
14. 王清, 徐楊博, 韓福剛, 等. 多節段脊柱結核的診斷與治療. 瀘州醫學院學報, 2006, 29(3): 234-237.
15. 施建黨, 王自立, 馬小民. 病灶清除植骨內固定治療相鄰多椎體脊柱結核.中國脊柱脊髓雜志, 2010, 20(2): 98-102.
16. 張西峰, 王巖, 肖嵩華, 等. 經皮穿刺置管沖洗引流持續局部化療治療活動期多椎體脊柱結核. 中國脊柱脊髓雜志, 2007, 17(11): 842-844.
17. 張強, 洪標輝, 李小海, 等. 一期前路植骨融合內固定治療相鄰多椎體結核.中華骨科雜志, 2006, 26(3): 179-182.
18. Shen X, Huang X, Xiao S, et al. Surgical treatment of selected patients with multilevel contiguous thoracolumbar spinal tuberculosis by only posterior instrumentation without any bone fusion. Int J Clin Exp Med, 2015, 8(10): 18611-18619.
19. Fukuta S, Miyamoto K, Masuda T, et al. Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine (Phila Pa 1976), 2003, 28(15): E302-308.
20. 吳鵬, 歐云生, 劉德龍, 等. 后路經單側椎弓根病灶清除植骨內固定治療胸腰椎結核的療效分析. 中國修復重建外科雜志, 2015, 29(10): 1259-1264.
21. XH Yin, SH Liu, JS Li, et al. The role of costotransverse radical debridement, fusion and postural drainage in the surgical treatment of multisegmental thoracic spinal tuberculosis: a minimum 5-year follow-up. Eur Spine J, 2016, 25(4): 1047-1055.
22. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976), 1994, 19(15): 1741-1744.
23. Zhou Y, Song Z, Luo J, et al.The efficacy oflocal continuous chemotherapy and postural drainage in combination with one-stage posterior surgery for the treatment of lumbar spinal tuberculosis. BMC Musculoskelet Disord, 2016, 17: 66.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of multiple segments of thoracolumbar tuberculosis using posterior unilateral debridement with bone graft and internal fixation

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