Mid- to long-term clinical efficacy analysis of different surgical approaches in the treatment of adult thoracolumbar tuberculosis

English Keywords:Spinal tuberculosis  Surgical approach  Thoracic and lumbar spine  Mid- to long-term  Clinical efficacy

English Abstract:

  【Abstract】 Objectives: To compare and analyze the mid- to long-term efficacies of posterior approach(Wiltse′s approach), anterior approach, and posterior-anterior approach in the treatment of adult thorcolumbar tuberculosis. Methods: A total of 421 patients with thoracolumbar tuberculosis underwent surgical treatment in our department from January 2008 to January 2016, among which, 341 patients received mid- to long-term follow-up. There were 190 males and 151 females, aged 18 to 73 years(42.1±15.1 years). 330 patients were given standardized anti-tuberculosis therapy for at least 2 weeks before operation(isoniazid+rifampicin+pyrazinamide+ethambutol), and the other 11 patients underwent emergency surgery. T1-T10 vertebrae were involved in 82 cases, T11-L2 in 165 cases, and L3-L5 in 94 cases. 179 cases were treated with posterior debridement(Wiltse′s approach) combined with intervertebral bone grafting and internal fixation(group A), 98 cases were treated with anterior debridement combined with intervertebral bone grafting and internal fixation(group B), and 64 cases were treated with internal fixation via Wiltse′s approach + anterior debridement and intervertebral bone grafting(group C). After operation, all the patients were given standard quadruple anti-tuberculosis drugs for 1.5-2.0 years. The operation time, intraoperative blood loss, hospitalization days were collected of three groups. The erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP) of all the three groups of patients were collected before surgery and at 1 week after surgery. At preoperation, 1 week after surgery, and the final follow-up, the VAS scores of thoracolumbar back pain were collected, and the Cobb angles of thoracolumbar kyphosis were measured on X-ray film to calculate the correction rate of thoracolumbar kyphosis and final follow-up correction loss angle. Besides, the recovery of neurologic function, bone graft fusion rate, and postoperative complications at the last follow-up were collected. Results: All the patients underwent operations uneventfully and were followed up for 5-13 years(8.4±2.1 years). The operation time, intraoperative blood loss and hospital stay in group A(207.8±50.0min, 570.0±309.6ml and 12.5±2.5d) were smaller than those in group B(I249.9±47.7min, 745.5±394.6ml and 16.8±9.7d) and group C(274.3±59.3min, 792.0±282.8ml and 17.3±3.4d)(P<0.001). At preoperation and 1 week after operation, the ESR was 68.8±26.1mm/h and 31.4±13.0mm/h, and CRP was 53.0±14.6mg/L and 27.9±7.1mg/L in group A; the ESR was 63.7±22.4mm/h and 27.9±10.0mm/h, and CRP was 53.4±20.3mg/L and 27.6±9.4mg/L in group B; ESR was 65.4±24.2mm/h and 31.1±11.1mm/h, and CRP was 55.2±16.9mg/L and 26.0±7.8mg/L in group C. Both ESR and CRP of all the three groups at 1 week after operation reduced significantly than those before operation, respectively(P<0.001). At preoperation, 1 week after operation, and the final follow-up, the VAS scores of group A were 5.1±1.1, 2.5±0.8, and 1.8±0.7, which of group B were 5.2±1.0, 2.6±1.0, and 2.0±0.6, and those of group C were 4.9±1.0, 2.5±1.1 and 2.0±0.7. The postoperative 1 week and final follow-up VAS scores of the three groups significantly improved than those before operation(P<0.001). At preoperation, 1 week after operation, and final follow-up, the Cobb angles of kyphosis were 27.0°±3.1°, 9.8°±2.0°, and 13.0°±1.9° in group A, 27.5°±1.9°, 10.4°±0.8°, and 14.4°±0.9° in group B, and 28.3°±4.8°, 10.6°±2.4°, and 13.9°±2.3° in group C. The kyphosis was significantly corrected in all the three groups(P<0.001). Loss of correction angle at final follow-up was 3.2°±1.1° in group A, 4.0°±0.7° in group B, and 3.3°±1.0° in group C. Loss of correction angle in group B was greater than that in group A and C(P<0.001). At the last follow-up, 15 patients failed to achieve grade 1 and grade 2 fusion, including 10 in group A(5.6%), 2 in group B(3.1%), and 3 in group C(3.1%)(P>0.05). The 24 patients with neurologic deficit improved significantly at the last follow-up. Postoperative complications occurred in 6 cases(3.4%) in group A, 6 cases(6.1%) in group B, and 5 cases(7.8%) in group C(P>0.05), all of which were cured by symptomatic treatment. In group B, one patient had tuberculosis recurrence 2 years after operation, and was cured by posterior debridement (Wiltse′s approach) combined with intervertebral bone graft fusion and internal fixation. Conclusions: All the three kinds of surgical approaches-posterior approach(Wiltse′s approach), anterior approach, and posterior-anterior approach can achieve satisfactory mid- to long-term results in treating adult thoracolumbar spinal tuberculosis on the basis of anti-tuberculosis drug treatment. The Wiltse′s approach is superior to anterior approach only and posterior combined anterior approach in operation time, blood loss, and length of hospital stay. While Wiltse′s approach and posterior combined anterior approach are superior to anterior approach only in correction and maintenance of kyphosis.