One-stage posterior approach via multifidus-longissimus cleavage planes for debridement combined with autogenous bone grafting and internal fixation in the treatment of thoracolumbar suppurative spondylitis in adults

English Keywords:Suppurative spondylitis  Thoracic and lumbar  Muscle interspaces  Lesion debridement  Bone grafting  Internal fixation

English Abstract:

  【Abstract】 Objectives: To explore the clinical effects of one-stage posterior approach via multifidus-longissimus cleavage planes for lesion debridement, bone grafting and internal fixation in the treatment of thoracolumbar suppurative spondylitis in adults. Methods: 73 patients with thoracic or lumbar pyogenic spondylitis who underwent one-stage posterior approach via multifidus-longissimus cleavage planes for lesion removal and bone grafting and internal fixation in the Department of Orthopedics, the Affiliated Hospital of Southwest Medical University from February 2019 to February 2021 were retrospectively analyzed. There were 52 males and 21 females, aged 35-75 years(56.5±10.7 years); T1-T10 in 15 cases, T11-L2 in 32 cases, and L3-L5 in 26 cases. Obvious kyphotic deformity was found locally in all the patients. 23 cases were accompanied with intraspinal epidural abscess, and 17 cases with paravertebral or psoas major muscle abscess. 7 cases were combined with neurological impairment, and the American Spinal Injury Association(ASIA) classification of neurological function was detailed in 1 case of grade C and 6 cases of grade D. 24 cases were complicated with cardiovascular and cerebrovascular diseases, 35 cases with diabetes, and 30 cases had a history of invasive operation. The venous blood was collected for bacterial culture before operation. All the patients were treated with one-stage posterior approach via multifidus-longissimus cleavage planes for lesion removal and bone grafting and internal fixation. The lesion tissue was taken for bacterial culture during operation. The postoperative irrigation lasted for 10-14d, and the anti-infection treatment lasted for 6-8 weeks. The operative time, intraoperative blood loss, and length of hospital stays, and complications were recorded; Erythrocyte sedimentation rate(ESR), C-reactive protein(CRP) and procalcitonin(PCT) were compared preoperatively and before discharge; Visual analogue scale(VAS) scores of thoracolumbar back pain before operation and discharge and at final follow-up were compared. The Cobb angles of kyphosis of the lesion segment were measured on radiographs, and the rate of correction of kyphosis and loss angle of correction at the final follow-up were calculated; The recovery of spinal cord function(ASIA grade) and bone graft fusion at final follow-up were observed and evaluated. Results: All the patients underwent the surgery successfully. The operative time was 195.8±15.5min, the intraoperative blood loss was 562.1±45.5mL, and the length of hospital stays were 18.0±2.0d. Postoperative complications occurred in 9 patients(12.3%): 2 patients had delirium syndrome, which gradually disappeared after oral administration of olanzapine; 4 cases had lower limb pain and numbness, and the symptoms disappeared after nutritional nerve treatment; 3 cases presented with pleural effusion and were cured after administration of closed chest drainage, anti-infection and strengthening of lung function exercises. 51 cases were positive of bacterial culture, including 29 cases of Staphylococcus aureus, 17 cases of Escherichia coli and 5 cases of Staphylococcus epidermidis. Preoperative ESR, CRP and PCT were 80.9±13.9mm/h, 58.4±13.5mg/L, 0.8±0.2ng/mL, and before discharge they were 29.6±8.9mm/h, 15.0±7.2mg/L and 0.1±0.0ng/mL. ESR, CRP, and PCT were significantly decreased before discharge compared with preoperative values(P<0.05). The patients were followed up for 12-30 months(20.1±4.0 months). At preoperation, before discharge and final follow-up, the VAS scores were 7.6±1.1, 2.2±0.6 and 1.6±0.6, respectively. Before discharge and final follow-up VAS scores were significantly lower than the preoperative score(P<0.05). The Cobb angle was 19.6°±1.6°, 6.2°±1.5°, 9.4°±1.0°, and the correction angle was 13.4°±0.6°, the correction rate was 68.7%±5.3%, which was significantly corrected before discharge(P<0.05). At final follow-up, the corrected angle loss was 3.2°±0.7° relative to before discharge, and the corrected angle loss rate was 24.0%±4.6%(P<0.05). At the final follow-up, one patient of preoperative ASIA grade C recovered to grade D, and six patients of grade D recovered to grade E. There was no change in ASIA grade after operation in patients without nerve injury before operation. Bone fusion was achieved in all patients at the final follow-up. Conclusions: On the basis of anti-infection, one-stage posterior approach via multifidus-longissimus cleavage planes for the treatment of thoracolumbar suppurative spondylitis enables removal of lesion, decompression of spinal canal, and fusion and fixation of intervertebral support implants with protection of paravertebral muscles as well as the posterior ligamentous complexes, and reduces chronic thoracolumbar back pain after operation.