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Comparison between single anterior and single posterior approaches of debridement interbody fusion and fixation for the treatment of mono-segment lumbar spine tuberculosis

Comparison between single anterior and single posterior approaches of debridement interbody... Purpose To compare the efficacy of single anterior and single posterior approach of debridement, interbody fusion, and fixation for the treatment of mono-segment lumbar spine tuberculosis (TB) patients. Methods Eighty-seven patients with mono-segment lumbar TB who underwent debridement, interbody fusion, and fixation through either single anterior (Group A) or single posterior approach (Group B) from January 2007 to January 2017 were enrolled in this study. The duration of the operation, blood loss, complication rate, visual analog scale (VAS), Oswestry disability index (ODI), Frankel scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), kyphosis angle, cor- rection rate, correction loss, and time taken for bone graft fusion were compared between the groups. Results The average period of follow-up was 34.3 ± 9.5 months (24–56 months). No significant differences were observed between patients in Group A and patients in Group B in terms of gender, age, body mass index (BMI), duration of illness and preoperative evaluative indices (P > 0.05). The mean operation time and blood loss was significantly higher in Group A (P = 0.000), along with a slightly higher rate of complications compared with Group B (P = 0.848). The VAS, ODI and Frankel scale scores showed significant improvement in both groups (P = 0.000), along with the ESR, CRP and kyphosis indices (P = 0.000), which were similar in both groups at the final follow-up. Conclusion Both single anterior and single posterior approaches of debridement, interbody fusion and fixation are effective for mono-segment lumbar TB patients, although the single posterior approach is of a shorter duration and results in less blood loss. Keywords Spinal tuberculosis · Anterior · Posterior · Mono-segment · Lumbar Introduction Despite considerable efforts made by the WHO during the past decade to prevent and control TB, spinal TB is still Spinal tuberculosis (TB) is a chronic infection of the spine prevalent in China, India, and other developing and unde- that causes pain, kyphotic deformity, and disability. Spinal veloped countries [1]. In addition, sporadic cases have also TB accounts for a large proportion of extrapulmonary TB been reported in some developed countries [2]. cases and is the most common form of bone and joint TB. * Weiwei Li Yayi Fan lww205@sina.com 18192366628@163.com Hangli Wu Yongchun Zhou 46570988@qq.com zycsine@sina.com Yaqing Cui Department of Orthopedic, Shaanxi Provincial People’s 347165762@qq.com Hospital, Xi’an 710068, Shaanxi, China Liqun Gong Department of Plastic and Reconstructive Surgery, Shaanxi gongortho@163.com Provincial People’s Hospital, Xi’an 710068, Shaanxi, China Jun Liu docspineliu@163.com Vol.:(0123456789) 1 3 3644 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 Most spinal TB patients can be cured using regular anti- Preoperative preparation TB drug chemotherapy along with bed rest and nutritional supplements [3]. However, anti-TB drugs are not effective The patients received 2–4 weeks of HREZ standard chem- against kyphosis deformity. Rajasekaran et al. [4] found otherapy regimen (including isoniazid, rifampicin, etham- that kyphosis deformity progressed in 39% of the pediatric butol, and pyrazinamide) before the operation. Sufficient patients with spinal TB who received non-surgical treatment. nutritional supplementation was also provided. Cold abscess sinus formation, spinal disability, neurological deficits, and severe kyphosis deformity are currently recog- Operative techniques nized as indications for surgical intervention for spinal TB [5]. The objectives of surgery are debridement, neurological Single anterior approach (Group A): An oblique incision decompression, and re-stabilization of the spine. An anterior was made above the groin, and the muscles were bluntly surgical approach was initially developed by Hodgson and separated layer by layer while protecting the retroperi- Stock [6] and has been known as the Hong Kong technique. toneum and intra-abdominal organs. The psoas muscle The single posterior approach of debridement, interbody abscess was cleared by rinsing and wiping it with a wet fusion and fixation was subsequently developed for patients gauze, and the necrotic disc, sequestrum, diseased granula- with lumbar TB [7], who account for a considerable propor- tion tissue and pus were carefully removed. A three-sided tion of spinal TB cases. However, only a few studies have cortical iliac was obtained from the same incision, and an compared the therapeutic efficacy of single anterior and sin- interbody bone graft was performed after debridement. A gle posterior approach of debridement, interbody fusion, and vertebral screw-rod system or a screw-plate was used for fixation. Therefore, the aim of this study is to compare the vertebral fixation (Fig.  1). therapeutic efficacy of both approaches for mono-segmental Single posterior approach (Group B): A midline inci- lumbar TB patients. sion was made, and the paravertebral muscle was dis- sected subperiosteally to expose the lamina and facet joints within the affected region. Pedicle screws were used in the normal vertebral body and occasionally in the affected ver - Materials and methods tebral body. The fixation range was minimized as much as possible. Total laminectomy and partial facet joint resec- Patient population tion were performed, followed by debridement under the protection of the dura and nerve root. The necrotic disc, The inclusion criteria were as follows: (1) confirmed diag- caseous granulated tissue and dead bones were removed nosis of lumbar spinal TB, (2) lesion was limited to one using different curettes. Non-structural interbody fusion disc and two adjacent vertebral bodies, (3) elective surgical was implemented using bone particles obtained from the debridement, interbody fusion, and fixation via either a sin- normal lamina and facet joints. Finally, two good bended gle anterior or a single posterior approach, and (4) follow- rods were placed on either side to fix the affected area up duration of at least 24 months. Patients with systemic (Fig. 2). TB, a history of abdominal or lumbar surgery and inability to sustain long-term and effective anti-TB drug treatment due to damaged hepatic function were excluded. Among Postoperative management the initial cohort of 167 patients with lumbar spinal TB, 38 were reluctant to undergo surgery and 42 did not meet the Antibiotics were administered for at least 24 h to prevent inclusion criteria. Finally, 87 cases that met the inclusion infection, while hepato-protective drugs were adminis- criteria and provided consent for surgery were enrolled. The tered prophylactically. Partial weight-bearing ambulation diagnosis was confirmed through MTB culture or patho- with a thoracolumbar brace was recommended to be used logical examination. Routine blood test, erythrocyte sedi- from the 6th week post-operation. The minimum dura- mentation rate (ESR), C-reactive protein (CRP) and T cell tion of HREZ standard chemotherapy administration was spot test for TB infection (T-SPOT.TB) were performed on 12 months (Fig. 3). all patients. X-ray, CT, and MRI examinations were pre- operatively performed to develop a diagnosis and treatment Evaluation indexes plan. All patients manifested varying degrees of back pain and fatigue, although only 33 cases (37.9%) presented with The duration of operation, blood loss, complication rate, typical symptoms of TB, such as low-grade fever in the eve- visual analog scale (VAS), Oswestry disability index nings, night sweats and fatigue. All participants provided (ODI), Frankel scale, ESR, CRP level, kyphosis Cobb’s written informed consent to participate in the study. 1 3 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 3645 Fig. 1 Flow chart for patients enrolled Fig. 2 A 73-year-old male patient with L2–3 mono- segmental spinal TB, who complained of severe back pain for 7 months, received single anterior debridement, interbody fusion and vertebral fixation. a, b Preoperative X-ray of AP and lateral images show lumbar degeneration and loss of L2-3 intervertebral height. c, d Preoperative CT and MRI images show the destruction of vertebral bodies and disc. e, f Postoperative X-ray of AP and lateral images show good posi- tion of vertebral screw fixation. g, h Postoperative CT images show solid interbody fusion had been achieved at the postopera- tive 24th month angle, kyphosis correction rate, kyphosis correction loss Results and duration of bone graft fusion were compared between the two groups. Demographic data Statistical analysis Group A included 24 males and 16 females of a mean age of 52.2 ± 13.4 years (24–76 years), mean body mass 2 2 Statistical analyses were performed using SPSS version 22.0 index (BMI) of 20.7 ± 2.6  kg/m (16–28  kg/m ), and software (SPSS Inc., Chicago, IL, USA). Independent sam- mean illness duration of 5.3 ± 1.6 months (1–8 months). ple t-test, Chi-squared and or Wilcoxon signed rank test were Group B included 31 males and 16 females of a mean conducted. A P value of < 0.05 was considered to indicate age 50.3 ± 9.9  years (25–74  years), mean BMI of statistical significance. 1 3 3646 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 Fig. 3 A 29-year-old male patient with L2–3 mono- segmental spinal TB, who complained of severe low back pain for 3 months, received single posterior debridement, interbody fusion and pedicle fixation. a, b Preoperative X-ray of AP and lateral images show roughly normal radiological presentation. c, d Preoperative CT and MRI images show the destruction of vertebral bodies and disc. e, f Postoperative X-ray of AP and lateral images show good position of pedicle screw fixation. g, h Postopera- tive CT images show solid inter- body fusion had been achieved at the postoperative 24th month Table 1 Evaluation indexes Evaluation indexes Group A (N = 40) Group B (N = 47) P value comparison between Group A and Group B Operation time (min) 218.5 ± 15.5* 163.8 ± 13.3* 0.000 Blood loss (ml) 663.8 ± 82.2* 509.8 ± 72.1* 0.000 Rate of surgical complications (%) 7.5% (3/40) 6.4% (3/47) 0.848 Time of bone graft fusion (months) 6.5 ± 0.8 6.6 ± 0.7 0.794 Kyphosis correction rate (%) 84.2 ± 14.7 80.2 ± 20.5 0.310 Correction loss rate (%) 6.1 ± 6.9 5.5 ± 6.5 0.696 Data are presented as n (%) or mean ± standard deviation (range) *: P < 0.05, the difference between Group A and Group B was significant 2 2 21.4 ± 2.9  kg/m (16–30 kg/m ), and mean illness dura- Table 2 Comparison of VAS, ODI, ESR, CRP, and kyphosis angle between Group A and Group B tion of 5.0 ± 1.2 months (1–8 months). Both groups were similar in terms of gender, age, and BMI (P > 0.05). The Schedule Group A Group B patients were followed-up for 24–56 months and the mean Pre-op FFU Pre-op FFU follow-up period was 34.3 ± 9.5 months VAS 4.2 ± 1.0 0.5 ± 0.6* 4.4 ± 1.0 0.4 ± 0.5* Surgical data ODI (%) 28.7 ± 10.0 7.4 ± 2.6* 30.9 ± 9.0 8.3 ± 4.6* ESR (mm/h) 58.7 ± 9.4 13.0 ± 2.0* 57.1 ± 6.7 12.8 ± 2.0* The mean duration of the operation and mean intra- CRP (mg/L) 58.7 ± 13.3 2.8 ± 0.9* 56.4 ± 15.0 2.7 ± 1.0* operative blood loss were significantly lower in Group Pre-op pre-operation, Post-op post-operation, FFU final follow-up B compared with that of Group A (P < 0.05; Table  1). *: P < 0.05, compared with pre-op indexes No intra-operative neurological, vascular, urethral, or visceral injuries had occurred in either group, although two cases of dura tear were reported from Group B. No cured using anterior debridement surgery three months cases of TB relapse were recorded in Group A, while one after the first surgery. The surgical complication rate in case of relapse was reported from Group B, which was 1 3 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 3647 Group A was insignificantly higher than that of Group B Table 4 Comparison of Frankel Preop- Final follow-up grade between Group A and (P > 0.05; Table 1). erative Group B A B C D E D 32 0 0 0 2 30 Lumbar symptoms and function E 8 0 0 0 0 8 D 37 0 0 0 3 34 No significant differences were observed between the E 10 0 0 0 0 10 pre-operative VAS and ODI values of the two groups (P > 0.05) and significant improvement was observed in both groups after the operation (P < 0.05). However, the Discussion post-operative and follow-up VAS and ODI values were similar in both groups (P > 0.05; Table 2). The aim of this study was to compare the therapeutic efficacy of a single anterior approach and single poste- rior approach for the debridement, interbody fusion, and Laboratory test fixation for patients with mono-segment lumbar TB. Both techniques performed well in terms of multiple indices, The pre-operative ESR and CRP values were similar in and achieved pain relief, lumbar function recovery, neu- both groups (P > 0.05) and decreased to baseline levels rological deficit improvement, lesion healing, and the res- in Group A and B patients within 6 months post-opera- toration and maintenance of normal lumbar alignment to tion. No significant differences were detected in any of a similar extent. Furthermore, both the anterior and poste- the indices in both groups at the postoperative and final rior approaches were associated with a low risk of surgical follow-up timepoints (P > 0.05; Table 2). complications. However, single posterior surgery required less time and led to lower blood loss compared with the anterior approach. Radiological evaluation Anterior debridement and interbody fusion can effec- tively reveal TB lesions, completely remove lesions, and The pre-operative kyphosis Cobb’s angles were similar in reconstruct the damaged column [8] and is the gold stand- both groups (P > 0.05), and patients in both groups showed ard for treating spinal TB [9]. In addition, the lack of adhe- significant kyphosis correction (P < 0.05). No significant sion of MTB on titanium instruments in vitro prompts spi- differences were observed in the post-operative kyphosis nal internal fixation, which has been proven to be clinically Cobb’s angles, kyphosis correction rate and correction effective and shows excellent radiological performance for loss (P > 0.05) as well as in the interbody fusion duration kyphosis correction [10, 11]. Dai et al. [12] conducted a between the two groups (P > 0.05; Table 3). prospective study on 39 spinal TB patients who had under- gone anterior debridement, autogenous bone grafting and instrumentation, and found that spinal fixation was a safe Neurological deficit assessment and effective method of treatment. In a study conducted on 62 spinal TB patients, Obaid-Ur-Rahman et al. [13] As shown in Table  4, no significant difference was reported that anterior debridement with internal fixation observed in the Frankel scale scores between the two resulted in better kyphosis correction and maintenance. groups (P > 0.05; Table 4). However, anterior debridement interbody fusion and Table 3 Comparison of Schedule Group A Group B radiological indexes between Group A and Group B Pre-op FFU Pre-op FFU Kyphosis angle (°) 11.2 ± 2.6 2.2 ± 2.0* 12.1 ± 2.8 1.8 ± 1.7* Time of bone graft fusion (M) 6.5 ± 0.8 6.6 ± 0.7 Kyphosis correction rate (%) 84.2 ± 14.7 80.2 ± 20.5 Correction loss rate (%) 6.1 ± 6.9 5.5 ± 6.5 Pre-op pre-operation, Post-op post-operation, FFU final follow-up *: P < 0.05, the difference of kyphosis angle between pre-op and FFU was significant in both Group A and Group B 1 3 3648 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 fixation have some inherent flaws, such as disturbance to size, and selection bias of surgical decision, which may have the gastrointestinal tract, complex anatomical structures, affected our conclusions. Therefore, our findings need to be large range of exposure, high risk of injury to neural, vas- validated using a larger cohort. cular, and urinary tissue, as well as poor strength of ver- tebral fixation [14]. Posterior pedicle fixation system is a three-dimensional Conclusion internal fixation technique that increases stability and cor - rects spine deformity. In fact, anterior debridement, inter- Both single anterior and single posterior approaches of body graft, and posterior pedicle fixation are ideal for spinal debridement, interbody fusion and fixation are effective for TB since it does not damage normal posterior anatomical mono-segment lumbar TB patients, although the single pos- structures, clearly demarcates the infected area, and can terior approach is of a shorter duration and results in less achieve a good radiological result of kyphosis correction blood loss. [15]. Mukhtar et al. [16] and Talu et al. [17] reported that anterior radical debridement, strut graft fusion and posterior instrumentation are feasible and effective methods for treat - Funding No applicable. ing TB lesions and achieving long-term correction of kypho- sis deformity. A combined anterior and posterior approach Declarations is only suitable for spinal TB cases with extensive or fluid Conflict of interest The authors declare that they have no conflict of paravertebral abscess pus or severely damaged spine stabil- interest. ity, since most cases can be treated using a single anterior or posterior surgical approach [18, 19]. Ethics approval and consent to participate Ethical approval from Studies have increasingly shown that thoracic and lumbar the Ethics Committee of Shaanxi Provincial People’s Hospital was obtained for this study. Each author certifies that all investigations were spinal TB can be successfully treated using a single poste- conducted in conformity with ethical principles. rior approach. Yu et al. [20] studied 28 elderly patients with lumbar TB who underwent posterior transforaminal lumbar Consent for publication All patients signed informed consent forms to debridement, interbody fusion, and instrumentation, and publish their personal details in this article. found that the operation led to significant ODI improve - ment and a decrease in the kyphosis angle, although a 2.0° Open Access This article is licensed under a Creative Commons Attri- kyphosis correction loss was observed during the follow-up bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long period. Xu et al. [21] found that single posterior debride- as you give appropriate credit to the original author(s) and the source, ment, compact bone grafting, and pedicle fixation signifi- provide a link to the Creative Commons licence, and indicate if changes cantly improved neurological deficit, ODI and led to steady were made. The images or other third party material in this article are kyphosis correction in 32 patients with mono-segmental included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in lumbar TB and vertebral body damage not more than 2/3rd the article’s Creative Commons licence and your intended use is not of the column height. Zhang et al. [22] retrospectively com- permitted by statutory regulation or exceeds the permitted use, you will pared a posterior-only, anterior-only, and combined ante- need to obtain permission directly from the copyright holder. To view a rior and posterior approaches for spinal TB cases and found copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . that the posterior-only approach was safer and less invasive, compared with the other two approaches. In contrast, Has- san et al. 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Eur Spine J 23(4):830–837. https:// doi. org/ 10. 1007/ s00586- 013- 3051-7 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Orthopaedic and Trauma Surgery Springer Journals

Comparison between single anterior and single posterior approaches of debridement interbody fusion and fixation for the treatment of mono-segment lumbar spine tuberculosis

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Abstract

Purpose To compare the efficacy of single anterior and single posterior approach of debridement, interbody fusion, and fixation for the treatment of mono-segment lumbar spine tuberculosis (TB) patients. Methods Eighty-seven patients with mono-segment lumbar TB who underwent debridement, interbody fusion, and fixation through either single anterior (Group A) or single posterior approach (Group B) from January 2007 to January 2017 were enrolled in this study. The duration of the operation, blood loss, complication rate, visual analog scale (VAS), Oswestry disability index (ODI), Frankel scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), kyphosis angle, cor- rection rate, correction loss, and time taken for bone graft fusion were compared between the groups. Results The average period of follow-up was 34.3 ± 9.5 months (24–56 months). No significant differences were observed between patients in Group A and patients in Group B in terms of gender, age, body mass index (BMI), duration of illness and preoperative evaluative indices (P > 0.05). The mean operation time and blood loss was significantly higher in Group A (P = 0.000), along with a slightly higher rate of complications compared with Group B (P = 0.848). The VAS, ODI and Frankel scale scores showed significant improvement in both groups (P = 0.000), along with the ESR, CRP and kyphosis indices (P = 0.000), which were similar in both groups at the final follow-up. Conclusion Both single anterior and single posterior approaches of debridement, interbody fusion and fixation are effective for mono-segment lumbar TB patients, although the single posterior approach is of a shorter duration and results in less blood loss. Keywords Spinal tuberculosis · Anterior · Posterior · Mono-segment · Lumbar Introduction Despite considerable efforts made by the WHO during the past decade to prevent and control TB, spinal TB is still Spinal tuberculosis (TB) is a chronic infection of the spine prevalent in China, India, and other developing and unde- that causes pain, kyphotic deformity, and disability. Spinal veloped countries [1]. In addition, sporadic cases have also TB accounts for a large proportion of extrapulmonary TB been reported in some developed countries [2]. cases and is the most common form of bone and joint TB. * Weiwei Li Yayi Fan lww205@sina.com 18192366628@163.com Hangli Wu Yongchun Zhou 46570988@qq.com zycsine@sina.com Yaqing Cui Department of Orthopedic, Shaanxi Provincial People’s 347165762@qq.com Hospital, Xi’an 710068, Shaanxi, China Liqun Gong Department of Plastic and Reconstructive Surgery, Shaanxi gongortho@163.com Provincial People’s Hospital, Xi’an 710068, Shaanxi, China Jun Liu docspineliu@163.com Vol.:(0123456789) 1 3 3644 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 Most spinal TB patients can be cured using regular anti- Preoperative preparation TB drug chemotherapy along with bed rest and nutritional supplements [3]. However, anti-TB drugs are not effective The patients received 2–4 weeks of HREZ standard chem- against kyphosis deformity. Rajasekaran et al. [4] found otherapy regimen (including isoniazid, rifampicin, etham- that kyphosis deformity progressed in 39% of the pediatric butol, and pyrazinamide) before the operation. Sufficient patients with spinal TB who received non-surgical treatment. nutritional supplementation was also provided. Cold abscess sinus formation, spinal disability, neurological deficits, and severe kyphosis deformity are currently recog- Operative techniques nized as indications for surgical intervention for spinal TB [5]. The objectives of surgery are debridement, neurological Single anterior approach (Group A): An oblique incision decompression, and re-stabilization of the spine. An anterior was made above the groin, and the muscles were bluntly surgical approach was initially developed by Hodgson and separated layer by layer while protecting the retroperi- Stock [6] and has been known as the Hong Kong technique. toneum and intra-abdominal organs. The psoas muscle The single posterior approach of debridement, interbody abscess was cleared by rinsing and wiping it with a wet fusion and fixation was subsequently developed for patients gauze, and the necrotic disc, sequestrum, diseased granula- with lumbar TB [7], who account for a considerable propor- tion tissue and pus were carefully removed. A three-sided tion of spinal TB cases. However, only a few studies have cortical iliac was obtained from the same incision, and an compared the therapeutic efficacy of single anterior and sin- interbody bone graft was performed after debridement. A gle posterior approach of debridement, interbody fusion, and vertebral screw-rod system or a screw-plate was used for fixation. Therefore, the aim of this study is to compare the vertebral fixation (Fig.  1). therapeutic efficacy of both approaches for mono-segmental Single posterior approach (Group B): A midline inci- lumbar TB patients. sion was made, and the paravertebral muscle was dis- sected subperiosteally to expose the lamina and facet joints within the affected region. Pedicle screws were used in the normal vertebral body and occasionally in the affected ver - Materials and methods tebral body. The fixation range was minimized as much as possible. Total laminectomy and partial facet joint resec- Patient population tion were performed, followed by debridement under the protection of the dura and nerve root. The necrotic disc, The inclusion criteria were as follows: (1) confirmed diag- caseous granulated tissue and dead bones were removed nosis of lumbar spinal TB, (2) lesion was limited to one using different curettes. Non-structural interbody fusion disc and two adjacent vertebral bodies, (3) elective surgical was implemented using bone particles obtained from the debridement, interbody fusion, and fixation via either a sin- normal lamina and facet joints. Finally, two good bended gle anterior or a single posterior approach, and (4) follow- rods were placed on either side to fix the affected area up duration of at least 24 months. Patients with systemic (Fig. 2). TB, a history of abdominal or lumbar surgery and inability to sustain long-term and effective anti-TB drug treatment due to damaged hepatic function were excluded. Among Postoperative management the initial cohort of 167 patients with lumbar spinal TB, 38 were reluctant to undergo surgery and 42 did not meet the Antibiotics were administered for at least 24 h to prevent inclusion criteria. Finally, 87 cases that met the inclusion infection, while hepato-protective drugs were adminis- criteria and provided consent for surgery were enrolled. The tered prophylactically. Partial weight-bearing ambulation diagnosis was confirmed through MTB culture or patho- with a thoracolumbar brace was recommended to be used logical examination. Routine blood test, erythrocyte sedi- from the 6th week post-operation. The minimum dura- mentation rate (ESR), C-reactive protein (CRP) and T cell tion of HREZ standard chemotherapy administration was spot test for TB infection (T-SPOT.TB) were performed on 12 months (Fig. 3). all patients. X-ray, CT, and MRI examinations were pre- operatively performed to develop a diagnosis and treatment Evaluation indexes plan. All patients manifested varying degrees of back pain and fatigue, although only 33 cases (37.9%) presented with The duration of operation, blood loss, complication rate, typical symptoms of TB, such as low-grade fever in the eve- visual analog scale (VAS), Oswestry disability index nings, night sweats and fatigue. All participants provided (ODI), Frankel scale, ESR, CRP level, kyphosis Cobb’s written informed consent to participate in the study. 1 3 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 3645 Fig. 1 Flow chart for patients enrolled Fig. 2 A 73-year-old male patient with L2–3 mono- segmental spinal TB, who complained of severe back pain for 7 months, received single anterior debridement, interbody fusion and vertebral fixation. a, b Preoperative X-ray of AP and lateral images show lumbar degeneration and loss of L2-3 intervertebral height. c, d Preoperative CT and MRI images show the destruction of vertebral bodies and disc. e, f Postoperative X-ray of AP and lateral images show good posi- tion of vertebral screw fixation. g, h Postoperative CT images show solid interbody fusion had been achieved at the postopera- tive 24th month angle, kyphosis correction rate, kyphosis correction loss Results and duration of bone graft fusion were compared between the two groups. Demographic data Statistical analysis Group A included 24 males and 16 females of a mean age of 52.2 ± 13.4 years (24–76 years), mean body mass 2 2 Statistical analyses were performed using SPSS version 22.0 index (BMI) of 20.7 ± 2.6  kg/m (16–28  kg/m ), and software (SPSS Inc., Chicago, IL, USA). Independent sam- mean illness duration of 5.3 ± 1.6 months (1–8 months). ple t-test, Chi-squared and or Wilcoxon signed rank test were Group B included 31 males and 16 females of a mean conducted. A P value of < 0.05 was considered to indicate age 50.3 ± 9.9  years (25–74  years), mean BMI of statistical significance. 1 3 3646 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 Fig. 3 A 29-year-old male patient with L2–3 mono- segmental spinal TB, who complained of severe low back pain for 3 months, received single posterior debridement, interbody fusion and pedicle fixation. a, b Preoperative X-ray of AP and lateral images show roughly normal radiological presentation. c, d Preoperative CT and MRI images show the destruction of vertebral bodies and disc. e, f Postoperative X-ray of AP and lateral images show good position of pedicle screw fixation. g, h Postopera- tive CT images show solid inter- body fusion had been achieved at the postoperative 24th month Table 1 Evaluation indexes Evaluation indexes Group A (N = 40) Group B (N = 47) P value comparison between Group A and Group B Operation time (min) 218.5 ± 15.5* 163.8 ± 13.3* 0.000 Blood loss (ml) 663.8 ± 82.2* 509.8 ± 72.1* 0.000 Rate of surgical complications (%) 7.5% (3/40) 6.4% (3/47) 0.848 Time of bone graft fusion (months) 6.5 ± 0.8 6.6 ± 0.7 0.794 Kyphosis correction rate (%) 84.2 ± 14.7 80.2 ± 20.5 0.310 Correction loss rate (%) 6.1 ± 6.9 5.5 ± 6.5 0.696 Data are presented as n (%) or mean ± standard deviation (range) *: P < 0.05, the difference between Group A and Group B was significant 2 2 21.4 ± 2.9  kg/m (16–30 kg/m ), and mean illness dura- Table 2 Comparison of VAS, ODI, ESR, CRP, and kyphosis angle between Group A and Group B tion of 5.0 ± 1.2 months (1–8 months). Both groups were similar in terms of gender, age, and BMI (P > 0.05). The Schedule Group A Group B patients were followed-up for 24–56 months and the mean Pre-op FFU Pre-op FFU follow-up period was 34.3 ± 9.5 months VAS 4.2 ± 1.0 0.5 ± 0.6* 4.4 ± 1.0 0.4 ± 0.5* Surgical data ODI (%) 28.7 ± 10.0 7.4 ± 2.6* 30.9 ± 9.0 8.3 ± 4.6* ESR (mm/h) 58.7 ± 9.4 13.0 ± 2.0* 57.1 ± 6.7 12.8 ± 2.0* The mean duration of the operation and mean intra- CRP (mg/L) 58.7 ± 13.3 2.8 ± 0.9* 56.4 ± 15.0 2.7 ± 1.0* operative blood loss were significantly lower in Group Pre-op pre-operation, Post-op post-operation, FFU final follow-up B compared with that of Group A (P < 0.05; Table  1). *: P < 0.05, compared with pre-op indexes No intra-operative neurological, vascular, urethral, or visceral injuries had occurred in either group, although two cases of dura tear were reported from Group B. No cured using anterior debridement surgery three months cases of TB relapse were recorded in Group A, while one after the first surgery. The surgical complication rate in case of relapse was reported from Group B, which was 1 3 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 3647 Group A was insignificantly higher than that of Group B Table 4 Comparison of Frankel Preop- Final follow-up grade between Group A and (P > 0.05; Table 1). erative Group B A B C D E D 32 0 0 0 2 30 Lumbar symptoms and function E 8 0 0 0 0 8 D 37 0 0 0 3 34 No significant differences were observed between the E 10 0 0 0 0 10 pre-operative VAS and ODI values of the two groups (P > 0.05) and significant improvement was observed in both groups after the operation (P < 0.05). However, the Discussion post-operative and follow-up VAS and ODI values were similar in both groups (P > 0.05; Table 2). The aim of this study was to compare the therapeutic efficacy of a single anterior approach and single poste- rior approach for the debridement, interbody fusion, and Laboratory test fixation for patients with mono-segment lumbar TB. Both techniques performed well in terms of multiple indices, The pre-operative ESR and CRP values were similar in and achieved pain relief, lumbar function recovery, neu- both groups (P > 0.05) and decreased to baseline levels rological deficit improvement, lesion healing, and the res- in Group A and B patients within 6 months post-opera- toration and maintenance of normal lumbar alignment to tion. No significant differences were detected in any of a similar extent. Furthermore, both the anterior and poste- the indices in both groups at the postoperative and final rior approaches were associated with a low risk of surgical follow-up timepoints (P > 0.05; Table 2). complications. However, single posterior surgery required less time and led to lower blood loss compared with the anterior approach. Radiological evaluation Anterior debridement and interbody fusion can effec- tively reveal TB lesions, completely remove lesions, and The pre-operative kyphosis Cobb’s angles were similar in reconstruct the damaged column [8] and is the gold stand- both groups (P > 0.05), and patients in both groups showed ard for treating spinal TB [9]. In addition, the lack of adhe- significant kyphosis correction (P < 0.05). No significant sion of MTB on titanium instruments in vitro prompts spi- differences were observed in the post-operative kyphosis nal internal fixation, which has been proven to be clinically Cobb’s angles, kyphosis correction rate and correction effective and shows excellent radiological performance for loss (P > 0.05) as well as in the interbody fusion duration kyphosis correction [10, 11]. Dai et al. [12] conducted a between the two groups (P > 0.05; Table 3). prospective study on 39 spinal TB patients who had under- gone anterior debridement, autogenous bone grafting and instrumentation, and found that spinal fixation was a safe Neurological deficit assessment and effective method of treatment. In a study conducted on 62 spinal TB patients, Obaid-Ur-Rahman et al. [13] As shown in Table  4, no significant difference was reported that anterior debridement with internal fixation observed in the Frankel scale scores between the two resulted in better kyphosis correction and maintenance. groups (P > 0.05; Table 4). However, anterior debridement interbody fusion and Table 3 Comparison of Schedule Group A Group B radiological indexes between Group A and Group B Pre-op FFU Pre-op FFU Kyphosis angle (°) 11.2 ± 2.6 2.2 ± 2.0* 12.1 ± 2.8 1.8 ± 1.7* Time of bone graft fusion (M) 6.5 ± 0.8 6.6 ± 0.7 Kyphosis correction rate (%) 84.2 ± 14.7 80.2 ± 20.5 Correction loss rate (%) 6.1 ± 6.9 5.5 ± 6.5 Pre-op pre-operation, Post-op post-operation, FFU final follow-up *: P < 0.05, the difference of kyphosis angle between pre-op and FFU was significant in both Group A and Group B 1 3 3648 Archives of Orthopaedic and Trauma Surgery (2022) 142:3643–3649 fixation have some inherent flaws, such as disturbance to size, and selection bias of surgical decision, which may have the gastrointestinal tract, complex anatomical structures, affected our conclusions. Therefore, our findings need to be large range of exposure, high risk of injury to neural, vas- validated using a larger cohort. cular, and urinary tissue, as well as poor strength of ver- tebral fixation [14]. Posterior pedicle fixation system is a three-dimensional Conclusion internal fixation technique that increases stability and cor - rects spine deformity. In fact, anterior debridement, inter- Both single anterior and single posterior approaches of body graft, and posterior pedicle fixation are ideal for spinal debridement, interbody fusion and fixation are effective for TB since it does not damage normal posterior anatomical mono-segment lumbar TB patients, although the single pos- structures, clearly demarcates the infected area, and can terior approach is of a shorter duration and results in less achieve a good radiological result of kyphosis correction blood loss. [15]. Mukhtar et al. [16] and Talu et al. [17] reported that anterior radical debridement, strut graft fusion and posterior instrumentation are feasible and effective methods for treat - Funding No applicable. ing TB lesions and achieving long-term correction of kypho- sis deformity. A combined anterior and posterior approach Declarations is only suitable for spinal TB cases with extensive or fluid Conflict of interest The authors declare that they have no conflict of paravertebral abscess pus or severely damaged spine stabil- interest. ity, since most cases can be treated using a single anterior or posterior surgical approach [18, 19]. Ethics approval and consent to participate Ethical approval from Studies have increasingly shown that thoracic and lumbar the Ethics Committee of Shaanxi Provincial People’s Hospital was obtained for this study. Each author certifies that all investigations were spinal TB can be successfully treated using a single poste- conducted in conformity with ethical principles. rior approach. Yu et al. [20] studied 28 elderly patients with lumbar TB who underwent posterior transforaminal lumbar Consent for publication All patients signed informed consent forms to debridement, interbody fusion, and instrumentation, and publish their personal details in this article. found that the operation led to significant ODI improve - ment and a decrease in the kyphosis angle, although a 2.0° Open Access This article is licensed under a Creative Commons Attri- kyphosis correction loss was observed during the follow-up bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long period. Xu et al. [21] found that single posterior debride- as you give appropriate credit to the original author(s) and the source, ment, compact bone grafting, and pedicle fixation signifi- provide a link to the Creative Commons licence, and indicate if changes cantly improved neurological deficit, ODI and led to steady were made. The images or other third party material in this article are kyphosis correction in 32 patients with mono-segmental included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in lumbar TB and vertebral body damage not more than 2/3rd the article’s Creative Commons licence and your intended use is not of the column height. Zhang et al. [22] retrospectively com- permitted by statutory regulation or exceeds the permitted use, you will pared a posterior-only, anterior-only, and combined ante- need to obtain permission directly from the copyright holder. To view a rior and posterior approaches for spinal TB cases and found copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . that the posterior-only approach was safer and less invasive, compared with the other two approaches. In contrast, Has- san et al. 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Journal

Archives of Orthopaedic and Trauma Surgery – Springer Journals

Published: Dec 1, 2022

Keywords: Spinal tuberculosis; Anterior; Posterior; Mono-segment; Lumbar

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