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.	陈林, 覃建朴, 敖俊, 等. 一期后路保留部分关节突开窗病灶清除短节段椎弓根螺钉内固定治疗腰骶椎结核. 中国修复重建外科杂志, 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.	张宏其, 郭强, 郭超峰, 等. 单纯后路、单纯前路或前后联合入路治疗成人腰椎结核的中期疗效比较. 中华骨科杂志, 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. 脊柱结核的病灶清除与融合固定问题. 中国脊柱脊髓杂志, 2006, 16(12): 888-889.
12.	瞿东滨, 金大地. 正确认识脊柱结核病灶清除术. 中国脊柱脊髓杂志, 2008, 18(8): 565-567.
13.	宋跃明. 如何理解脊柱结核病灶彻底清除? 中国脊柱脊髓杂志, 2010, 20(10): 798.
14.	施建党, 王骞, 王自立. 胸、腰椎结核融合及内固定范围的合理选择. 中华骨科杂志, 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.	武启军, 王自立, 戈朝晖, 等. 脊柱单节段前中柱切除后不同节段椎弓根螺钉内固定的稳定性测试. 中国脊柱脊髓杂志, 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, 梁国辉, 蔡小利, 等. 后路脊柱固定联合双侧经腹膜外病灶清除术治疗腰骶椎结核. 中国修复重建外科杂志, 2008, 22(5): 539-542.
20.	刘树平, 刘跃洪, 徐巍, 等. 一期前路病灶清除植骨后路内固定治疗下腰椎结核. 中国修复重建外科杂志, 2008, 22(10): 1274-1276.
21.	唐永超, 梁德, 江晓兵, 等. 一期经后路固定联合侧前方入路病灶清除植骨融合术治疗老年下腰椎结核. 中国修复重建外科杂志, 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. 陈林, 覃建朴, 敖俊, 等. 一期后路保留部分关节突开窗病灶清除短节段椎弓根螺钉内固定治疗腰骶椎结核. 中国修复重建外科杂志, 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. 张宏其, 郭强, 郭超峰, 等. 单纯后路、单纯前路或前后联合入路治疗成人腰椎结核的中期疗效比较. 中华骨科杂志, 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. 脊柱结核的病灶清除与融合固定问题. 中国脊柱脊髓杂志, 2006, 16(12): 888-889.
12. 瞿东滨, 金大地. 正确认识脊柱结核病灶清除术. 中国脊柱脊髓杂志, 2008, 18(8): 565-567.
13. 宋跃明. 如何理解脊柱结核病灶彻底清除? 中国脊柱脊髓杂志, 2010, 20(10): 798.
14. 施建党, 王骞, 王自立. 胸、腰椎结核融合及内固定范围的合理选择. 中华骨科杂志, 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. 武启军, 王自立, 戈朝晖, 等. 脊柱单节段前中柱切除后不同节段椎弓根螺钉内固定的稳定性测试. 中国脊柱脊髓杂志, 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, 梁国辉, 蔡小利, 等. 后路脊柱固定联合双侧经腹膜外病灶清除术治疗腰骶椎结核. 中国修复重建外科杂志, 2008, 22(5): 539-542.
20. 刘树平, 刘跃洪, 徐巍, 等. 一期前路病灶清除植骨后路内固定治疗下腰椎结核. 中国修复重建外科杂志, 2008, 22(10): 1274-1276.
21. 唐永超, 梁德, 江晓兵, 等. 一期经后路固定联合侧前方入路病灶清除植骨融合术治疗老年下腰椎结核. 中国修复重建外科杂志, 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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