Treatment of thoracolumbar spinal tuberculosis by posterior focus debridement and bone grafting and fixation combined with psoas abscess debridement and local chemotherapy via different approachs_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

PENG Qiqi ,  OU Yunsheng , ZHU Yong , ZHAO Zenghui , LUO Wei , DU Xing , LI Jianxiao

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：

Thoracolumbar spinal tuberculosis; psoas abscess; focus debridement; local chemotherapy

DOI：

10.7507/1002-1892.201801068

Video：

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ObjectiveTo compare the effectiveness of posterior and anterior psoas abscess debridement and local chemotherapy in abscess cavity combined with focus debridement, bone grafting, and fixation via posterior approach in treatment of thoracolumbar spinal tuberculosis, and explore the feasibility of psoas abscess debridement via posterior approach.MethodsBetween June 2012 and December 2015, the clinical data of 37 patients with thoracolumbar spine tuberculosis and psoas abscess were retrospectively analyzed. All the patients underwent posterior focus debridement, bone grafting, and internal fixation, and were divided into two groups according to different approaches to psoas abscess debridement. Twenty-one patients in group A underwent abscess debridement and local chemotherapy in abscess cavity via posterior approach; 16 patients in group B underwent abscess debridement and local chemotherapy in abscess cavity via anterior approach. No significant difference was found between two groups in gender, age, disease duration, involved segments, preoperative erythrocyte sedimentation rate (ESR), preoperative C-reactive protein (CRP), side of psoas abscess, maximum transverse diameter and sagittal diameter of psoas abscess, accompanying abscess, abscess cavity separation, preoperative Cobb angle of involved segments, preoperative American Spinal Injury Association (ASIA) classification (P>0.05). The operation time, intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion were recorded and compared between 2 groups. The change of pre- and post-operative involved segments Cobb angle was observed. Neurological function was assessed according to ASIA classification.ResultsExcept that the operation time of group B was significantly longer than that of group A (t=–2.985, P=0.005), there was no significant difference in intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion between 2 groups (P>0.05). All patients were followed up 18-47 months (mean, 31.1 months). No cerebrospinal ﬂuid leakage occurred intra- and post-operation. Four patients in group A underwent second-stage operation of abscess debridement and local chemotherapy in abscess cavity via anterior approach. All patients got abscess absorption, meanwhile ESR and CRP level normalized at last follow-up. The involved segments Cobb angle improved significantly when compared with preoperative values in both 2 groups (P<0.05); and there was no significant difference between 2 groups at last follow-up (P>0.05). Nine patients with spinal cord injury had significant neurological recovery at last follow-up (Z=–2.716, P=0.007).ConclusionPosterior focus debridement, bone grafting, and internal fixation combined with abscess debridement and local chemotherapy in abscess cavity is effective in treatment of thoracolumbar spinal tuberculosis, but in some cases anterior abscess debridement is still required.

Citation： PENG Qiqi, OU Yunsheng, ZHU Yong, ZHAO Zenghui, LUO Wei, DU Xing, LI Jianxiao. Treatment of thoracolumbar spinal tuberculosis by posterior focus debridement and bone grafting and fixation combined with psoas abscess debridement and local chemotherapy via different approachs. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(7): 912-919. doi: 10.7507/1002-1892.201801068 Copy

1.	Hao Z, Zhang Y, Shen X, et al. Staged treatment of thoracic and lumbar spinal tuberculosis with flow injection abscess. Int J of Clin Exp Med, 2015, 8(10): 18383-18390.
2.	Yacoub Wn, Sohn HJ, Chan S, et al. Psoas abscess rarely requires surgical intervention. Am J Surg, 2008, 196(2): 223-227.
3.	Büyükbebeci O, Seçkiner I, Karslı B, et al. Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis. Eur Spine J, 2012, 21(3): 470-473.
4.	Zhang X, Zhang Z, Zhang Y, et al. Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis. Surg Endosc, 2015, 29(8): 2451-2455.
5.	Tuli SM. Historical aspects of Pott’s disease (spinal tuberculosis) management. Eur Spine J, 2013, 22 Suppl 4: 529-538.
6.	Kim KT, Lee SH, Lee YH, et al. Clinical outcomes of 3 fusion methods through the posterior approach in the lumbar spine. Spine (Phila Pa 1976), 2006, 31(12): 1351-1358.
7.	Yin XH, Zhou ZH, Yu HG, et al. Comparison between the antero-posterior and posterior only approaches for treating thoracolumbar tuberculosis (T10-L2) with kyphosis in children: a minimum 3-year follow-up. Childs Nerv Sits, 2016, 32(1): 127-133.
8.	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.
9.	张宏其. 脊柱结核病灶应清除到何种程度? 中国脊柱脊髓杂志, 2010, 20(10): 798-799.
10.	Kumar MN, Joseph B, Manur R. Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting. Eur Spine J, 2013, 22(3): 624-632.
11.	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.
12.	Garg N, Vohra R. Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine. Clin Orthop Relat Res, 2014, 472(6): 1855-1867.
13.	Zaveri GR, Mehta SS. Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar underbody fusion (TLIF) and posterior instrumentation. J Spinal Disord Tech, 2009, 22(4): 257-262.
14.	Zhang P, Pang W, Wang X, et al. Minimum 5-year follow-up outcomes for single-stage transpedicular debridement, posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults. Br J Neurosurg, 2016, 30(6): 666-671.
15.	Jain AK, Jain S. Instrumented stabilization in spinal tuberculosis. Int Orthop, 2012, 36(2): 285-292.
16.	张宏其, 唐明星, 王昱翔, 等. 多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用. 中国矫形外科杂志, 2014, 22(15): 1353-1358.
17.	Jain A, Jain RK, Kiyawat V. Evaluation of outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis. Asian Spine J, 2017, 11(1): 31-36.
18.	Gao Y, Ou Y, Deng Q, et al. Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis. PLoS One, 2017, 12(4): e0175567.
19.	赵增辉, 朱勇, 罗伟, 等. 一期后路经单侧入路病灶清除植骨内固定治疗多节段胸腰椎结核. 中国修复重建外科杂志, 2017, 31(9): 1073-1079.
20.	吴鹏, 欧云生, 刘德龙, 等. 后路经单侧椎弓根病灶清除植骨内固定治疗胸腰椎结核的疗效分析. 中国修复重建外科杂志, 2015, 29(10): 1259-1264.
21.	Pang X, Shen X, Wu P, et al. Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, underbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg, 2013, 133(6): 765-772.
22.	Tofuku K, Koga H, Komiya S. Percutaneous drainage combined with hyperbaric oxygen therapy for pyogenic spondylitis with iliopsoas abscess. Asian Spine J, 2014, 8(3): 253-259.
23.	Dinç H, Ahmetoğlu A, Baykal S, et al. Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses: midterm results. Radiology, 2002, 225(2): 353-358.
24.	Raviglione M, Marais B, Floyd K, et al. Scaling up interventions to achieve global tuberculosis control: progress and new developments. Lancet, 2012, 379(9829): 1902-1913.
25.	甫拉提·买买提, 徐韬, 买买提艾力·尼亚孜, 等. 原发性结核性腰大肌脓肿的诊断和治疗. 中华医学杂志, 2016, 96(43): 3511-3514.
26.	Soares Do Brito J, Tirado A, Fernandes P. Surgical treatment of spinal tuberculosis complicated with extensive abscess. Iowa Orthop J, 2014, 34(4): 129-136.
27.	Sundararaj GD, Behera S, Ravi V, et al. Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine. J Bone Joint Surg (Br), 2003, 85(1): 100-106.
28.	Suh KT, Seong YJ, Lee JS. Simultaneous anterior and posterior surgery in the management of tuberculous spondylitis with psoas abscess in patients with neurological deficits. Asian Spine J, 2008, 2(2): 94-101.
29.	Li J, Li XL, Zhou XG, et al. Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery. J Spinal Disord Tech, 2014, 27(8): 309-314.
30.	张西峰, 王岩, 刘郑生, 等. 经皮穿刺病灶清除灌注冲洗局部化疗治疗脊柱结核脓肿. 中国脊柱脊髓杂志, 2005, 15(9): 528-530.
31.	Sarathy JP, Zuccotto F, Ho HP, et al. Prediction of drug penetration in tuberculosis lesions. Acs Infect Dis, 2016, 2(8): 552-563.
32.	Kumar K. The penetration of drugs into the lesions of spinal tuberculosis. Int Orthop, 1992, 16(1): 67-68.
33.	Jutte PC, Rutgers SR, Van Altena R, et al. Penetration of isoniazid, rifampicin and pyrazinamide in tuberculous pleural effusion and psoas abscess. Int J Tuberc Lung Dis, 2004, 8(11): 1368-1372.

1. Hao Z, Zhang Y, Shen X, et al. Staged treatment of thoracic and lumbar spinal tuberculosis with flow injection abscess. Int J of Clin Exp Med, 2015, 8(10): 18383-18390.
2. Yacoub Wn, Sohn HJ, Chan S, et al. Psoas abscess rarely requires surgical intervention. Am J Surg, 2008, 196(2): 223-227.
3. Büyükbebeci O, Seçkiner I, Karslı B, et al. Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis. Eur Spine J, 2012, 21(3): 470-473.
4. Zhang X, Zhang Z, Zhang Y, et al. Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis. Surg Endosc, 2015, 29(8): 2451-2455.
5. Tuli SM. Historical aspects of Pott’s disease (spinal tuberculosis) management. Eur Spine J, 2013, 22 Suppl 4: 529-538.
6. Kim KT, Lee SH, Lee YH, et al. Clinical outcomes of 3 fusion methods through the posterior approach in the lumbar spine. Spine (Phila Pa 1976), 2006, 31(12): 1351-1358.
7. Yin XH, Zhou ZH, Yu HG, et al. Comparison between the antero-posterior and posterior only approaches for treating thoracolumbar tuberculosis (T10-L2) with kyphosis in children: a minimum 3-year follow-up. Childs Nerv Sits, 2016, 32(1): 127-133.
8. 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.
9. 张宏其. 脊柱结核病灶应清除到何种程度? 中国脊柱脊髓杂志, 2010, 20(10): 798-799.
10. Kumar MN, Joseph B, Manur R. Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting. Eur Spine J, 2013, 22(3): 624-632.
11. 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.
12. Garg N, Vohra R. Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine. Clin Orthop Relat Res, 2014, 472(6): 1855-1867.
13. Zaveri GR, Mehta SS. Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar underbody fusion (TLIF) and posterior instrumentation. J Spinal Disord Tech, 2009, 22(4): 257-262.
14. Zhang P, Pang W, Wang X, et al. Minimum 5-year follow-up outcomes for single-stage transpedicular debridement, posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults. Br J Neurosurg, 2016, 30(6): 666-671.
15. Jain AK, Jain S. Instrumented stabilization in spinal tuberculosis. Int Orthop, 2012, 36(2): 285-292.
16. 张宏其, 唐明星, 王昱翔, 等. 多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用. 中国矫形外科杂志, 2014, 22(15): 1353-1358.
17. Jain A, Jain RK, Kiyawat V. Evaluation of outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis. Asian Spine J, 2017, 11(1): 31-36.
18. Gao Y, Ou Y, Deng Q, et al. Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis. PLoS One, 2017, 12(4): e0175567.
19. 赵增辉, 朱勇, 罗伟, 等. 一期后路经单侧入路病灶清除植骨内固定治疗多节段胸腰椎结核. 中国修复重建外科杂志, 2017, 31(9): 1073-1079.
20. 吴鹏, 欧云生, 刘德龙, 等. 后路经单侧椎弓根病灶清除植骨内固定治疗胸腰椎结核的疗效分析. 中国修复重建外科杂志, 2015, 29(10): 1259-1264.
21. Pang X, Shen X, Wu P, et al. Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, underbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg, 2013, 133(6): 765-772.
22. Tofuku K, Koga H, Komiya S. Percutaneous drainage combined with hyperbaric oxygen therapy for pyogenic spondylitis with iliopsoas abscess. Asian Spine J, 2014, 8(3): 253-259.
23. Dinç H, Ahmetoğlu A, Baykal S, et al. Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses: midterm results. Radiology, 2002, 225(2): 353-358.
24. Raviglione M, Marais B, Floyd K, et al. Scaling up interventions to achieve global tuberculosis control: progress and new developments. Lancet, 2012, 379(9829): 1902-1913.
25. 甫拉提·买买提, 徐韬, 买买提艾力·尼亚孜, 等. 原发性结核性腰大肌脓肿的诊断和治疗. 中华医学杂志, 2016, 96(43): 3511-3514.
26. Soares Do Brito J, Tirado A, Fernandes P. Surgical treatment of spinal tuberculosis complicated with extensive abscess. Iowa Orthop J, 2014, 34(4): 129-136.
27. Sundararaj GD, Behera S, Ravi V, et al. Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine. J Bone Joint Surg (Br), 2003, 85(1): 100-106.
28. Suh KT, Seong YJ, Lee JS. Simultaneous anterior and posterior surgery in the management of tuberculous spondylitis with psoas abscess in patients with neurological deficits. Asian Spine J, 2008, 2(2): 94-101.
29. Li J, Li XL, Zhou XG, et al. Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery. J Spinal Disord Tech, 2014, 27(8): 309-314.
30. 张西峰, 王岩, 刘郑生, 等. 经皮穿刺病灶清除灌注冲洗局部化疗治疗脊柱结核脓肿. 中国脊柱脊髓杂志, 2005, 15(9): 528-530.
31. Sarathy JP, Zuccotto F, Ho HP, et al. Prediction of drug penetration in tuberculosis lesions. Acs Infect Dis, 2016, 2(8): 552-563.
32. Kumar K. The penetration of drugs into the lesions of spinal tuberculosis. Int Orthop, 1992, 16(1): 67-68.
33. Jutte PC, Rutgers SR, Van Altena R, et al. Penetration of isoniazid, rifampicin and pyrazinamide in tuberculous pleural effusion and psoas abscess. Int J Tuberc Lung Dis, 2004, 8(11): 1368-1372.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of thoracolumbar spinal tuberculosis by posterior focus debridement and bone grafting and fixation combined with psoas abscess debridement and local chemotherapy via different approachs

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