Elsevier

The Spine Journal

Volume 11, Issue 8, August 2011, Pages 726-733
The Spine Journal

Clinical Study
One-stage surgical management for thoracic tuberculosis by anterior debridement, decompression and autogenous rib grafts, and instrumentation

https://doi.org/10.1016/j.spinee.2011.06.009Get rights and content

Abstract

Background context

Patients with thoracic tuberculosis have been not always successfully treated by radical debridement and bone grafting with or without supplementary posterior instrumentation and fusion, although most surgeons use posterior instrumentation to support anterior strut grafts.

Purpose

To determine the efficacy of anterior instrumentation after radical debridement and autogenous rib grafts in patients with thoracic tuberculosis over a 6-year period at a single institution.

Study design

A retrospective clinical study of one-stage surgical management for thoracic tuberculosis by anterior radical debridement, decompression and autogenous rib grafts, and instrumentation.

Patient sample

Procedure was performed in 42 patients.

Outcome measures

Kyphotic angle was measured to assess the severity of the thoracic tuberculosis. Neurologic outcome was evaluated using Frankel grade, infection activity using erythrocyte sedimentation rate value and C-reactive protein value, and pain using a visual analog scale pain score.

Methods

In this retrospective study, the authors evaluated 42 patients (25 men and 17 women; average age, 47.7 years) with thoracic tuberculosis, who underwent one-stage anterior radical debridement, decompression and autogenous rib grafts, and instrumentation. The average follow-up period was 50.8 months (range, 24–85 months).

Results

A solid fusion was achieved in all cases. Of all 42 patients with preoperative kyphosis, the deformity was corrected from an average of 19.8° on admission to an average of 3.7° after surgery and to an average of 4.6° at the final visit. No significant loss of deformity correction was noted in these patients. There was no other recurrence of the tuberculous infection.

Conclusion

The authors think that the one-stage anterior autogenous rib grafts and instrumentation are safe and effective methods in the surgical management of thoracic tuberculosis.

Introduction

Evidence & Methods

Surgical intervention for tuberculosis of the thoracic spine often includes radical debridement, fusion, and anterior/posterior instrumentation. The authors of this study assessed outcomes with anterior surgery alone using modern instrumentation.

In this case series report, the authors found fusion rates, kyphosis correction, and functional outcomes to be favorable. No local recurrences of infection were noted.

While the usual limitations of a case series should be noted, there is enough background information on the surgical treatment of tuberculosis to lend reasonable support to the authors' findings.

—The Editors

Tuberculosis continues to be the leading cause of death from infectious disease in the world, and it is causing more widespread concern than ever before [1]. Spinal tuberculosis, the most common pattern of extrapulmonary tuberculosis, also has increased rapidly around the world in recent years, especially in the undeveloped and developing countries [2]. Patients with spinal tuberculosis often have evident collapse of vertebrae because of tuberculous destruction resulting in kyphosis and neurologic deficits. Developments in antituberculous agents are the most important achievements in the management of tuberculosis, and most of the patients with spinal tuberculosis can be successfully treated with effective medication [3], [4]. However, there may be treatment failure because of unresponsiveness or noncompliance with antituberculous chemotherapy. Surgical intervention is sometimes indicated for the patients with severe pain from an expanding abscess, neurologic deterioration from spinal cord compression, sequestered bone and disc, progressive kyphotic deformity, and instability. The goals of surgery are to eradicate the infection and prevent or treat neurologic deficits or spinal deformity [5].

Anterior radical debridement and spinal fusion have been advocated [6] and now widely applied to patients with spinal tuberculosis. A series of controlled clinical trials have been made by the Medical Research Council of the United Kingdom in multiple centers to compare various modes of treatment. The results reported at the 5-, 10-, and 15-year follow-ups [7], [8], [9] indicated that, although a favorable outcome rate of 87% was obtained in all three groups, radical debridement plus anterior spinal fusion was superior to drug treatment or simple anterior debridement, especially when solid fusion and deformity correction are considered [10].

Because anterior radical debridement may further deteriorate biomechanical stability of the spine, anterior grafting with posterior instrumentation has been recommended for stabilization of the involved motion segments and prevention of deformity progression [11], [12]. Supplementary posterior instrumentation and fusion, either simultaneous or staged, as an adjunct to anterior fusion in patients with spinal tuberculosis, particularly when deformity correction is necessary, have greatly improved the outcome [13]. However, the combined procedure was associated with increased operating time, greater blood loss, more postoperative complications, and longer hospital stay [14], [15], although it proved to be a well-documented technique.

We, therefore, report here a group of 42 cases with the exudative stage of thoracic spinal tuberculosis treated by the one-stage anterior radical debridement, decompression and autogenous rib grafts, and instrumentation. The purpose of this study was to determine the efficacy of anterior instrumentation after radical debridement and autogenous bone grafting in patients with spinal tuberculosis over a 4-year period at a single department.

Section snippets

Patient population

All patients with thoracic spinal tuberculosis treated with the one-stage anterior radical debridement, decompression and autogenous rib grafts, and instrumentation at our department between June 2003 and May 2008 were included in this study. Forty-two consecutive patients were identified, their hospital medical records as well as radiographs were reviewed, and the demographic data were recorded. Plain radiography, computerized tomography (CT), and magnetic resonance imaging (MRI) studies had

Results

The Table provides a summary of the patients’ data. All patients were for at least 24 months of follow-up. The average follow-up duration at the time of submission was 50.8 months (range, 24–85 months). No one died of postoperative complications.

Discussion

Tuberculosis is still common in today’s society, especially in developing countries. Over the past two decades, the incidence of tuberculosis has tended to increase [19], [20]. Spinal involvement is the most common form of skeletal tuberculosis, accounting for half of the cases [1], [2]. Because of its complications, such as late-onset neurologic deficit, instability and kyphotic deformity, and poor chemotherapy effectiveness, more and more authors emphasis the important role of surgery in

Conclusions

In summary, our results confirm that the one-stage anterior radical debridement, decompression and autogenous rib grafts, and instrumentation show more advantages in selected patients because they can provide sufficient segmental stability of the affected spine, good correction of kyphotic deformity, and promotion of bony fusion. Combined with standard chemotherapy, early reconstruction of spinal stability plays an important role in surgical management of spinal tuberculosis. Regular

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    FDA device/drug status: Investigational (VentroFix system).

    Author disclosures: ML: Nothing to disclose. JD: Nothing to disclose. HM: Nothing to disclose. ZW: Nothing to disclose. ZL: Nothing to disclose.

    Mo Li and Junjie Du contributed equally to this work and should be considered as co-first authors.

    No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.

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