Efficacy And Safety Of Different Surgical Approaches And Bone Grafts For The Treatment Of Thoracic And Lumbar Spinal Tuberculosis: A Meta-Analysis

Objective: A meta-analysis was conducted to evaluate the clinical efficacy and safety of different surgical approaches(anterior,posterior,anterior and posterior approaches)and different bone graft materials(autologous bone,allograft,titanium mesh)for the treatment of spinal TB.Methods: A literature search up to December 2017 was performed on PubMed,Embase,Web of Science,CNKI,VIP,Wanfang,CBM database.According to the inclusion and exclusion criteria,two researchers screened the literature,extracted data and evaluated the quality of the literature.Using MD / SMD / RR as effect indicators,Stata software was used to analyze the operative time,intraoperative blood loss,length of hospital stay,complications,correction and loss of Cobb angle,fusion time,fusion rate and nerve Function to improve the situation for data analysis.Results: In the final 73 articles,a total of 6943 patients with spinal tuberculosis were included in this meta-analysis.The results showed that,in the simple posterior group,the operation time [MD =-75.48,95%CI(-100.06,-50.91),P = 0.000],intraoperative blood loss [MD =-234.99,95% CI(-291.40,-178.58),P = 0.000],length of hospital stay [MD =-4.52,95% CI(-4.88,-4.16),P = 0.000],complications [RR = 0.35,95% CI(0.21,0.57),P = 0.000] is superior to the anteroposterior approach group;the posterior group is superior to the anterior approach group in the correction and loss of Cobb angle [MD =-3.97,95% CI(-5.58,-2.37),P = 0.000].[MD = 1.76,95% CI(0.07,3.44),P = 0.57],but similar to the combined approach group [MD =-1.03,95% CI(-2.71,0.65),P = 0.230] and [MD = 0.29,95% CI(-0.14,0.71),P = 0.183];There was no significant difference in improvement of neurological function between the three approaches(P > 0.05).Autologous granuloid bone was superior to massive bone(P < 0.05)in terms of intraoperative blood loss,bone graft fusion time,and early(postoperative June and September)bone graft fusion rate,and in the long-term(December)bone graft fusion.There was no significant difference in rate and length of stay(P > 0.05).Allogeneic bone was superior to autologous bone in terms of operation time and intraoperative blood loss(P < 0.05),but there was no difference in hospitalization time [MD =-2.59,95% CI(-4.90,10.08),P = 0.497].The titanium cage group was superior to autologous bone in terms of operative time [MD = 62.91,95% CI(26.37,99.45),P = 0.001],while the Cobb angle correction and loss,hospital stay,intraoperative blood loss,bone graft fusion time The rate of bone graft fusion(postoperative 3/6/9/12 months)was not different(P > 0.05).Subgroup analysis and sensitivity analysis of the different segments of the approach route suggested that the results were stable,but bias detection revealed publication bias.Conclusion:(1)Treatment of spinal tuberculosis with anterior approach,posterior approach,and anterior-posterior approach can achieve good neurological improvement.Spinal tuberculosis posterior fixation can obtain better kyphosis and less orthopedic loss.The combined approach extended the operation time and increased the amount of intraoperative blood loss.Anterior or combined approaches significantly increase the incidence of surgical complications.(2)Autologous granule bone was superior to lumpy bone in terms of intraoperative blood loss,bone graft fusion time,and early(postoperative 6 and 9 months)bone graft fusion rate.Compared with lumbosacral bone,lumpy bone was more helpful for deformity correction.Maintain,allogeneic bone or titanium mesh bone graft may achieve clinical efficacy similar to that of autogenous bone with shorter operation time and less intraoperative blood loss.