A Clinical Study Of One-stage Surgical Treatment For Thoracic Spinal Tuberculosis Via Posterior Articular Process And Intervertebral Foramen Approach

Background In recent years,with the occurrence of multi-drug resistant tuberculosis and the upsurge in infection rate of HIV,the morbidity of tuberculosis remained high in the global.The rate of typical pulmonary tuberculosis gradually decreased,but the rate of atypical extrapulmonary tuberculosis increased,particularly the spinal tuberculosis accounted for more than half of bone and joint tuberculosis.Spinal tuberculosis can invade vertebral body and surrounding soft tissue and form abscess,which also can extend to superior and inferior vertebral body.Mostly,abscess can destroy the balance of the spine and lead to saggital imbalance of spine.Abscess also can directly or indirectly press dural sac and cause different degrees of neurological defects,such as numbness,motor dysfunction,and even death.So,debridement and vomica drainage with surgery is an essential method to treat spinal tuberculosis.Due to complexity of thoracic vertebra,the surgery of thoracic spinal tuberculosis is very difficult.According to surgical exploration in the last few decades,there are many surgical approaches have been used in clinic,but the results of different surgical methods are different.However,anterior approach,combination of the anterior and posterior approach and classical posterior approach are destructive.So,more minimally invasive surgical methods are necessary to be explored in future surgical development.Objective To evaluate the clinical effect and feasibility of surgical treatment by one-stage debridement,internal fixation and fusion via posterior articular process and intervertebral foramen approach for thoracic spinal tuberculosis.Method A total of 32 patients with thoracic spinal tuberculosis with vertebral destruction were included in the investigation in our hospital from November 2012 to August 2015.There are 18 males and 14 females with an average age 48.9 years(range 10 to 76 years).According to preoperative ASIA score,there are 5 grade B,9 grade C,10 grade D,8 grade E.The involved segments included: 1 segment 23 cases;2 segments 4 cases;3 segments 4 cases;4 segments 1 case.The kyphotic Cobb angle is range from 13.3° to 50.5°(mean 27.6°).All the patients were treated by one-stage posterior articular process approach to focus debridement,bone autograft and transpedicular screw fixation.Oral potent anti-tubercular drugs were taken strictly during pre-operation and post-operation.The followed-up indexes including:ASIA,JOA,VAS and Cobb angle.Meanwhile,erythrocyte sedimentation rate(ESR)and C-reactive protein(CRP)were used to evaluate the activity of tuberculosis(TB).Result All 32 patients with thoracic spinal tuberculosis were followed-up mean 25.6 months(range 12 to 45 months).All 30 patients were completely cured and there were no recurrence,but 2 patients(6.25%)were recurrent.One was cured by surgery and the other was cured by conservative therapy.The mean time of operation is 158±86min(120-220min)and intraoperative blood loss is 324±286ml(200-750ml).There were 9 cases improved by two grades,13 cases improved by one grades with ASIA.The mean improvement rate of ASIA is 91.7%(including improving 1 or 2 grades).Statistical analysis revealed that there was a significant difference between pre-operation and the final followed-up(P < 0.01).Kyphotic cobb angle decreased to 6.2-18.9°(mean 10.5°)postoperatively(t=12.267,P <0.01),with an average correction angle is 17.1° and average correction rate of 62%,and a loss of correction only 1.8° at the final follow-up(t=11.687,P<0.01).JOA score was 5.5±3.3 preoperatively,which increased to 8.8±3.3 at the final follow-up(t=-7.287,P < 0.01)and mean rate of improvement is 60%.VAS of pain was 6.8±1.6 preoperatively,which dropped to 1.7±2.3 during the final follow-up(t=14.739,P < 0.01)and the average rate of improvement is 75%.Finally,preoperative ESR and CRP were 35.5±20.0mm/h and 45.3±46.8 mg/L,which dropped to 8.6±5.8mm/h(t=9.876,P<0.01)and 8.8±7.4 mg/L(t=11.324,P<0.01)at the final follow-up.Conclusion One-stage surgical treatment by one-stage internal fixation,debridement and fusion via posterior articular process approach for thoracic spinal tuberculosis seems to be an efficient and feasible method,which has less trauma and destruction of posterior structure of the thoracic vertebrae.However,careful patient selection is critical to the successful outcome with this technique.