Hong-qi Zhang Min-zhong Lin Jin-song Li Ming-xing Tang Chao-feng Guo Jian-huang Wu Jin-yang Liu

Arch Orthop Trauma Surg (2013) 133:333 341 DOI 10.1007/s00402-012-1669-2 ORTHOPAEDIC SURGERY One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series Hong-qi Zhang Min-zhong Lin Jin-song Li Ming-xing Tang Chao-feng Guo Jian-huang Wu Jin-yang Liu Received: 1 October 2012 / Published online: 16 December 2012 Ó Springer-Verlag Berlin Heidelberg 2012 Abstract Purpose The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time. Methods Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B. Results The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which H. Zhang (&) M. Lin J. Li M. Tang C. Guo J. Wu J. Liu Department of Spine Surgery, Xiangya Hospital of Central South University, Xiangya Road 87, ChangSha 410008, China e-mail: zhq9996@163.com became normal (9.0 ± 2.8 mm/h) within 3 months in all patients. Conclusions Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries. Keywords Lumbar tuberculosis Posterior Transforaminal lumbar interbody fusion Introduction Spinal tuberculosis is one of the most common severe spinal diseases that frequently cause kyphotic deformity, neurologic deficit and even spinal cord compression. With the development of techniques for treating spinal tuberculosis, the aim of treatment is to eradicate the TB lesion, relief of spinal nerve compression, reconstruction of spinal stability, and correction of spinal deformity to improve the quality of life of patients. Surgical procedures still play an important role in treating spinal tuberculosis, although antituberculous chemotherapy is proven to be effective in most cases and has become the mainstay of the treatment [1 3]. The choice of treatment will depend on the severity of the disease and the available surgical expertise and facilities. Useful supportive care and standard chemotherapy at the early stage of the disease are the keys to early eradication and minimizing complications. Various methods of the surgical management in patients with lumbar tuberculous spondylitis have been reported [4 11]. Transforaminal lumbar interbody fusion (TLIF) was initially popularized by Harms et al. [12] as a modification of posterior lumbar interbody fusion (PLIF), and it

334 Arch Orthop Trauma Surg (2013) 133:333 341 overcomes the issue of neural retraction. To our knowledge, anterior-only approach may not be applicable in treating the lumbar spinal tuberculosis [13, 14]. Posterior fusion or posterior instrumentation without anterior debridement and strut graft does not achieve spinal stability, nor does it stop progression of kyphotic deformity. Furthermore, the combined posterior and anterior procedures lead to greater blood loss, increased operating time, prolonged anesthesia, and increased mortality and complications [14]. In this study, we report our results regarding the treatment of spinal tuberculosis by one-stage posterior debridement, TLIF and instrumentation in selected patients. Materials and methods Basic information From May 2004 to June 2012, 37 patients with the diagnosis of lumbar tuberculosis underwent surgery at our spinal center: 19 were males and 18 were females, aged 6 63 (with an average age of 41.2 ± 14.7 years). All 37 patients were from an underprivileged background. The higher incidence of advanced cases in these patients was related closely with a delayed diagnosis due to ignorance and negligence on the part of the parents. The diagnosis of lumbar tuberculosis was guided by nonspecific laboratory findings such as anemia, hypoproteinemia, elevation of erythrocyte sedimentation rate (ESR), and by imaging including spinal X-ray films, computed tomography, and magnetic resonance imaging. All the patients presented with constitutional symptoms including weakness, malaise, night sweats, back pain and stiffness, local tenderness and spasm of the posterior muscles of the waist, and lower fever with weight loss and variable degree of local deformity angle. Radiographic findings of tuberculous spondylitis included intraosseous and paraspinal abscess formation with disc preservation, subligamentous spreading of infection, vertebral body destruction and collapse, and extension in the spinal epidural space. Nineteen patients underwent one-stage posterior debridement, TLIF and instrumentation to treat lumbar TB (Group A). Another 18 cases that underwent posterior internal fixation, anterior debridement and fusion in a single-stage procedure to treat lumbar TB were the control group (Group B). Patients who satisfied the operation conditions were randomly assigned to Group A or Group B. However, patients who suffered anterior abscess formation or multilevel involvement where an anterior debridement was necessary were added to Group B. Of 37, there were 33 patients complicated with incomplete paraplegia. The Frankel scoring system (Tables 1, 2) was used to assess the neurological deficits: Frankel s grade B in 6 patients, grade C in 8, and grade D in 19. Erythrocyte sedimentation rate was used to evaluate whether the lesion was active and whether the disease was healed. The ESR of patients upon admission ranged from 30 to 120 mm/h, with an average of 60.7 ± 22.5 mm/h. The mean preoperative lumbar kyphotic angle was 23.9 ± 7.6 (range: 18.0 49.6 ) in Group A. The mean preoperative lumbar kyphotic angle was 28.5 ± 6.5 (range: 18.0 44.7 ) in Group B. Preoperative procedure Three weeks prior to the operation, the patients were administered an anti-tuberculosis drug with isoniazid (5 10 mg/kg/day with no more than 300 mg/day), rifampicin (5 10 mg/kg/day with no more than 300 mg/day), and ethambutol (15 mg/kg/day with no more than 500 mg/ day). When the patients resumed normal appetite without low fever, anemia and hypoproteinemia were rectified completely, and ESR returned to normal or had significant decrease, surgery was carried out. Operative procedure The patients (Group A) were in the prone position after administration of general endotracheal anesthesia. Through a posterior midline approach, the lamina, facet joints, and transverse processes costotransverse articulations were exposed. Posterior pedicle screws were used in the side of vertebral lamina based on preoperative symptoms and imaging. Longer segmental fixation was applied where flexion moment or a tendency to kyphosis was noticed, at least two above and one below the lesion. Transpedicular screws were also placed in the affected vertebrae if the upper part of the vertebrae was not destroyed by infection. A temporary rod on the mild side of the focus was stabilized to avoid spinal cord injury induced by instability of the spine during decompression and focal debridement. The severe lesion segment was performed to drain prevertebral abscess and exposed diseased vertebral bodies. Including collapsed vertebras, in-between intervertebral disc and cold abscess, were completely removed by curettes through to healthy bleeding bone for spinal cord decompression. The deformity was corrected by installing permanent rods with compression maneuvers under vision. Then appropriate distraction of the intervertebral space at the involved level and collateral anterior spinal cord decompression was obtained. A titanium mesh cage which was filled with bicortical iliac-bone allograft would be implanted in the bone defect. Then the rest of bicortical iliac-bone allograft was selected for posterior fusion at the segments that underwent decompression and focal debridement. At last, treatment with 1.0 g streptomycin and 0.2 g isoniazid was locally administered (Figs. 1, 2).

Arch Orthop Trauma Surg (2013) 133:333 341 335 Table 1 Clinical data on patients of Group A Patient No. Age Sex Operation time(min) Blood loss(ml) Follow-up (months) Lumbar kyphotic angle ( ) Frankel grade ESR Pre Post LV Pre Post LV Pre Post 3 months 1 33 F 160 400 71 20.5 8.7 8.9 C D E 67 13 2 63 M 240 500 70 23.0 6.7 8.2 B D E 80 7 3 60 F 250 550 48 22.8 7.3 9.8 D E E 120 5 4 46 M 195 360 58 18.0 9.4 10.1 D E E 48 5 5 11 M 180 410 17 49.6 8.0 9.8 C D E 45 9 6 29 F 155 350 40 18.4 8.5 10.5 B D D 95 14 7 59 F 200 510 65 21.5 8.6 11.1 D E E 83 12 8 55 F 240 600 33 22.3 6.9 8.7 D E E 50 6 9 58 M 185 300 45 22.1 6.0 7.3 C E E 43 12 10 49 M 255 650 27 29.4 8.4 10.9 B E E 38 6 11 55 M 210 400 24 20.3 7.9 9.6 C D E 49 11 12 50 F 240 430 53 32.3 9.6 10.8 D E E 35 9 13 43 M 230 270 68 18.9 7.4 8.9 C E E 63 10 14 25 M 235 400 51 20.7 8.6 9.3 D E E 70 14 15 33 F 225 350 64 21.9 9.0 9.6 D E E 30 7 16 54 F 190 380 42 19.2 8.8 9.3 E E E 59 10 17 48 M 175 350 31 18.2 7.1 9.3 B D D 46 7 18 20 F 185 300 29 33.2 7.7 9.0 E E E 67 7 19 29 F 200 270 49 21.8 6.3 8.6 D D E 45 11 Mean values 43.2 ± 14.6 207.9 ± 30.9 409.5 ± 107.9 46.6 ± 16.7 23.9 ± 7.6 7.9 ± 1.0 9.5 ± 1.0 59.6 ± 22.7 9.2 ± 3.0

336 Arch Orthop Trauma Surg (2013) 133:333 341 Table 2 Clinical data on patients of Group B Patient No. Age Sex Blood loss(ml) Operation time(min) Follow-up (months) Lumbar kyphotic angle ( ) Frankel grade ESR Pre Post LV Pre Post LV Pre Post 3 months 1 06 M 1300 400 23 31.5 7.1 8.2 D D E 47 9 2 45 M 800 350 59 28.3 6.7 8.2 D E E 91 13 3 33 F 600 380 48 42.8 9.3 10.8 D E E 50 4 4 63 F 850 360 58 18.0 6.4 8.1 E E E 48 5 5 27 M 1000 330 27 29.3 8.0 9.8 C D E 45 9 6 21 F 900 380 43 18.0 7.5 9.5 B D D 93 10 7 53 M 660 300 42 28.5 6.6 8.1 D E E 83 11 8 52 F 700 310 29 31.3 7.3 8.7 D E E 44 6 9 58 M 850 410 40 22.1 6.0 7.3 C D E 43 12 10 44 M 700 350 27 27.4 8.4 9.9 B D E 36 6 11 57 M 940 365 38 30.3 7.9 9.0 D D E 49 9 12 52 F 1050 380 53 20.3 6.6 8.8 D E E 35 9 13 41 M 650 310 68 28.1 7.4 8.0 C E E 86 11 14 11 F 800 290 51 44.7 7.6 9.0 D E E 99 14 15 30 F 770 300 64 31.9 8.0 9.1 D E E 75 7 16 36 F 900 315 66 29.2 6.8 7.3 E E E 91 9 17 49 M 750 405 70 28.0 7.1 9.3 D D E 60 8 18 28 F 900 360 49 23.9 7.7 8.7 D E E 37 7 Mean values 39.2 ± 15.1 840.0 ± 168.7 349.7 ± 38.9 47.5 ± 15.0 28.5 ± 6.5 7.4 ± 0.8 8.7 ± 0.9 61.8 ± 22.9 8.8 ± 2.7

Arch Orthop Trauma Surg (2013) 133:333 341 337 Fig. 1 A 46-year-old female was diagnosed as having tuberculous spondylitis after a 13 months history of severe back pain. The infection had been resistant to chemotherapy for 3 months. The destructive changes seen at L2 L3 on plain radiographs were progressive and the lumbar kyphotic angle was 18.0 degree (a e). We performed one-stage posterior debridement, transforaminal In Group B, posterior instrumentation without fusion was performed first, and then anterior debridement and allografting were applied in single-stage (Fig. 3). Postoperative procedure The drain was usually removed when drainage flow was less than 50 ml/24 h. After surgery, patients were allowed to ambulate after remaining supine for 14 28 days (mean 20 days) postoperatively. After surgery, all patients received anti-tb chemotherapy with the four drugs mentioned above for at least 9 months, and with isoniazid, rifampicin and ethambutol (HRE) treatment for another 3 6 months. Follow-up index and statistical analysis For Group A, the average follow-up period was 46.6 ± 16.7 months (17 71 months). For Group B, the average follow-up period was 47.5 ± 15.0 months (23 70 months). The following indexes were recorded pre-, postoperatively, and during the follow-up: (1) lumbar kyphotic angle, (2) neurological status that was recorded by Frankel grade system, (3) ESR. Using SPSS 19.0 software, lumbar lumbar interbody fusion and instrumentation (f, g) from L2 to L4, the postoperative lumbar kyphotic angle became 9.4 (f, g). Twentytwo months after surgery, the infected site had healed and radiographs showing good bone fusion, the last visited lumbar kyphotic angle was 10.1 (h) kyphotic angle and ESR were statistically analyzed by paired t test pre-, postoperatively, and during the follow-up. Test for surgery duration (min), blood loss (ml), postoperation lumbar kyphotic angle and final follow-up lumbar kyphotic angle suggested a significant difference between two groups (p \ 0.05). Discrepancy of the normal distribution was analyzed by a rank-sum test with a significance level of 0.05. Results The mean duration of surgery was 207.9 ± 30.9 min in Group A and 349.7 ± 38.9 min in Group B. The amount of blood loss during the surgery was 409.5 ± 107.9 and 840.0 ± 168.7 ml in Group A and Group B, respectively. Wounds were healed without chronic infection or sinus formation. No complications related to instrumentation occurred. In Group A, the lumbar kyphotic angle became 7.9 ± 1.0 (range: 6.0 9.6 ) postoperatively, and transformed to 9.5 ± 1.0 (range: 7.3 11.1 ) at the last visit. The average pretreatment ESR was 59.6 ± 22.7 mm/h (30 120 mm/h), which became normal (9.2 ± 3.0 mm/h) within 3 months in patients (Table 1). In Group B, the

338 Arch Orthop Trauma Surg (2013) 133:333 341 Fig. 2 An 11-year-old boy was diagnosed as having tuberculous spondylitis after a 7 months history of severe back pain. The infection had been resistant to chemotherapy for 3 months. The destructive changes seen at T12 L1 on plain radiographs were progressive and the lumbar kyphotic angle was 49.6 (a d).the lesion around the vertebral body of T12 L1 developed a great abscess with marked bony destruction. The abscess involved into the spinal canal with cord compromise resulted in neurologic deficit. We performed one-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation (e, f) from T11 to L3, the postoperative lumbar kyphotic angle became 8.0 degree (e, f). Follow-up MRI showing complete resolution of epidural abscess and decompression of neural component (g). Forty month after surgery, lateral radiographs showing good bone fusion and maintenance of the correction (h, i) lumbar kyphotic angle became 7.4 ± 0.8 (range: 6.0 9.3 ) postoperatively, and transformed to 8.7 ± 0.9 (range: 7.3 10.8 ) at the last visit. The average pretreatment ESR was 61.8 ± 22.9 mm/h (35 99 mm/h), which became normal (8.8 ± 2.7 mm/h) within 3 months in patients (Table 2). At the last follow-up visit, neurologic status of the 37 patients with preoperative neurologic deficit was grade D in 17, all of them recovered to normal; grade B in 6, three recovered to grade D and three recovered to normal; grade C in 8, all of them went to grade E (Table 3). CT and X-ray were used to assess the fusion and the formation of a bone bridge (Figs. 1, 2, 3). The average operative duration and blood loss of Group A were obviously less than those of Group B. All patients achieved bone fusion within 6 10 months after surgery. Discussion Particular anatomical features of the lumbar spine, which include a capacious spinal canal, with floating nerve roots, can be relatively tolerant to compression because of abscess or granulation tissue, which may develop slowly, and make tuberculosis in this region amenable to conservative treatment. Although chemotherapy is a very effective way of controlling and treating the disease and is an indispensable treatment strategy [13, 15, 16], vertebral collapse may continue. Kyphosis requiring extensive reconstructive procedures is a common complication of spine tuberculous in patients treated by chemotherapy alone [17, 18]. Several researchers [4, 11, 13, 19] reported that patients with spinal tuberculosis who suffered from functional neurological disturbance obtain satisfactory functional restoration and recovery from tuberculosis through debridement, stabilization, and decompression of the spinal cord. In our series, patients with functional nerve impairment: 19 with grade D, all of them recovered to normal; 6 with grade B, three recovered to grade D and three recovered to normal; 8 with grade C, all of them went to grade E. All patients had bone fusion. Various methods of the surgical management in patients with lumbar tuberculous spondylitis have been reported [4 11], the aims of such procedures were debridement, spinal cord decompression, stability reconstruction,

Arch Orthop Trauma Surg (2013) 133:333 341 339 Fig. 3 An 11-year-old girl was diagnosed as having tuberculous spondylitis after a 5 months history of severe back pain. The infection had been resistant to chemotherapy for 2 months. The destructive changes seen at L3 L4 on plain radiographs were progressive and the lumbar kyphotic angle was 44.7 (a d). We performed posterior instrumentation, anterior debridement and bone graft in a single-stage (f, g) from L2 to S1, the postoperative lumbar kyphotic angle became 7.6 (e, f). Twenty-five months after surgery, the infected site had healed and radiographs showing good bone fusion, the last visited lumbar kyphotic angle was 9.0 (g, h) Table 3 Outcome of two different surgical treatment for lumbar tuberculosis Group A (N = 19) Group B (N = 18) Total P (A, B) Operation time (min) 207.9 ± 30.9 349.7 ± 38.9 \0.001 Blood loss (ml) 409.5 ± 107.9 840.0 ± 168.7 \0.001 Lumbar kyphotic angle Preoperation 23.9 ± 7.6 28.5 ± 6.5 0.096 Postoperation 7.9 ± 1.0 7.4 ± 0.8 0.037 Final follow-up 9.5 ± 1.0 8.7 ± 0.9 0.005 Fusion time (mon) 8.3 ± 1.7 7.9 ± 1.9 0.576 Frankel scale (final follow-up) D 2 1 3 E 17 17 34 ESR Preoperation 59.6 ± 22.7 61.8 ± 22.9 60.7 ± 22.5 0.826 Postoperation 3 months 9.2 ± 3.0 8.8 ± 2.7 9.0 ± 2.8 0.584

340 Arch Orthop Trauma Surg (2013) 133:333 341 deformity correction and late onset deformity prevention. Several surgeons [8, 9, 18, 20] have advocated surgical treatment of anterior debridement and posterior instrumentation and emphasized its advantages as reaching the focal point of the disease directly and decompression of the spinal cord effectively. However, for anterior debridement and fusion, it has the advantages of direct access to the focus of disease and rapid bony union [21] but is associated with complications such as postoperative ileus [22] and retrograde ejaculation in males [23]. One-stage debridement and bone grafting fusion with instrumentation via posterior approach only for the spinal TB has been reported by some surgeons [4, 13, 24 26], Mehta et al. [26] and Guven et al. [25] also reported satisfactory function of stabilization and kyphosis prevention after posterior transpedicular debridement and instrumented fusion without anterior debridement. Zaveri et al. [19] reported 15 cases of lumbar and lumbo-sacral tuberculosis with TLIF and pedicle screw fixation and all cases were cured with the longterm follow-up in the average of 41 months. To our knowledge, there was no article compare the outcomes between posterior approach only surgery and posterior plus anterior surgery for the lumbar spinal TB in patients. In our series, one-stage posterior debridement, TLIF and instrumentation (Group A) obtained more satisfactory outcome than posterior plus anterior approach surgery (Group B) in minor surgical invasion and less procedure-related complications. Nonetheless, the rate and time of fusion in the two groups have no significant differences, which indicated that both groups achieved a reliable reconstruction of segmental stability (Table 3). Indications for surgery are neurological deficits, spinal instability, severe and/or progressive kyphosis, no response to chemotherapy treatment, non-diagnostic and large paraspinal abscess [5 11]. The author considers that onestage posterior debridement, TLIF and instrumentation reported above are radical. Therefore, we must confirm the indication of this study: (a) dura and nerve root was seriously deformed and the presence of spinal stenosis and severe kyphotic deformity. (b) The patient has had several anterior operations and the anatomical structure is unclear. (c) The presence of significant vertebral collapse caused by bone destruction and spinal instability, we can clean the lesions with posterior approach. (d) Spinal cord compression by paravertebral/epidural abscesses but with less or no psoas abscess, and severe or progressive neurologic dysfunction. One-stage posterior debridement, TLIF and instrumentation we have adopted created enough operating room through resection of spinous process and unilateral facet joint resection, allowing posterior decompression, debridement and strut bone graft under direct visualization of the spinal dura mater. However, the use of this posterior only procedure is restricted. First, the distant focus was inaccessible and it would be difficult to obtain an adequate drainage and debridement if the prevertebral or paravertebral abscess was huge or expanded to other segments. Second, if bone destruction was severe, it is hard to achieve adequate structural support of anterior column through the limited space of transforaminal approach. We removed focal tissues and tissues in focal edges, especially the sclerotic walls, dead spaces, etc., reaching the subnormal substance of bones between normal cancellous bones and pathologic bones. Third, the operation had high risk of spinal cord, aorta abdominalis and iliac blood vessels injury by decompression and debridement. It has been a common understanding that a reliable reconstruction of segmental stability in follow-up should be responsible for the fusion in TB spondylitis. There are several kinds of graft materials can be used in the literature, such as autogenous iliac crest and allograft [27 30]. Autogenous bone grafts were considered as gold standard for their biocompatibility, immune compatibility and osteoinductive capability. We adopted titanium mesh cage which was filled with allograft in the center and autogenous on either ends or autogenous iliac crest because of the limitations in quantity of bone available, and all the patients got bony fusion within 10 months postoperatively. Ozdemir et al. [31] recommended that when the autogenous grafts are insufficient in volume or strength to achieve a fusion, allografts were used to supplement or substitute for autogenous grafts. In our serious, autogenous iliac crest or allografts were applied in both groups and there were no significant differences in the time to obtain bony fusion. The treatment of lumbar tuberculosis remains difficult and controversial; each patient needs individual consideration. The choice of treatment will depend on the severity of the disease and the available surgical expertise and facilities. Our study showed that surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. The procedure has the advantage of minor surgical invasion, effective kyphosis correction and less complications. This approach obtained better clinical outcomes than combined posterior and anterior surgeries. It might be a better surgical treatment for lumbar spinal TB, especially for patients in early phase of bone destruction and/or mild and moderate kyphosis. However, we still should take anterior debridement for ventral stabilization of spine immediately, when the patient has poor bone fusion, tuberculosis recurrence, anterior column collapse or posterior process deformity aggravation. Moreover, this approach alone cannot be used in cases of anterior abscess formation or multilevel involvement where an anterior debridement is necessary.

Arch Orthop Trauma Surg (2013) 133:333 341 341 Conclusion One-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis can be an effective treatment method. This method can effectively relieve pain symptoms, improve neurological function, and reconstruct the spinal stability. In addition, good general supportive care and an effective institution of chemotherapy at the early stage of the disease are the keys to the early eradication and minimizing the complications. So far, the clinical and radiographic results of these patients were good. Meanwhile, further study with a large number of patients and longer follow-up will be necessary. Acknowledgments This publication was funded in part by the Major Program of the Hunan Province Fu Rong Scholar Academy of Sciences. References 1. Moon MS, Moon YW, Moon JL et al (2002) Conservative treatment of tuberculosis of the lumbar and lower lumbar spine. Clin Orthop 398:40 49 2. 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