One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis

Abstract

There are few articles in the literature concerning anterior instrumentation in the surgical management of spinal tuberculosis in the exudative stage. So we report here 23 cases of active thoracolumbar spinal tuberculosis treated by one-stage anterior interbody autografting and instrumentation to verify the importance of early reconstruction of spinal stability and to evaluate the results of one-stage interbody autografting and anterior instrumentation in the surgical management of the exudative stage of throracolumbar spinal tuberculosis. Twenty-three patients, including two children (9 and 15 years old, respectively) and 21 adults with thoracolumbar spinal tuberculosis were treated surgically. T9 to L4 spinal segments were affected, and MRI/CT showed evident collapse of the vertebrae because of tuberculous destruction and paravertebral abscess. Neurological deficits were found in 15 patients. Before surgery, patients received standard anti-tuberculosis chemotherapy for 2 to 3 weeks. Under general endotracheal anaesthesia, the patients were placed in right recumbent positions, and a transthoracic, lateral extracavitary or extrapleural approach was chosen according to the tuberculosis lesion segment. After exposure, the tuberculous lesion region, including the collapsed vertebrae and in-between intervertebral disc, was almost completely resected in order to release the segmental spinal cord. Then, autologous iliac, rib or fibular graft was harvested to complete interbody fusion, and an anterior titanium-alloy plate-screw system was used to reconstruct the stability of the affected segments. Anti-tuberculosis chemotherapy was continued for at least 9 months, and the patients were supported with thoracolumbosacral orthosis for 6 months after surgery. All patients were followed up for an average of 2 years. All 23 cases were healed without chronic sinus formation or any recurrence of tuberculosis during the follow-up period. Spinal fusion occurred at a mean of 3.8 months after surgery. Of all patients with neurological deficits, 14 patients showed obvious improvement; only one patient with Frankel C lesion remained unchanged, but none of the patients got worse. During the follow-up period, a mean of 18 degrees of kyphosis correction was achieved after surgery in the adult group. Moderate progressive kyphosis because of this procedure fusion occurred postoperatively in a 9-year-old child after 2 1/2 years; another 15-year-old child did not demonstrate this phenomenon. Except for the early loosening of one screw in two cases (which did not affect the reconstruction of spinal stability), no other complications associated with this procedure were found during follow-up. Early reconstruction of spinal stability plays an important role in the surgical management of spinal tuberculosis. One-stage anterior interbody autografting and instrumentation in the surgical management of the exudative stage of spinal tuberculosis show more advantages in selected patients, but supplementary posterior fusion should be considered to pre...

Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting

“…Earlier apprehensions regarding the use of metal implants in the presence of active tubercular infection were overcome following the realization that tubercle bacilli had slow rates of division, lower bacillary counts than pyogenic infections, and do not produce adhesion molecule and bio-film [24,25]. Two reports of isolated anterior instrumented fusion have been published where the authors have claimed good results [26,27]. However, other authors have reported good outcomes with posterior fusion.…”

“…Some authors have considered anterior approach to be too invasive and often unnecessary in the context of spinal tuberculosis. Anterior approach may involve division of the diaphragm and segmental spinal vessels [26,27]. Campbell et al [30] have reported higher rates of complications with isolated anterior fusion and combined anterior and posterior spinal fusion compared to isolated posterior fusions.…”

A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis

“…However, the majority of surgeons favour the anterior approach because of concern over the safety of the posterior approach [8,9]. The anterior surgical approach includes an anterolateral extrapleural approach and a transpleural anterior approach, which was developed by Hodgson et al [1,14] and has been used by many surgeons for spinal tuberculous lesions [2,[15][16][17]. The anterior approach is considered to be very important because it can provide the surgeon with direct access to the diseased vertebral segments to perform radical surgical debridement of the infected tissues.…”

The results of simultaneous posterior–anterior–posterior surgery in multilevel tuberculosis spondylitis associated with severe kyphosis

“…In their study on stainless steel, Oga et al [24] reported that M. tuberculosis has low adhesion capability and forms only a few microcolonies surrounded by a biofilm. Benli et al, Yılmaz et al and Jin et al [1,14,33] showed that anterior implant can be safely used in tuberculous spondylitis. Liljenqvist et al and Hee et al [10,18] reported the titanium mesh cage to be safe in vertebral osteomyelitis.…”