Materials
From September 2013 to March 2017, 16 patients (age range 23–74 years, with an average age of 46.3 ± 14.5years) with paraplegia or incomplete paralysis of short segment thoracic vertebrae tuberculosis, including 7 men and 9 women, who underwent anterior debridement, bone grafting fusion and anterior fixation in our hospital enrolled the study.
Patients who met of the following conditions were selected: (i) Thoracic tuberculous with destruction of one or two segments of the vertebral body, (ii) A mild kyphotic deformity(Cobb angle<30º), (iii) persisting back pain attributed to spinal instability and (iv) poor response to medical management,(v) the vertebral segment can be treated with right anterior internal fixation, (vi) the patient has developed paraplegia or incomplete paralysis,(vii)there were no contraindications for cardiac function and pulmonary function.
Exclusion criteria were: (i) multi-segmental involvement with severe destruction of vertebral bodies, (ii) the patient did not have paraplegia or incomplete paralysis, (iii) severe kyphosis (Cobb angle >30º), (iv) previous thoracic surgery and (v) severe or active tuberculosis,(vi)there are contraindications to thoracotomy.
Spinal tuberculosis was diagnosed based on patients’ symptoms (local pain and percussion pain accompanied with fever, night sweats, and neurological dysfunction), laboratory results (T-spot, tuberculosis antibody, erythrocyte sedimentation rate [ESR], and C-reactive protein [CRP]) and radiologic findings (radiography, computed tomography, and magnetic resonance imaging) and was confirmed by postoperative pathology examinations. Imaging studies showed vertebral body destruction, intervertebral space collapse, kyphosis, paravertebral abscess, and intraspinal invasion. Regarding thoracic vertebral damage, 1 patients had thoracic vertebrae 5 and 6 damage (T5-T6), 2 patients had thoracic vertebrae 6 and 7 damage (T6-T7), 2 patients had thoracic vertebrae 7 and 8 damage (T7-T8), 4 patients had thoracic vertebrae 8 and 9 damage (T8-T9), 5 patients had thoracic vertebrae 9 and 10 damage (T9-T10),2 patients had thoracic vertebrae 10 and 11 damage (T10-T11) (Table 1). The same surgeons reviewed the surgical indications and performed the procedures.The patients were evaluated preoperatively and postoperatively in terms of Frankel Grade, kyphotic Cobb angle, and bony fusion.
Table 1 Summary of the patients’ data
Patient no.
|
Age(y)/sex
|
Level
|
Follow-up
(months)
|
Kyphosis angle(º)
|
Frankel grade
|
Fusion
(months)
|
PRE
|
POST
|
FFU
|
PRE
|
POST
|
FFU
|
1
|
23/M
|
T8-T9
|
24
|
23
|
11
|
11
|
A
|
B
|
D
|
4
|
2
|
47/F
|
T9-T10
|
36
|
12
|
8.4
|
10
|
A
|
B
|
E
|
5
|
3
|
48/F
|
T8-T9
|
48
|
21
|
10.6
|
11
|
C
|
D
|
E
|
5
|
4
|
56/M
|
T6-T7
|
48
|
18
|
10
|
10
|
B
|
C
|
D
|
6
|
5
|
57/M
|
T9-T10
|
42
|
17
|
9
|
9
|
B
|
C
|
E
|
5
|
6
|
37/M
|
T5-T6
|
24
|
22
|
10.2
|
12
|
A
|
B
|
D
|
4
|
7
|
42/F
|
T7-T8
|
24
|
18
|
7.2
|
8
|
A
|
B
|
E
|
5
|
8
|
29/M
|
T8-T9
|
30
|
20
|
7
|
6
|
B
|
D
|
E
|
4
|
9
|
32/F
|
T10-T11
|
36
|
24
|
8.8
|
10
|
C
|
D
|
E
|
4
|
10
|
48/F
|
T10-T11
|
24
|
13
|
10.3
|
12
|
C
|
D
|
E
|
5
|
11
|
45/F
|
T9-T10
|
36
|
23
|
9.6
|
11
|
A
|
C
|
D
|
6
|
12
|
55/M
|
T9-T10
|
48
|
14
|
9.8
|
11
|
B
|
C
|
E
|
6
|
13
|
24/M
|
T9-T10
|
24
|
11
|
5.6
|
7
|
A
|
C
|
E
|
5
|
14
|
62/M
|
T8-T9
|
48
|
19
|
13
|
11
|
B
|
D
|
E
|
6
|
15
|
74/F
|
T7-T8
|
42
|
15
|
8
|
10
|
C
|
D
|
D
|
8
|
16
|
61/F
|
T6-T7
|
36
|
21
|
6.4
|
6
|
C
|
D
|
E
|
6
|
Mean values
|
46.3 ± 14.5(ages)
|
|
35.6 ± 9.6
|
18.2± 4.1
|
9.1 ±1.9
|
9.7 ± 1.9
|
|
|
|
5.3 ±1.1
|
|
|
|
|
|
|
|
|
|
|
|
|
PRE preoperative, FFU final follow-up, POST postoperative
Written informed consent was obtained from all patients, and the study protocol was approved by the Institutional Ethics Review Board of Xi'an chest Hospital.
Methods
Preoperative preparation
All patients received at least 2–4 weeks of first-line anti-tuberculous treatment (rifampicin 0.45g, isoniazid 0.4g, pyrazinamide 1.5g,and ethambutol 0.75g) preoperatively, and supporting therapy and symptomatic treatment were conducted when the patient being hospitalized. Doses of anti-tb drugs were appropriately increased in patients with tuberculosis in other parts of the body, or in patients weighing more than 50kg. For patients with paraplegia or incomplete paralysis, surgery should be performed as early as possible.
Surgical approach
Informed consent for surgery is signed by the patients.Patients were instructed to lay in lateral position. Transthoracic patients received tracheal intubation with a double lumen tube, and the side lobe was collapsed intraoperatively. A standard lateral anterior approach was used, and an right anterior posterolateral surgical incision was made. Skin and subcutaneous tissues were dissected layer by layer using only an incision of the oblique costal margin. The right latissimus dorsi muscle and pectoralis major muscle were dissected layer by layer. Ribs opposite to the diseased vertebra are exposed, stripped and cut, and the cutoff parts were reserved as autologous bone graft. The right thoracic cavity was opened with an thoracotomy device, and the right lung was collapsed and the right spinal column series was exposed. The right diseased vertebral body and anterior fascia were examined with obvious swelling and abnormal color and the paravertebral abscess was aspirated with a syringe as a culture specimen. The anterior fascia of the diseased vertebral body was cut longitudinally and segmental vessels were ligated. Cheese-like substance, necrotic granulation tissue, dead bone particles and other lesions were completely removed, while normal vertebral bone tissue was retained. An abscess in the opposite direction was drawn and flushed repeatedly through the vertebral body defect. The compression of the spinal cord was completely relieved. The wound was washed repeatedly with saline, and 1–2g of streptomycin powder was administered. Autogenous bone and graft fusion with a titanium cage strut combined with an anterior vertebral screw-plate internal fixation system were used to recover the normal spinal curvature of patients with kyphosis(Fig. 1,2). The drainage tube was placed postoperatively, and culture specimens were sent for pathological examination.
Postoperative treatment
Conventional electrocardiographic monitoring and anti-infection and anti-tuberculosis treatment were provided. A drainage tube was placed for 1-3 days and removed until the 24-h drainage flow was < 50 mL. In addition, complete lung expansion was confirmed by radiography. The drainage time was extended in patients with penetrable pus cavities. Nutritional support was provided in patients with postoperative anemia, low serum albumin levels, or loss of appetite. The patients were required to get out of bed for 2 weeks after the operation.After hospital discharge, anti-tuberculosis therapy was maintained for 18–24 months.
Evaluation of clinical outcomes
All patients were examined clinically and radiologically at 3,6 and 12 months after surgery and then once a year.The ESR and CRP were measured to evaluate the activity of short segment thoracic vertebrae tuberculosis with paraplegia or incomplete paralysis . Roperatively and postoperatively in terms of Frankel Grade, kyphotic Cobb angle, and bony fusion were recorded to evaluate changes before and after surgery. Kyphosis angle:observing the lateral X-ray,the kyphotic angel was the angle formed by two lines obtained by joining the antero-superior and postero-superior corners of the above lesion,and the antero-inferior and postero-inferior corners of the vertebral below lesion[12].Postoperative radiographs were conducted to assess the level of bony fusion using the radiologic criteria of Bridwell[13].
Statistical analysis
Data were analyzed using the independent sample t test and SPSS statistical software (IBM Corp.) p values < 0.05 were considered statistically significant.