Spinal tuberculosis accounts for about 50% of all osteoarticular tuberculosis in the body, often secondary to spinal cord and nerve injury, and can lead to kyphotic deformity in advanced stages. For patients who meet the indications for surgery, early surgical treatment is required to prevent sequelae. However, due to the emergence of drug-resistant tuberculosis bacteria, inappropriate choice of surgical approach, incomplete removal of lesions, and irregular chemotherapy, postoperative spinal tuberculosis can have a recurrence and retreatment rate of 1.28% to 25%, manifested by postoperative abscess formation, increased bone destruction, non-remission or re-emergence of tuberculosis toxicity, non-healing incision and sinus tract formation, and in severe cases, spinal nerve compression symptoms, resulting in lower limb numbness, pain, weakness and dysfunction of the lower limbs.
The orthopedic department of our hospital admits a large number of patients with recurrent and relapsed spinal tuberculosis each year, for which it is often difficult to adjust the medication regimen and surgery is the most effective treatment. However, if the surgical approach is not chosen properly and the intraoperative lesion is not completely removed, it is likely to lead to a recurrence of spinal tuberculosis. In our experience, the choice of surgical approach should be based on a combination of the initial surgical approach, the site and extent of the abscess and dead bone, the patient’s symptoms and signs, and general status. Postoperatively, drugs should be adjusted appropriately to enhance the therapeutic effect of surgery based on the intraoperative removal of tissue from the lesion, bacterial culture of pus and drug sensitivity results, thus ensuring the ultimate cure of recurrent or relapsed spinal tuberculosis. If the anterior approach was used for the initial surgery, the anterior internal fixation should be avoided during the reoperation, and only the removal of anterior internal fixation and lesion removal should be performed, along with bone graft fusion and posterior internal fixation. If the posterior approach is used in the initial surgery, the posterior approach can still be used for patients with small abscesses and few dead bones, and the internal fixation without loosening can be retained; for patients with large abscesses and many dead bones, the anterior approach should be chosen in the reoperation, and lesion removal and bone graft fusion should be performed, and the loosened posterior internal fixation should be replaced, and the fixed segment should be extended appropriately. Spinal stability reconstruction is very important for retreatment and recurrent tuberculosis, and is a prerequisite to ensure lesion repair and bone graft fusion. The following are a few typical cases.
Case 1, a 34-year-old male patient was admitted to the hospital with “1 year of postoperative lumbar spine tuberculosis and 2 weeks of left lower abdominal swelling”. The patient had undergone anterior lesion removal and internal fixation with bone graft fusion in an outside hospital 1 year ago. Two weeks before admission, a left lower abdominal mass was found, and MRI and CT showed tuberculosis of the lumbar 2 to 5 vertebrae, anterior internal nail and rod system internal fixation of the lumbar 3 to 5 vertebrae, and paravertebral abscess formation. On the day of admission, the patient’s abscess broke down. After admission, posterior internal fixation, anterior internal fixation and titanium cage removal, and bone graft fusion were performed. The anterior internal fixation and titanium cage were seen to be loose during the operation, and after removal, an autologous iliac bone graft was performed. There was no recurrence of lumbar spine tuberculosis 1 year after surgery.
Preoperative X-ray showed loosening of anterior internal fixation
Preoperative CT film showed lumbar 2-5 vertebral tuberculosis, anterior internal fixation was loose, and bone graft was not fused
Preoperative MRI showed tuberculosis of lumbar 2-5 vertebrae and paravertebral abscess formation
sinus tract formation
intraoperative loosening of internal fixation
Postoperative internal fixation was good and the bone graft was well positioned
1 year postoperative CT showed fusion of bone graft
Case 2, a 26-year-old male patient was admitted to the hospital with “4 years of postoperative lumbar spine tuberculosis, low back pain with left lower abdominal mass for 1 month”. The patient had undergone anterior lesion removal and internal fixation with bone graft fusion in an outside hospital 4 years ago. MRI and CT showed tuberculosis of the lumbar 4 and 5 vertebrae, anterior internal fixation of the lumbar 4 and sacral 1 vertebrae with nail and rod system, and paravertebral abscess formation. After admission, posterior internal fixation, anterior internal fixation and titanium cage removal, and bone graft fusion were performed. Intraoperatively, the anterior internal fixation and titanium cage were seen to be loose, and after removal, an autologous iliac bone graft was performed. There was no recurrence of lumbar spine tuberculosis 1 year after surgery.
Pre-operative X-ray showed loosening of anterior internal fixation
Preoperative CT film showed tuberculosis of lumbar 4 and 5 vertebrae with loose anterior internal fixation and massive dead bone formation
Preoperative MRI showed tuberculosis of lumbar 4 and 5 vertebrae and paravertebral abscess formation
sinus tract formation
intraoperative loosening of internal fixation
1 year postoperative X-ray and CT showed fusion of bone graft
Case 3, a 42-year-old female patient was admitted to the hospital with “pain and weakness in the right lower extremity for 1 week 3 months after lumbar spine tuberculosis surgery”. The patient underwent posterior lumbar spinal tuberculosis lesion removal and internal fixation with bone graft fusion 3 months ago at an outside hospital. After the operation, the lumbar pain and right lower extremity pain were relieved, but 1 month after the operation, he again developed lumbar pain and right lower extremity pain and weakness, and had perianal numbness and difficulty in urination. MRI and CT showed that after posterior internal fixation of lumbar 4 and 5 vertebral tuberculosis, an abscess was formed in the spinal canal and the dura was compressed. Physical examination: muscle strength of right lower limb grade 2 to 3, left lower limb grade 4, bilateral hypesthesia below lower leg. Since the first two posterior surgeries failed, we used anterior lesion removal and autologous iliac bone graft fusion. Two months after surgery, MRI showed that the abscess in the spinal canal disappeared and the patient’s symptoms completely disappeared.
Preoperative X-ray showed posterior internal fixation of the lumbar spine with interbody destruction of lumbar 3 and 4 vertebrae
Preoperative CT film showed tuberculosis of lumbar 3 and 4 vertebrae, dead bone formation and unfused bone graft
Preoperative MRI showed tuberculosis of lumbar 3 and 4 vertebrae and abscess formation in the spinal canal
2 months postoperative X-ray shows lumbar 3 and 4 intervertebral iliac bone graft
2 months postoperative MRI showed disappearance of the intravertebral canal abscess and good position of the bone graft.