1 Indications for surgery
Spinal tuberculosis can be effectively treated with regular anti-tuberculosis medication and brace braking. The indications for surgery for spinal tuberculosis are: (1) negative closed puncture biopsy with a clear pathological diagnosis; (2) neurological signs due to spinal cord compression; (3) obvious deformity or severe destruction of vertebral body; (4) mixed infection with poor conservative treatment; (5) persistent pain or persistent high blood sedimentation; (6) sinus tract formation and co-infection. Jian-Dang Shi, Department of Spinal Orthopedics, General Hospital of Ningxia Medical University
2 Timing of surgery
The timing of surgery for spinal tuberculosis should pay attention to: (1) standardized treatment with anti-tuberculosis drugs must be more than 4 weeks; (2) pulmonary and other extrapulmonary tuberculosis are in quiescence or relatively stable; (3) bone lesions are basically stable, abscesses are no longer enlarged, common bacterial culture has no bacterial growth, and mixed infection is controlled; (4) the patient’s general condition improves, appetite is good, body temperature is normal or only low fever, and blood sedimentation shows a significant decrease (5) diabetes mellitus and hypertension are treated, blood glucose and blood pressure are controlled within the basic normal range, and there are no other serious systemic comorbidities; (6) recent heart, lung, liver and kidney functions and electrolytes are not abnormal.
3 Surgical methods
3.1 Lesion removal: This procedure was first developed by Professor Fang Xianzhi of the Department of Orthopedics of Tianjin Hospital in the 1950s. The main step is to enter the lesion directly through surgery, remove pus, dead bone, tuberculous granulation tissue and caseous necrotic material, and place anti-tuberculosis drugs locally. Various surgical procedures have been developed since then based on this. It is still the primary aim and important step of all surgical approaches.
3.2 The Hong Kong procedure (anterior lesion removal and autologous bone graft fusion): In the 1970s, the “Hong Kong procedure” was based on anterior lesion removal and intervertebral bone graft fusion using autologous bone, combined with postoperative external fixation, in order to reduce the incidence of kyphosis. In the early stage of application, good early results were obtained, however, with the prolongation of observation, scholars found that this procedure had various disadvantages, including resorption of the bone graft, collapse, fracture, pseudoarticular formation, loss of correction angle, aggravation of the kyphosis deformity, and even serious complications of the bone graft protruding into the spinal canal and compressing the spinal cord.
3.3 Focal removal, bone graft fusion, and internal fixation: In recent years, a major advance in the surgical treatment of spinal tuberculosis is reflected in the application of internal fixation techniques. The main purpose of internal fixation is to provide sufficient stability to the lesioned segment immediately after surgery, to provide a good mechanical environment for spinal fusion and quiescence of the tuberculosis lesion, to maintain the correction of the posterior convexity deformity, to reduce the recurrence rate of tuberculosis, and to improve the fusion rate of the lesioned segment. The safety of internal fixation in spinal tuberculosis surgery has been controversial. Experimental studies at home and abroad have confirmed the safety and effectiveness of internal fixation based on adequate preoperative preparation, complete intraoperative debridement of the lesion, and regular postoperative anti-TB treatment.
Most scholars advocate posterior fixation in the choice of internal fixation method, believing that anterior fixation endoprosthesis is directly located in the lesion, which has the risk of causing persistent non-healing of tuberculosis and spreading of infection. However, a large number of clinical data show that anterior fixation is also safe when adequately prepared and is more effective than posterior fixation in correcting deformity and maintaining spinal stability. Compared to posterior fixation, anterior fixation results in shorter operative time, less blood loss, fewer postoperative complications, and more effective correction of deformity and maintenance of spinal stability. We believe that in practice, it is not absolute which surgical approach to use, whether to place the internal fixation in the anterior approach or to make another incision in the posterior approach, and that the formulation of the surgical strategy and the choice of internal fixation should be based on the anatomical characteristics of the diseased segment, the size and extent of the abscess, etc.
3.4 Minimally invasive surgery: It has the advantages of less trauma, less pain, faster recovery, reliable efficacy and meeting cosmetic requirements. Many scholars have applied it to the diagnosis and treatment of a variety of thoracic spine diseases, and some scholars have recently applied it to the diagnosis and treatment of thoracic spine tuberculosis and achieved satisfactory results. While seeing the advantages of minimally invasive surgery for spinal tuberculosis, it should be recognized that this technique has certain limitations, such as narrow indications; high risk of sinus tract formation; short clinical application time and long-term efficacy to be observed; high requirements for hospital hardware facilities and operator’s level; and radiation damage to surgeons and patients. In conclusion, it represents a developmental direction in the surgical treatment of spinal tuberculosis and is a useful and necessary supplement to traditional open surgery, but it cannot completely replace it.
4 Efficacy evaluation and prognosis
The criteria for the cure of spinal tuberculosis: (1) postoperative cases treated with drugs for more than six months, good general condition, no fever, normal appetite, and no local pain. (2) Blood sedimentation is within the normal range on multiple retests. (3) X-ray films showed that the lesioned vertebrae had bony healing and the implanted bone block had grown well. The outline of the lesion area was clear and there was no abnormal shadow. (4) Resumption of normal activities and light work for 3 to 6 months without symptomatic relapse. The cure rate of spinal tuberculosis was significantly improved after a large amount of anti-tuberculosis drugs and various procedures such as lesion removal.