With population growth and increased mobility, the emergence and spread of drug-resistant tuberculosis, especially multidrug-resistant tuberculosis, and the prevalence of acquired immunodeficiency syndrome, which mutually promote the progression of lesions, the global tuberculosis epidemic is worsening [1], especially the proportion of refractory tuberculosis is increasing. Spinal tuberculosis is one of the common extrapulmonary tuberculosis, accounting for about 3%-5% of all tuberculosis and 50%-60% of bone and joint tuberculosis [2], with tuberculosis of the thoracolumbar spine being the most common. Spinal tuberculosis is easy to involve the spinal canal, producing spinal cord, nerve compression and even paralysis, and non-standardized treatment is an important cause of recurrence and disability of spinal tuberculosis. In recent years, various internal fixators and minimally invasive techniques have been increasingly used in the treatment of spinal tuberculosis, which has played a positive role in significantly improving the efficacy of treatment, but there are also many problems. Wang Chuanqing, Department of Thoracic Surgery, Shandong Chest Hospital 1 Clinical characteristics of spinal tuberculosis Spinal tuberculosis is mostly secondary to tuberculosis of the lungs, and it is not uncommon to find spinal tuberculosis without any tuberculosis manifestation in the lungs, especially in young and middle-aged lumbar spine tuberculosis patients. After entering the human body, Mycobacterium tuberculosis can survive in the spine, which is heavily loaded and easily damaged, due to the characteristics of the vertebral body, such as high content of cancellous bone, slow blood flow and arterial supply of terminal blood vessels, etc., and it can be latent for several months, years or even longer, and develops into clinical spinal tuberculosis when it is damaged by external forces, long-term labor injury and lowered resistance of the body. Typical spinal tuberculosis, in addition to symptoms of tuberculosis toxicity such as loss of appetite, generalized weakness, low afternoon fever, night sweats, emaciation, etc., the local symptoms are mainly spinal pain, effusion abscess, posterior convexity deformity and spinal cord compression symptoms. Different parts of the lesion have different clinical manifestations. Cervical spine tuberculosis mainly manifests as neck pain, dysphagia, weakening of upper limb muscles and cervical compression; cervico-thoracic tuberculosis mainly focuses on spinal cord compression symptoms, narrowing of the thoracic spinal canal, the spinal cord is prone to paraplegia symptoms of compression, and can be earlier occurrence of spinal kyphosis; lumbar vertebrae and lumbosacral spine tuberculosis is mainly manifested as lumbar pain, cold abscess formation, due to the lumbar spine vertebral canal is wider, unless there is extensive destruction of the vertebral body, the nerve roots and spinal cord is not easy to be affected by the The nerve roots and spinal cord are less susceptible to compression by abscesses and necrotic tissues unless there is extensive destruction of the vertebral body. On imaging, narrowing of the intervertebral space, bone destruction, abscess formation (paravertebral abscess and/or effusion abscess), deformation of the vertebral body and spine (mainly kyphosis), and spinal canal involvement with compression of the spinal cord or dural sacs are often manifested. Early and atypical spinal tuberculosis is difficult to diagnose, with mild symptoms of tuberculosis toxicity, and lumbar back stiffness is the earliest positive sign [3]; cervical tuberculosis is associated with neck stiffness, thoracic tuberculosis is associated with back stiffness, and lumbar tuberculosis is associated with lumbar stiffness.Bone structure may be normal on X-ray images, showing only straightening of the physiologic curvature of the spine. Three-dimensional CT scanning can detect subtle skeletal changes earlier, such as small dead bones, cavities or small abscesses in the vertebral body, finding dead bone fragments of cancellous bone, fine calcifications in the paravertebral soft tissues and lumbar major muscles, mild narrowing of the spinal canal, slight destruction of the anterior part of the vertebral body and indentation defects at the anterior margin of the vertebral body, etc. MRI has a high sensitivity and specificity for the early diagnosis of spinal tuberculosis [4], and it can detect tuberculous lesions 4-6 months ahead of time [5], which not only It can show the number of involved vertebrae and the range of lesions, but also can show different pathological changes of spinal tuberculosis, T1-weighted image is low signal, T2-weighted image is high signal, especially it can show the pressure of pus on the dural sac and spinal cord of the involved vertebrae, and can be divided into vertebral inflammation type, vertebral inflammation combined with abscess type, vertebral inflammation combined with abscess and intervertebral disc inflammation type [6]. Complex spinal tuberculosis [7] mainly refers to: 1) multi-organ tuberculosis, including the combination of pulmonary tuberculosis, pyothorax, hepatic tuberculosis, splenic tuberculosis, intestinal tuberculosis, renal tuberculosis, tuberculous meningitis, and other osteoarticular tuberculosis and other 2 or more organs at the same time or successively tuberculosis; our department has received the patients who have tuberculous foci at the same time in 17 parts of the whole body; 2) multisegmental tuberculosis: including tuberculosis of spine in 3 or more consecutive segments; (3) jumping spinal tuberculosis: such as cervical tuberculosis combined with lumbar tuberculosis, thoracic spine jumping tuberculosis; (4) spinal tuberculosis combined with impaired neurological function: spinal tuberculosis with signs and symptoms of compression of the dural sac or nerve roots, including paraplegia and incomplete paraplegia, and the imaging to support the clinical diagnosis; (5) spinal tuberculosis combined with serious spinal instability: spinal tuberculosis combined with severe spinal instability, kyphosis or scoliosis deformity; (6) drug-resistant spine tuberculosis: including multidrug-resistant spinal tuberculosis; 7) recurrent spinal tuberculosis; and 8) spinal tuberculosis in children.2 Aims of surgical treatment of spinal tuberculosisSpinal tuberculosis, as a part of systemic tuberculosis, is treated with the main aim of curing the tuberculosis and its complications, i.e., complete removal of tuberculous foci, relief of spinal cord and nerve compression, correction of spinal deformities, and maintenance of the stability of the spinal column [8]. In the early stage of spinal tuberculosis, it is only tuberculous osteitis or soft tissue tuberculitis, which is mainly manifested as local ischemia of bone or inflammation of soft tissue without dead bone, necrosis, or abscess, which can be recovered by standardized anti-tuberculosis drug treatment, and generally does not require surgical intervention. When spinal tuberculosis develops to the stage of necrosis, often manifested as dead bone, abscess, the presence of a large number of tuberculosis granulation and necrotic tissue, making it difficult for anti-tuberculosis drugs to play a normal therapeutic effect, resulting in spinal cord nerve compression, spinal instability and other complications, at this time the need for surgical intervention, to create more favorable conditions for drug therapy [9], to reduce the severity of the complications. As a very important auxiliary means, in the comprehensive treatment of spinal tuberculosis, the choice of surgical intervention without losing time is more conducive to the complete healing of tuberculosis foci, significantly shortening the bed rest time and treatment course, reducing the occurrence of complications, and improving the patient’s quality of life [10].3 Timing of spinal tuberculosis surgery Spinal tuberculosis is not a disease that must be operated on, nor is it a disease where the earlier the surgery, the better the outcome. The earlier the outcome, the better the disease. Surgery is recognized as an effective adjuvant therapy, which requires not only the correct selection of surgical indications, but also the appropriate timing of surgery in order to achieve a better therapeutic effect, otherwise it may not be the case. For general spinal tuberculosis patients, most scholars advocate that after 2-4 weeks of effective anti-tuberculosis treatment [11], body temperature, blood sedimentation, C-reactive protein is normal or close to normal, the symptoms of tuberculosis toxicity have significantly improved, and the patient’s general condition is able to tolerate the surgery, then surgical treatment can be selected. For patients who have developed paraplegia and patients with progressive aggravation of neurological dysfunction, surgery should be carried out as early as possible to salvage neurological function under the guarantee of safety, and in principle, it is not subject to the limitation of the time of anti-tuberculosis treatment; however, for those who have been proved to be tuberculous abscess compression, the neurological symptoms may be relieved during the course of anti-tuberculosis treatment, which is differentiated from the acute compression of bone. For complex spinal tuberculosis, preoperative antituberculosis treatment can be appropriately prolonged, but in principle not more than 3-6 months.4 Surgical indications for spinal tuberculosis Since 1957, Fang Xianzhi et al. put forward osteoarticular tuberculosis foci clearing therapy [12], foci clearing surgery has become the basic surgical treatment of spinal tuberculosis, and the later emergence of implant fusion with extremely easy internal fixation application and so on have all been developed on the basis of the second. The indications for lesion debridement [12] are: 1) the presence of a clear abscess. Abscess formation suggests that the combined lesion is progressing or has not yet stopped progressing, which can affect the blood flow of the vertebral body and produce contact corrosive damage to the vertebral body, and should be removed as soon as possible.2) Those with the presence of clear dead bone. Dead bone often coexists with abscess, is not easy to be absorbed, image lesion healing, and may lead to recurrence, should be taken as early as possible to remove. 3) There is a chronic sinusoidal presence of secondary infection. Secondary infection often leads to chronic vertebral osteomyelitis, which does not heal, and should be removed as early as possible to prevent mixed infection of the vertebral body.4) Those with combined spinal cord or nerve root (cauda equina area) compression symptoms.5) Those with negative closed puncture biopsy who need clinicopathological diagnosis [13], can also consider surgical lesion removal along with pathological and bacteriological examination.Moon et al [14] believe that the effect of chemotherapy is poor, the emergence of drug-resistant patients with poor chemotherapy results and drug resistance, as well as those with severe bone destruction and low back pain, spinal deformity and instability, also require surgical treatment. With the continuous development of spinal surgical techniques and the updating of treatment concepts, the traditional surgical indications for spinal tuberculosis have yet to be further clarified. At what level does a cold abscess require surgery? At what site and in what state does dead bone necessitate surgery? At what quantitative time standard does sinus tract formation require surgery? All of these require clinical studies with larger samples to draw conclusions. Xu Jianzhong proposed the concepts of absolute and relative indications [15]: 1) spinal cord compression with neurological dysfunction, 2) destabilization of the spine, 3) severe or progressive kyphosis of the spine, and 4) compression of vital organs are absolute indications; abscesses, dead bones, and sinus tracts are relative surgical indications for spinal tuberculosis, and a comprehensive treatment plan should be formulated according to the location, degree, and age of the lesion.5 Surgery for spinal tuberculosis The surgical treatment of spinal tuberculosis has undergone three milestones: simple lesion debridement, lesion debridement + intervertebral implant fusion (Hong Kong operation), and lesion debridement + intervertebral implant fusion + internal fixation, which basically reflects the course of the continuous improvement and progress of the surgical treatment of spinal tuberculosis. For patients with spinal tuberculosis, the best optimized surgical plan should be selected according to the principle of individualization between surgical treatment and non-surgical treatment, between open surgery and minimally invasive surgery, and between the use of internal fixation or not, based on a comprehensive analysis of the patient’s physical condition, age, occupation, economic ability, lesion site, lesion degree, comorbidities, and other factors [16,17]. Surgery should be small rather than large, choose the least traumatic to the patient; should be simple rather than complicated, choose simple, easy, can solve the main problem of the operation; should be fine rather than coarse, choose the operation with adequate preplanning, alternative options, and preventive countermeasures against accidents; should be familiar rather than raw, choose more familiar, skilled operation.5.1 Focal debridement Focal debridement is the basis of all spinal tuberculosis surgery, complete removal of pus, It is the basis of all spinal tuberculosis surgeries to completely remove pus, caseous necrotic material, tuberculosis granules, dead bones, sinus tracts and corresponding intervertebral discs, decompression of the spinal canal to relieve spinal cord compression, and to make anti-tuberculosis drugs penetrate into the diseased vertebrae to reach an effective concentration, and to promote the healing of the lesions. Some scholars mainly resected 4mm of the sclerotic wall of spinal tuberculosis [18], which will inevitably sacrifice some subnormal bone, which may aggravate spinal instability, so the so-called “thorough” is relative [13], as far as possible to remove the tuberculosis lesion tissue, as far as possible to retain the healthy and subhealthy tissues, can not be for the sake of thoroughness to expand the resection, and can not be left behind for the sake of preserving the tissue of tuberculosis. TB foci should not be left behind for the sake of tissue preservation. Thorough removal of TB foci is the key to the success of surgical treatment of spinal TB, and the operator should fully assess the possible problems encountered during the operation and the treatment countermeasures according to the preoperative imaging data, focusing on the following: adequate drainage of pus, with special attention to the drainage of separated abscesses and neighboring abscesses; a combination of scraping, excision, nipping and chiseling to remove the necrotic discs, endplates, and bony tissues, and the walls of the abscesses as well as part of the foramen ovale. Necrotic tissue is repeatedly scraped with a spatula until the wound bleeds in spots; repeated wiping, for larger abscess walls, dry gauze repeatedly wiped, is particularly effective in removing necrotic tissue; pressure flushing of the wound, the application of sterile hydrogen peroxide, metronidazole solution, physiological saline and other repeated pressure flushing, which reduces the amount of local bacteria and makes the wound cavity cleaner. The approach of lesion removal should prefer anterior lesion removal because spinal tuberculosis mainly invades the anterior and middle columns, and anterior lesion removal can be completed under direct vision, which is more direct, reasonable, and thorough, and is especially conducive to the treatment of paravertebral abscesses and fluid abscesses. For patients with good spinal stability, no obvious kyphosis, and small bone defects after lesion removal, simple lesion removal is an effective surgical procedure.5.2 Lesion removal + bone grafting and fusion This surgical procedure is less and less frequently used, but Korea Wei et al.[19] recently reported 39 cases of anterior lesion removal, spinal cord decompression, and fontanous iliac bone (or rib) grafting with a 12-72-month follow-up. At 12-72 months follow-up, X-rays of all patients showed no change in the density and location of the implant block, trabecular bone passing through the fusion area or significant bony healing with the adjacent vertebrae, no significant improvement in kyphosis before and after surgery, and loss of the Cobb angle from 0° to 25°, with an average of 6°. The purpose of bone grafting is to maximally restore the normal sequence of the spine and its physiological curvature damaged by tuberculosis, stabilize the spine and reduce deformity, but there are shortcomings such as insecure bone grafting, easy to slip out of position, the need for prolonged bed rest, a low fusion rate, and many complications.5.3 Lesion debridement + grafting and fusion + internal fixation includes one-stage anterior lesion debridement and grafting plus anterior endoprosthetic fixation, one-stage posterior lesion debridement plus posterior pedicle internal fixation, one-stage anterior lesion debridement and bone grafting plus posterior pedicle internal fixation, and staged anterior lesion debridement and bone grafting plus posterior pedicle internal fixation, etc. The one-stage surgical approach has been recognized by most scholars, but whether to adopt anterior or posterior or combined anterior and posterior surgery is still highly controversial. One-stage anterior lesion removal and bone grafting plus anterior internal fixation of the vertebral body, for those with severe vertebral body destruction, combined with a large abscess, and anterior spinal cord compression, can fully reveal the lesion, effective lesion removal, abscess removal, spinal cord decompression, and fusion of intervertebral body grafts, and internal fixation can be accomplished within the same incision, which is a more ideal choice, with the disadvantages of greater trauma, inability to carry out long segment fixation, and less than optimal correction of the posterior convexity of the deformity of only 10±6° [20]. One-stage posterior lesion removal plus posterior pedicle internal fixation, for patients with vertebral tuberculosis whose lesions are mainly located in the posterior region, such as pedicle tuberculosis, plate tuberculosis, spinous process tuberculosis, or lesions confined to one side of the vertebral tuberculosis, the removal of the lesions is relatively thorough, less traumatic, and can be fixed for a long segment, with simple surgical operation and few complications, but for the majority of vertebral tuberculosis, especially for patients with abscesses, the removal of the lesions is incomplete, and there is the risk of draining infected foci into sterile areas. However, in most cases of vertebral tuberculosis, especially in combination with abscesses, there is a risk that the lesion will not be removed completely and the infected lesion will drain into the sterile area, and although there are more successful experiences [21], caution should be exercised in the practical application of the procedure. In one-stage anterior lesion debridement with bone grafting and posterior endoprosthesis, lesion debridement under direct anterior visualization has a wide field of vision, and it is easy to remove the lesion, and it is even easier to remove the abscess and granulation located in the posterior longitudinal ligament and the intervertebral body that spreads up and down over long distances [22], so that the spinal cord is relieved of the anterior dural pressure more completely, and the neurological symptoms are relieved more obviously. Neurological symptoms were relieved more obviously, and at the same time, a large bone support implant was performed to stabilize the anterior middle column. Posterior pedicle nail system fixation is performed under completely aseptic conditions, preserving the vertebral plate and pedicle structure intact, and can effectively correct the kyphosis, which is especially suitable for patients with thoracolumbar vertebral tuberculosis. With the use of minimally invasive internal fixation devices, this procedure will have a broader application prospect.6 Minimally invasive surgery for spinal tuberculosis Minimally invasive surgery has the advantages of small trauma, fast recovery, reliable efficacy, and meets the requirements of cosmetic surgery, which is becoming more and more popular among patients, and patients with spinal tuberculosis are also adapted to minimally invasive treatment. Television-assisted thoracoscopic technology has been applied in the diagnosis and treatment of thoracic spinal tuberculosis, and the scope of surgery has developed from diseased vertebral biopsy and thoracic disc removal to vertebral body resection, reconstruction, and internal fixation, and some people have reported that the excellent rate of 90% in the treatment of thoracic spinal tuberculosis using this technology [23] and thoracoscopically completed the removal of lesions of thoracic spinal tuberculosis and implant fusion [24], and it shows the best results in terms of the length of the incision, the amount of intraoperative hemorrhage, the flow of drainage from the thoracic cavity, the pain time and hospitalization time, etc. CT, B ultrasound, C-arm guided puncture biopsy, abscess drainage, and tube placement and flushing improve the drug concentration in the lesion [25], dilute the pathogen density, and reduce the pathogenicity of the pathogen, which is gradually becoming a part of the comprehensive treatment of spinal tuberculosis, forming the concept of step therapy [26], and the general condition improves after elimination of the abscess, which provides a good foundation for further treatment, and also improves the safety of practicing open surgery for those with aggravated neurological symptoms. The development of minimally invasive posterior surgical instruments has facilitated the use of minimally invasive techniques for posterior pedicle screw internal fixation, and one-stage anterior lesion debridement and fusion with autologous bone implantation [27], which have also achieved good results. In conclusion, the surgical treatment of spinal tuberculosis has made great development, internal fixation reconstruction has improved spinal stability, so that the therapeutic efficacy is significantly improved, minimally invasive surgery for spinal tuberculosis puts forward the concept of step therapy, so that the connotation of comprehensive treatment is more enriched, but how to cope with more and more multidrug-resistant cases, how to be able to further shorten the bed rest time and course of treatment, how to reduce the recurrence rate of the surgery, and how to be able to earlier However, multi-center and large-sample collaborative studies are needed to identify and diagnose patients with spinal tuberculosis. References [1] Tang Shenjie,Xiao Heping. Comprehensive treatment of multidrug-resistant tuberculosis. Chinese Journal of Tuberculosis and Respiratory. 2003,26(11):715.[2] Ma Yuanzheng,Xue Haibin. Surgical treatment strategy for spinal tuberculosis. Chinese Spinal Cord Journal,2009,19(11):805-806.[3] Shi JD, Wang ZL. Early diagnosis of atypical spinal tuberculosis. Chinese Journal of Spinal Cord.2010, 20(5):432-434.[4]Danchaivijitr N,Temram S,Thepmongkhol K. Diagnostic accuracy of MR imaging in tuberculous spondylitis. J Med Assoc Thai,2007,90(8):1581-1589.[5]Desai SS. Early diagnosis of spinal tuberculosis by MRI. J Bone Joint Surg Br,1994,76(6):863-869.[6]Sun XH,Wang B,Chang Guanghui. MRI manifestations and early diagnosis of spinal tuberculosis. Journal of Clinical Radiology. 2000,19(5):302-304.[7] Wang ZL. Problems of lesion removal and fusion fixation in spinal tuberculosis. Chinese Journal of Spinal Cord, 2006,16(12):888-889.[8] Hao Dingjun, Guo Hua, Wu Qining, et al. Clinical characteristics and surgical approach of complex spinal tuberculosis. Journal of the Third Military Medical University. 2009,31(20):1947-1950.[9] Jain AK, Aqqarwal A, Dhammi IK. Extrapleural anterolateral decompression in tuberculosis of the dorsal spine. j Bone Jonint Surg, 2004,86:1027-1031.[10] Chen WI, Wu CC, Jung CH, et al. Combined anterior and posterior surgeries in the treatment of spinal tuberculous spondylitis. Clin Orthop, 2002,398:50-59.[11] Zheng QX, Pan HT, Guo XD, et al. Anterior radical debridement and bone grafting with one-stage instrumentation anteriorly or posteriorly for the treatment of thoracic and lumbar spinal tuberculosis. Chinese Journal of Tuberculosis and Respiratory,2008,31(2):99-102.[12]Fang Xianzhi,Tao Fu, Guo Jiling,et al. Removal therapy of osteoarticular tuberculosis foci. Beijing: People’s Health Publishing House, 1957,1-68.[13] Zhai Dongbin, Jin Dadi. Correct understanding of spinal tuberculosis focus removal. Chinese Spinal Cord Journal. 2008,18(8): 565-567.[14]Moon Ms,Lee MK. The change of the kyphosis of the tuberculous spine in children following ambulant treatment. Korean Orthop Assoc,1971,6:203-208.[15] Xu JZ. Reconsideration of surgical indications and surgical modalities for spinal tuberculosis. Chinese Spinal Cord Journal,2006,16(12): 889-890.[16] Rezai AR,Lee M,Cooper PR,et al. Modern management of spinal tuberculosis. Neurosurgery,1995,36(1):87-97.[17 ] Wang S,Duan CY,Wang Q. Reflections on individualized comprehensive treatment of spinal tuberculosis. Medicine and Philosophy (Clinical Decision Forum Edition).2009.30(4):31-32.[18 ] Wang ZL. Problems of lesion removal and fusion fixation in spinal tuberculosis. Chinese Journal of Spinal Cord,2006,16(12): 888-889.[19] Han Guo-Wei, Liu Shao-Yu, Liang Chun-Xiang, et al. Anterior decompression and bone grafting surgery for the treatment of thoracolumbar tuberculosis with paraplegia in 39 cases. Journal of Sun Yat-sen University (Medical Science Edition) 2009,30: 79-80.[20] Qu Dongbin, Jin Dadi, Chen Jianting, et al. One-stage surgical treatment of spinal tuberculosis. Chinese Medical Journal,2003,1:110-113.[21] Zhang X,Liu J,Wang MY,et al. One-stage posterior transpedicular osteotomy lesion removal and bone graft internal fixation for thoracolumbar spinal tuberculosis. Chinese Journal of Orthopaedic Surgery.2010,18(17):1476-1478.[22] Wu JH,Deng ZS,Zhang HQ,et al. One-stage posterior transpedicular internal fixation, anterior lesion removal, and implant fusion for thoracolumbar tuberculosis. Chinese Journal of Modern Medicine.2009,19(4):557-560.[23] Huang TJ, Hsu RW, Chen SH, et al. Video-assisted thoracoscopic surgery managing tuberculous spondylitis. Clin orthop,2000,379:143-153.[24] ]Hsu HZ,Chi YL,Lin Z,et al. Television thoracoscopic anterior surgery for thoracic tuberculosis with enlarged operating incision. Chinese Journal of Orthopedics,2000,20(5):287-288.[25] Xifeng Zhang,Zhimin Xia,Yan Wang,et al. Clinical analysis of minimally invasive method to increase intra-lesional drug concentration in the treatment of spinal tuberculosis. Journal of the Third Military Medical University.2009,31(20):1936-1939.[26]Zhang XF,Wang Y,Xiao SH,et al. Clinical study of minimally invasive surgery for lumbosacral spine tuberculosis. Chinese Journal of Orthopaedics.2008, 28(12):[27]Guo L,Chen J,Tian YB,et al. One-stage posterior minimally invasive internal fixation and anterior debridement with bone graft fusion in the treatment of thoracolumbar tuberculosis. Chinese Spinal Cord Journal,2008,18(8):579-583.