1. Do all spinal tuberculosis require surgery? A: No. Most early spinal tuberculosis can be cured by conservative treatment such as chemotherapy, braking and nutritional support, especially in children with spinal tuberculosis. However, because the destruction of the vertebral body is more severe and the abscess is already larger when most patients are found, the choice of surgery will be more likely. Also, due to the characteristics of spinal tuberculosis itself, chemotherapeutic drugs may have difficulty in reaching effective concentrations locally in the lesion, or some patients may have drug resistance problems, leading to poor results of conservative treatment and the choice of surgery. 2.What cases of tuberculosis of the spine require surgical treatment? Is surgery necessary to treat spinal tuberculosis only after the tuberculosis has been cured? A: The general indications for surgery for spinal tuberculosis are: (1) severe bone destruction, more dead bone, and larger abscesses (2) combined neurological dysfunction such as paraplegia (3) abscess penetration into adjacent organs (4) poor spinal stability due to tuberculosis It is important to note that surgery is not necessary to treat spinal tuberculosis only after the tuberculosis is treated. In the case of spinal tuberculosis, it must be clear before surgery what problem the patient is trying to solve with this surgery. Is it a lesion that is difficult to absorb with drugs? Or is it to restore the stability of the spine? Spinal tuberculosis lesion removal is the classic procedure for treating spinal tuberculosis and the most basic procedure for treating spinal tuberculosis. The purpose of this procedure is to: remove lesions that are difficult to absorb with drugs, promote their rapid healing, and reduce their damage and compression of surrounding tissues. Therefore, when drug treatment is not effective, surgery can be considered. 3.Is surgery still necessary for paraplegia in spinal tuberculosis? A: Paraplegia in spinal tuberculosis is an absolute indication for surgery, and surgery is certainly necessary. Most patients with spinal tuberculosis combined with paraplegia can recover after surgery, and some patients can even recover on the same day of surgery. In some cases, it is difficult to recover from paraplegia because of the degenerative necrosis of the spinal cord caused by the long compression of spinal tuberculosis lesions. Pre-operative MRI examination can initially assess the degree of spinal cord compression. However, it can only be used as a reference. After all, the recovery of nerve function can sometimes have unexpected effects, so as long as there is an opportunity for surgery, try to implement lesion removal and spinal canal decompression. 4.Why do I need anti-tuberculosis treatment before surgery? How long does it take to treat? A: Tuberculosis is a systemic disease, and spinal tuberculosis is a local manifestation of tuberculosis, therefore, wherever tuberculosis is present, systemic treatment such as chemotherapy is required. For this reason, preoperative anti-tuberculosis treatment is not only for spinal tuberculosis, but also to control the systemic tuberculosis activity in the body. For another reason, it is best to have limited and stable TB lesions elsewhere before preparing for spinal TB surgery so that postoperative spread of TB, which has the risk of causing death, may not occur. The duration of preoperative antituberculosis is usually 4-6 weeks, but the stability of the spinal tuberculosis itself and other sites of tuberculosis needs to be evaluated as well. 5. Why do I need to take anti-tuberculosis drugs after surgery? How long do I need to take them? A: Although spinal tuberculosis lesion removal is a basic and classic surgical procedure, it has its limitations in that the tuberculosis lesion is not easily removed completely. Some cases of spinal tuberculosis are still in the progressive stage at the time of surgery. Therefore, anti-tuberculosis drugs are still required after surgery. Only TB drugs can kill Mycobacterium tuberculosis and stop it from doing further damage, and the scalpel cannot kill Mycobacterium tuberculosis. Therefore, it can be said that surgery is “detoxification” and anti-tuberculosis drugs are “detoxification”. The duration of postoperative anti-tuberculosis medication depends on the results of postoperative drug sensitivity testing and strain identification. In the case of spinal tuberculosis caused by a sensitive bacterium, the effective duration of postoperative anti-tuberculosis is not less than one year; in the case of spinal tuberculosis caused by a drug-resistant bacterium, the duration of postoperative anti-tuberculosis is not less than two years; in the case of spinal lesions caused by a non-tuberculous mycobacterium, the duration is not less than one year and the duration of anti-tuberculosis treatment is extended at any time according to the test results. In case of multiple sites of tuberculosis combined with other sites of tuberculosis, the duration is longer and requires comprehensive assessment to avoid premature discontinuation of medication and relapse. 6.What are the effects of unauthorized drug reduction or discontinuation after surgery? A: Postoperative anti-tuberculosis treatment for spinal tuberculosis should not be discontinued without authorization. The development of chemotherapy regimens for spinal tuberculosis is complex and includes a variety of factors such as empirical treatment, standard treatment and individualized treatment, so they are generally developed by experienced tuberculosis physicians based on many factors such as preoperative disease and intraoperative conditions. If you really need to adjust the plan, you need to tell the doctor who gave you the plan that you can change or switch the drugs. 7.What are the ways of surgical treatment of spinal tuberculosis? A: There are many ways to operate on tuberculosis of the spine, and there are different surgical methods for different segments. According to the surgical access, it can be divided into anterior surgery and posterior surgery, lesion removal is generally done by anterior surgery, and internal fixation surgery is generally done by posterior surgery, while some people remove the lesion from the posterior route and some people fix it from the anterior route; in terms of the number of surgeries, it can be divided into one-stage surgery and two-stage surgery. In addition, anterior surgery, such as thoracic spinal tuberculosis, some use transthoracic surgery, some use transverse rib resection approach; lumbar spinal tuberculosis, some use extraperitoneal approach, some use transabdominal approach. All of these methods depend on the patient’s condition. 8.Does all spinal tuberculosis surgery require bone grafting? Do they use their own bone or artificial bone? A: Bone grafting during spinal tuberculosis surgery is controversial. Not all spinal tuberculosis requires bone grafting. The purpose of bone grafting is to repair defects, restore the height of the spine, and promote bony fusion of the diseased vertebrae. Bone grafting is not required for small bone defects caused by bone destruction; for large bone defects, bone grafting is recommended. However, to this day, it is still controversial whether to implant bone because bone resorption after implantation is difficult to resolve. Sometimes it also becomes dead bone because the lesion is not completely removed. Regarding the question of whether to use autologous bone or artificial bone, if the bone graft is to support the spine and maintain its stability, it is recommended to use autologous bone. From the perspective of repairing bone defects and drug delivery, artificial bone is recommended. 9.When is internal fixation required for spinal tuberculosis? What is the use of internal fixation? A: There is still a debate on the circumstances under which internal fixation is required for spinal tuberculosis. Generally speaking, internal fixation is considered when there are clear indications for lesion removal, neurological impairment, signs of spinal cord and cauda equina compression, and severe kyphotic deformity of the lesioned segment. During internal fixation surgery, plates and pedicle nails should be implanted away from the diseased vertebrae. At the same time, I have always believed that spinal tuberculosis is still an infectious lesion and it is not easy to implant foreign bodies such as titanium mesh in the lesion unless the lesion is stable and cleared. The surgical treatment of spinal tuberculosis should be based on the rational use of internal fixation, both anterior and posterior, and the choice of fixed segments should be decided on a case-by-case basis, and should be based on complete lesion removal, with both lesion removal and preservation of spinal motion segments, along with reasonable postoperative antituberculosis chemotherapy, in order to achieve a satisfactory treatment outcome. The purpose of internal fixation is to stabilize the spine and not to further aggravate the unstable spine leading to the aggravation of spinal cord injury and deformity. 10.Does the internal fixation need to be removed? What is the effect of taking out or not taking out? A: There is controversy. Some hospitals do not take out 99% of them, and some hospitals take out routinely. Take out or not take out the impact is not big. If you really want to take out the internal fixation, 1-2 years after surgery is more appropriate. If you take it after 3-5 years, it is often difficult to take it out. The internal fixation is usually titanium alloy, which can stay in the body for life and has no effect. The possible effect is that the metal detector will sometimes alarm when passing through the security check in the future. You can just show the wound to the security officer. For air travel, a medical certificate is required abroad. Generally, the internal fixation plays a role of temporary fixation of the spine, and after 3-6 months, the implant heals, the internal fixation basically has no effect. It can be removed or not. However, in the case of spinal tuberculosis, the fusion may take longer. If you remove it, you need to cut the wound again; if you do not remove it, occasionally the internal fixation will break after many years, but it is usually not a problem.