Spinal tuberculosis is a common disease, accounting for about 50% of bone and joint tuberculosis . Despite the continuous efforts of the World Health Organization and local health authorities, tuberculosis is still widespread in some developing countries and affects all susceptible people, including the elderly .
Anti-tuberculosis treatment, bed rest and supportive treatment are the basis for the treatment of spinal tuberculosis, and are also the main treatment options. If there is no drug treatment, the risk of surgery will increase significantly, and the mortality, risk of infection transmission and recurrence rate will also increase . However, due to the poor health of elderly patients, they often have a variety of chronic diseases and cannot withstand surgical treatment. In most cases, anti-tuberculosis chemotherapy is conservatively treated to avoid surgical risks and related complications. This may lead to aggravation of spinal deformity and nerve damage . At the same time, prolonged bed rest not only affects the quality of life, but also causes serious complications. In addition, the tuberculosis lesion is surrounded by bone, which may result in the ineffective penetration of anti-tuberculosis drugs and poor treatment effects. Therefore, for elderly patients, surgical treatment plays an important role in removing necrotic tissue, removing paravertebral abscess, alleviating nerve compression, and improving spinal deformity.
However, there are many controversies in the surgical treatment of STSTND in the elderly. Anterior surgery has the advantages of directly removing tuberculosis lesions and facilitating bone grafting, but it is not effective in correcting kyphosis and relieving nerve compression . In addition, the sternum, clavicle, ribs, and mediastinal organs interfere with the surgical operation, which makes anterior surgery more difficult. Combined anterior and posterior surgery has a good clinical effect. However, the large amount of operation, long operation time, heavy bleeding, longer postoperative recovery time and more complications often make it difficult to perform in elderly patients .
In the past few decades, posterior surgery has made significant progress in the treatment of spinal tuberculosis. The posterior pedicle screw system is popular as a revolutionary technology for correcting spinal deformities and increasing spinal stability. It has been shown to be effective in treating thoracic spine diseases that cause segmental instability and neurological dysfunction .
Posterior transforaminal lumbar interbody fusion (TLIF) was originally promoted by Harms et al. . As an improvement of posterior lumbar interbody fusion (PLIF), it overcomes the problem of nerve retraction. However, the traditional TLIF surgical approach requires extensive stripping of the multifidus muscle, which damages the blood supply and innervation of the multifidus muscle, resulting in postoperative degeneration of the multifidus muscle, which manifests as muscle atrophy, fibrosis and fat deposition; at the same time, it takes a long time during the operation. Extensive retraction of the paraspinal muscles, the innermost multifidus muscle, has the largest increase in intramuscular pressure, leading to local blood supply interruption, irreversible ischemic degeneration and necrosis, which seriously affects the physiological function of the multifidus muscle and increases the chronic low back pain after surgery. Incidence rate . In 1968, Dr. Wiltse and others proposed a new method, which is to perform surgery through the gap between the multifidus and the longissimus muscle. This approach can significantly reduce the damage to the multifidus muscle caused by dissection and traction during the operation, and maximize the integrity of the posterior bone structure and ligament complex .
In the practice of exploring the application of intermuscular approach, this approach is applied to T LIF surgery for the treatment of spinal tuberculosis in elderly patients with osteoporosis. We believe that the Wiltse approach TLIF surgery has the following advantages. First of all, the Wiltse approach is simple in anatomy. It enters from the natural space between the multifidus and the longissimus muscle without dissection and extensive retraction of the paraspinal muscles, which avoids the denervation of the multifidus muscle and reduces the localization of the multifidus muscle. Ischemic degeneration and necrosis caused by interruption of blood supply. Therefore, the intermuscular approach can retain more of the physiological function of the multifidus muscle, maintain the stability of the spine, reduce the occurrence of chronic low back pain, and help the elderly to recover after surgery. Early functional exercises can avoid complications caused by long-term bed rest. Secondly, elderly patients are often in poor physical conditions and more serious illnesses. The Wiltse approach TLIF can reduce the length of surgery and the length of anesthesia, reduce surgical bleeding, and reduce the risk of surgery. Third, the posterior internal fixation helps prevent the kyphosis from getting worse, correct the kyphosis, and relieve the pain caused by spinal instability. Finally, the posterior internal fixation of the spine keeps the instrument away from the tuberculosis focus, which is conducive to tuberculosis healing. However, the TTIF of the Wiltse approach has two limitations. First, decompression can increase the risk of spinal cord injury. Secondly, anterolateral debridement is difficult to complete, but with the development of anti-tuberculosis drugs, tuberculosis lesions can spontaneously merge and heal, and the thorough debridement of the lesions is not overemphasized .