Our research project was approved by the Ethics Committee of Handan Central Hospital. All patients signed informed consent forms. All methods were performed in accordance with the relevant guidelines and regulations.
The clinical data of patients with lumbar tuberculosis treated by unilateral pedicle screw combined with CBT screw fixation + contralateral Wiltse approach for lumbar tuberculosis debridement from October 2014 to January 2021 were retrospectively analysed.
Inclusion criteria: X-ray, CT, MRI, and other imaging examinations of patients showed vertebral and intervertebral space destruction, sequestrum formation, intervertebral and paravertebral cold abscess formation, spinal instability/deformity, etc., which were consistent with the characteristics of spinal tuberculosis; the presence of a caseous substance was consistent with the diagnosis of spinal histopathology tuberculosis; the patient had symptoms such as night sweats, low fever in the afternoon, and fatigue; and the patient had intractable low back pain, progressive neurological impairment, and other symptoms.
Exclusion criteria: huge abscess anterior to the lumbosacral spine; lumbar infusion abscess.
Preoperative preparation
All patients were absolutely bedridden; high-energy and high-protein diets were given to improve nutritional status; anaemia and hypoproteinemia were corrected before surgery. All patients received standard combinations of 4 drugs for 2–4 weeks (H, isoniazid: 300 mg/day, R, rifampicin: 450 mg/day, E, ethambutol: 750 mg/day, Z, pyrazinamide: 750 mg/day).
Surgical strategy
The patient underwent general anaesthesia and tracheal intubation in the prone position. The target segment was positioned, a midline incision was made in the posterior lumbar spine, the paraspinal muscle was stripped on the opposite side of the lesion; the spinous process, lamina, and facet joints were exposed, and the pedicle was implanted according to the preoperative plan. CBT screws, pre-bent titanium rods, and fixation sutures were used. A wound incision was made on the opposite side, the original muscle space was separated to reach the intervertebral space, the channel was expanded step by step, a quadrant dilator was placed, the facet joint was exposed, and electrocautery was used to stop bleeding and peel the surface soft tissue. Osteotomy removed part of the inferior and superior articular processes and limited cleavage of the lamina was used to expose the spinal canal. Exposure and protection occurred under direct vision, and the dural sac and nerve root were retracted before exposure of the intervertebral space, suction to remove pus, curette of diseased vertebral body and intervertebral space abscess, sequestrum and caseous necrosis with different angle spatulas until the surface of the healthy bone reached a slight oozing. After the lesions were completely removed, the dural sac was carefully checked to ensure that there was no damage, and a large amount of iodophor hydrogen peroxide and normal saline were injected through a syringe to flush the intervertebral space. After washing, 1.0 g of streptomycin was sprinkled into the wound, and the pre-bent titanium rod was fixed and locked; the indwelling negative pressure drainage tube was placed in the deep paraspinal muscle, and the incision was closed.
Postoperative management
The motor and sensory functions of the legs of the patients were closely observed, and the patients were encouraged to perform straight leg raising exercises. When the drainage volume was less than 50 ml in 24 hours, the drainage was removed. Standard H/R/E/Z combinations were administered for at least 6 months and a lumbar brace was worn for at least 12-16 weeks after surgery. It was recommended that the patients perform their daily activities without weight bearing. Routine blood examination, liver and kidney function, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were reviewed monthly according to the situation during the application of anti-tuberculosis drugs. X-rays were reviewed at 1, 3, 6, 9, and 12 months after the operation and every year after, and CT was reviewed every 3 months. Trabecular bone connection between vertebrae was determined as bone fusion.
Data acquisition and factors of interest
Preoperative and last follow-up CRP and ESR were recorded and evaluated; preoperative, 3 months after operation, and last follow-up Oswestry disability index (ODI), American Spinal Injury Association (ASIA) classification, low back pain visual analogue scale (VAS); all patients were followed up for at least one year, and the time of bony fusion was recorded.
Statistical Analysis
Statistical analysis was performed using SPSS 18.0 software (IBM, USA). Continuous variables conforming to a normal distribution were used to indicate ESR and CRP before surgery and last follow-up were compared by paired t test; ODI and VAS before surgery, 3 months after surgery, and last follow-up were analysed by one-way analysis of variance. The LSD test was used for comparisons between two groups; P<0.05 was considered statistically significant.