Debridement, decompression and interbody fusion by using biportal spine endoscopy on patients diagnosed with lumbar spine tuberculosis: 1 year follow-up

doi:10.21203/rs.3.rs-2222018/v1

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Debridement, decompression and interbody fusion by using biportal spine endoscopy on patients diagnosed with lumbar spine tuberculosis: 1 year follow-up

https://doi.org/10.21203/rs.3.rs-2222018/v1

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Objectives

The study is aimed to evaluate clinical outcomes of debridement, decompression and interbody fusion by using biportal spine endoscopy to treat patients diagnosed with lumbar spine tuberculosis (LST).

Methods

Forty patients diagnosed with LST who underwent debridement, decompression and interbody fusion by using biportal spine endoscopy between January 2020 to March 2021 were studied. The operation time, blood loss, complication rate, fusion rate, Visual Analog Scale (VAS), Oswetry disability index (ODI), Japanese Orthopedic Association (JOA), Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP) and kyphotic Cobb’s angle were measured to explore the effects on LST patients.

Results

The patients were followed up for 12–16 months, with a mean of 14.6 months. The mean operation time was 223.4 ± 94.4 min (range, 140–410 min), together with 235.0 ± 190.5 cc of blood loss (range, 120–700 cc). From preoperation till last phase of follow-up, the mean preoperative VAS (5.86 ± 0.86) and ODI (74.29 ± 6.26) decreased significantly to 1.57 ± 0.65 and 8.29 ± 3.05, respectively. Additionally, the mean JOA increased from preoperative (10.29 ± 2.58) to (24.93 ± 1.86). Meanwhile, the mean preoperative ESR and CRP (74.36 ± 8.18 and 71.28 ± 8.58, respectively) decreased to average values. The preoperative kyphotic Cobb’s angle (21.40 ± 2.22 ) decreased to (9.86 ± 0.76 ) postoperatively. However, the kyphotic correction remained unchanged at the last phase of follow up. Furthermore, the fusion rate was identified to be 90%. Besides, the complication rate was 7.3% ( three cases of cerebrospinal fluid leakage).

Conclusion

Debridement, decompression and interbody fusion by using biportal spine endoscopy might be an ideal options to treat LST patients. More long term and multi-samples studies are needed to further verify the perspective.

As well known, tuberculosis is one of the antiquated infectious diseases. Traces of tuberculosis have been discovered in Egyptian mummies as early as 3500 BC [1]. Nearly 11 million people got infected with tuberculosis each year in the world, including about 150,000 cases of spinal tuberculosis [2]. Although most patients with spinal tuberculosis would eventually acquire a satisfactory effect after treatment with anti-tuberculosis drugs [3], surgical intervention is still necessarily needed for patients with neurological injury, large abscess formation, spinal instability, and kyphosis [4]. From the previous literature, combined anti-tuberculosis with surgical treatment has been verified to be valid due to better debridement, neural decompression and reconstruction of the anterior vertebral column [5]. However, the current method of surgical options for spinal tuberculosis were mainly for open surgery which has long been controversial for larger damage to soft tissues, more loss of blood, more postoperative complications rate, and an increased length of hospitalization. Moreover, it might make difference to patients’ immunity function. Thus, some patients might not be suitable for traditional open surgery [6–7].

Percutaneous spine endoscopy, an unique technique shedding light on minimal invasion, is currently applied to treat various of degenerative spinal diseases [8–9]. As the rapid progression of the technique, few literature in recent years have already come up with the concept that it could be utilized to deal with spinal tuberculosis [10–11]. Hitherto, several surgeons have already made some achievements to use percutaneous endoscopic technique to perform simply debridement and decompression to treat spine tuberculosis [12–14]. But even the researcher themselves ever realized that the purely debridement and decompression could not address essential problems as mentioned above. Subsequently, lumbar interbody fusion by using endoscopic should be taken into consideration. However, relevant evaluation for the clinical outcome has not been reported yet. This study is aimed to appraise the clinical efficacy and feasibility of debridement and interbody fusion by using biportal spine endoscopy for patients diagnosed with lumbar spine tuberculosis (LST).

Forty LST patients arranged from 38–61 years old and consisting of ten males and four females who underwent debridement, decompression and interbody fusion by using biportal spine endoscopy between January 2020 to March 2021 were collected into this study. The study was approved by the ethics committee of the affiliated Hospital of Chengdu University of Traditional Chinese Medicine (approval no.NT-6711). Informed consent was taken from all patients for their participation in the study. All research methods were performed in accordance with the relevant guidelines and regulations.

The patients were primarily diagnosed through presentations, laboratory indexes, and imaging manifestations, and was finally confirmed by mycobacterium TB (MTB) culture or histopathological performance of caseous necrosis and typical granuloma. The average age of the subjects was 51.07 ± 6.40 years ( range from 38–62 years) with a mean duration of disease before definite diagnosis to be 15.07 ± 1.73 months, which ranged from 13 to 19 months (Table. 1). Among the series, there were 9 cases with two affected vertebras, 4 cases with three affected vertebras and two cases with four or more affected vertebras. All the patients presented with low back pain in different extent, while only three of them combined with radiating pain of the unilateral lower extremity and two of them showed the neurological deficit at the same time (Table. 1).

As for the clinical evaluation index, the means of the preoperative Visual Analog Scale (VAS), preoperative Oswestry disability index (ODI) and preoperative Japanese Orthopedic Association (JOA) scores were 10.29 ± 2.58 (range, 8–16), 74.29 ± 6.26 (range, 65–82) and 10.29 ± 2.58 (range, 8–16), respectively (Table 2). The mean preoperative Erythrocyte Sedimentation Rate (ESR) and the mean Creactive protein (CRP) value were 73.36 ± 8.18 mm/h (range, 62–83 mm/h) and 71.28 ± 8.58 (59.14–81.35 mg/L), respectively. The mean preoperative kyphotic Cobb’s angle was 21.40 ± 2.22° (range, 18.8°-25.5°) (Table 2).

Preoperative Management

The chemotherapeutic protocol was employed as routine followed by injecting isoniazid (intravenous drip, 300 mg per day), rifampin (oral, 450 mg per day), pyrazinamide (oral, 750 mg per day), ethambutol (oral, 750 mg per day), and levofloxacin (intravenous drip, 0.4 g, per day). The chemotherapy lasted for 2 weeks until obvious declines in ESR and CRP values were both observed. Anemia and hypoproteinemia were recorded if existing and it would be corrected before the operation with nutritional support provided spontaneously, along with limited movement out of bed.

Surgical Procedure

After induction of general anesthesia, the patient was positioned in the prone position. The surface markings of the pedicles, the puncture point, the vertebra body and the intervertebral space were made, and the surgical area was routinely disinfected and draped. First, four K-wires were inserted under intraoperative X-ray guidance. Second, the endoscopic puncture needle was inserted into the point marked earlier. The needle had reached the interlaminar space as confirmed by C-arm. The intersection point of the laminar space and the puncture needle line on the operative side was used as a midpoint, and two 1 cm incisions at the cephalic and caudal sides were made about 1 cm from the midpoint. Then, the detacher was used to detach the soft tissue attaching to the edge of the laminar. The working channel with the lens was then inserted along the tube, and connected to the light source, the imaging system and the water conduit. Third, soft tissue was cleared by using an endoscopic grasper and unipolar electrode to expose the bony margin of the lamina and interlaminar space. The intersection of the medial fringe of the superior articular process and the lamina superior border, an important anatomical marker called the point L, could be visualized through the endoscope. Next, the osteotome was used to remove a part of the lamina and facet joint. The Kerrison rongeur was also used to improve the precision of the laminectomy as well as clean up the necrotic discs, dead bones, and caseous granulomatous. The ligamentum flavum was removed step-by-step to reveal the thecal sac and nerve root. After pulling the nerve using a nerve retractor, the nucleus pulposus was revealed, and was resected using a grasper. After the disc was removed, the intervertebral space was cleared with sclerotic bone removed for radical debridement and the establishment of a suitable bone graft zone. After the coagulation was finalized by uniportal electrode ablation, the autogenous ticortical iliac bone graft with a length of 2 to 2.5cm was performed under endoscopic guidance. Fourth, we confirmed once more that the nerve root and dural sac were unwound without any remaining fragment bone or tissue compression. After exiting endoscopy, four pedicle screws and two connecting rods were implanted percutaneously. Finally, the surgical site was rinsed thoroughly with a large volume of saline, and the surgical incision was sutured after ensuring hemostasis with a catheter remained for drainage. Ropivacaine and tranexamic acid injection were injected into the wound before covering it with a sterile dressing (Fig. 1). The entire surgical procedure was in line with the essential steps for biportal endoscopic technique we most frequently applied [15].

Postoperative Management

Prophylactic antibiotic therapy was given to patients for 24 h, and the drainage tube was removed once the volume of drainage was less than 30 ml in 24 h postoperatively. After that, the patients were suggested to ambulate slightly under the protection of brace. The brace couldn’t be taken down until the fusion was done which could be observed during follow ups. Regular anti-TB medication treatment would last for entire 18 months according to the standard fabricated by previous study [16–17]. ESR and CRP together with liver function were all monitored throughout the follow ups.

Evaluation Indexes

The evaluation indexes included the operation time, blood loss, three times follow up for VAS, ODI, JOA, ESR, CRP and kyphotic Cobb’s angle (KA). Additionally, the interbody fusion would be recorded once it finalized confirmed by the presence of trabecular bone bridging between the bone graft and adjacent vertebras on CT scan during follow ups.

Statistics

SPSS 22.0 statistical software was employed for the data analysis. The data of evaluative indexes was expressed as mean ± SD. A paired samples test was used for comparison of indexes before and after the operation. P value of less than 0.05 was considered to be significantly significant.

Forty patients included were followed up for a period ranging from 12–16 months (average 14.6 months). The mean operation time was 223.4 ± 94.4 min (range, 140-410min) and mean blood loss was 235.00 ± 190.53 min (Table. 3). The fusion condition was evaluated by two residents independently and confirmed by an experienced attending surgeon. After all, the eventual fusion rate was identified to be 90% (Table. 3). Besides, the complication rate was 7.5% and three cases of cerebrospinal fluid leakage occurred but the patients got more taut suture after then with well managed before discharge (Table. 3). As for clinical outcome, the mean postoperative VAS was 3.14 ± 0.86 (range, 2–4) which was significantly lower than preoperative one (p<0.05), and continually declined significantly to 1.57 ± 0.65 (range, 1–3) (p<0.05) at the final follow up time point (Table. 4). The mean postoperative ODI was 27.1 ± 5.6 (range,21–35) which was significantly lower than preoperative one (p<0.05), and sequentially decreased significantly to 8.3 ± 3.0 (range,4–12) (p<0.05) at the final follow up time point (Table. 4). The mean postoperative JOA was 18.6 ± 5.6 (range, 16–21) which was significantly improved compared to preoperative one (p<0.05), and continually declined significantly to 24.9 ± 1.9 (range,21–27) (p<0.05) at the final follow up time point (Table. 4). As for blood test index, the mean postoperative ESR was 33.4 ± 7.1 (range, 24–43) which was significantly lower than preoperative one (p<0.05), and sequentially decreased significantly to 13.5 ± 1.8 (range,11–16) (p<0.05) at the final follow up time point (Table. 5). The mean postoperative CRP was 22.5 ± 3.3 (range, 18.10-27.55) which was significantly lower than preoperative one (p<0.05), and sequentially declined significantly to 2.3 ± 0.5 (range, 1.56–3.32) (p<0.05) at the final follow up time point (Table. 5). As for KA, the mean postoperative KA was 9.7 ± 0.9 (range, 18.8–25.5), which was significantly lower than preoperative one (p<0.05), and had insignificantly change to 9.9 ± 0.8 (range, 9.1–11.8) (p>0.05) till the last follow up time point (Table. 5) (Fig. 2–3).

Spine tuberculosis has long been regarded as one of the most obstinate diseases in spine surgery, which occurs in lower thoracic and lumbar spine resulting in sever pain, neural dysfunction, vertebral collapse and even causing kyphotic deformity as time passes [14]. The current controversy for LST in the recent decade is about posterior or anterior approach [18–20]. Jincheng Qiu, et al. retrospectively analyzed 52 patients with thoracic and lumbar tuberculosis by using VAS score, ASIA grade and Cobb angle of local kyphosis to evaluate the outcomes. They eventually found out anterior approach surgery might have greater advantages in kyphosis correction, bone fusion, wound healing, protection of the normal spine, and medical consumables and cost [18]. Chen Zhao, et al. collected 35 cases diagnosed with thoracic and lumbar tuberculosis, underwent posterior-only approach or anterior-only approach. The evaluation index was average Cobb angle of kyphosis. Their conclusion eventually showed preference for posterior-only approach [19]. Bolong Zheng, et al. also conducted a comparative research for anterior-only approach and posterior-only approach and the result was similar Chen Zhao, et al.’s literature. Moreover, they even pointed out that the posterior approach is superior to the anterior approach with respect to the surgery time, intraoperative hemorrhage [20]. But no matter it is posterior approach or anterior approach, they are both open surgery.

Given the shortages of large trauma and high rate of perioperative complication from open surgery, minimally invasive spine surgery, which has already been pretty mature being applied to treat degenerative spine diseases, provides spine surgeon a novel option to cope with this sort of infection disease. Wei Xiong, et al. did a prospective, non-randomized study on expandable tubular retractor by analyzing 23 patients with thoracic or lumbar spine tuberculosis who underwent this new technique. The study came out with satisfying result and they drew the conclusion that the expandable tubular retractor could be recommended to treat thoracic and lumbar spine tuberculosis [21]. Zhifa Zhang, et al. reviewed 106 consecutive patients who underwent MIS for spine tuberculosis with psoas abscess from January 2002 to Oct 2012. The mean follow-up period was 7.21 ± 3.15 years. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination [22].

Most previous literature describing the minimally invasive method treating spine tuberculosis are about microscope and tubular retractor. Otherwise, in recent years, more and more surgeons start to focus on endoscopic technique [14–16]. Zheng, Liu et al. retrospectively analyzed 17 patients with upper cervical spine tuberculosis underwent endoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion for 12–18 months postoperatively. The evaluation indexes included the operation time, intraoperative blood loss, follow-up duration, VAS, Kirkaldy-Willis criteria and fusion rate. The outcomes were all positive so that the author came up with the conclusion that endoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion is a feasible and effective surgical method for the treatment of upper cervical spine tuberculosis [14]. Dongying, Wu et al. reviewed 40 patients with lumbar spine tuberculosis who underwent uniportal or biportal percutaneous endoscopic debridement and lavage for 18 months after treatment. The study showed two procedures yielded comparable and satisfactory results. Unilateral endoscopy showed shorter operative time and decreased intraoperative fluoroscopy times compared with bilateral one. So they recommended unilateral endoscopy rather than bilateral one [15]. Seung-Kook Kim, et al. shed light on the biportal endoscopic technique and asserted that minimally invasive endoscopic and percutaneous screw technique can aid the diagnosis and treatment of spinal tuberculosis [16].

The result from our study is in line with the previous literature. Moreover, we clarified the surgical step of the biportal endoscopic lumbar interbody fusion treating lumbar tuberculosis and evaluated its outcome by conducting a retrospective research. In our study, the mean operation time and blood loss were both acceptable compared to former literature [14–16]. As for clinical presentation, all patients acquired satisfied relief for tuberculosis toxic symptoms, low back pain and lower limb radiating pain. Most patients rehabilitated more or less from neurological deficit with only one patient remaining the same till the final follow up. After we carefully checked the postoperative radiographic data and took into consideration that beside neurological deficit, the other presentations of this patient improved as anticipated before operation. We would like to further track the patient’s status. As for the evaluation indexes, in both postoperatively and final follow up, VAS, ODI, JOA, KA, fusion rate and blood test (ESR and CRP) were all gratifying. Only one case occurred cerebrospinal fluid leakage postoperatively and a more taut suture has been done once it was discovered. And the patient got well managed throughout the whole follow up process. It could demonstrated that not only purely debridement and decompression could be done by biportal endoscopy but also the surgical procedure of fusion could be finalized effectively, which together with postoperative regular and regular anti-TB medication treatment are considered as the two essential steps to treat spine tuberculosis [23–25].

Limitations

The study has some inherent limitations needed to be addressed in the further research. First and foremost, the amount of the samples included was small and the follow up period was short. Additionally, unlike randomized controlled trial, the retrospective study was not employed in randomized, controlled and blinded manner with comparative cohort, which could easily lead to selectional bias and lack of suitable methods for immunity assessment. These condition shall get improved in the future study.

Funding

Funder: Chengdu Science and Technology Bureau

No.2022-YF05-02035-SN

Consent for publication

Consent for publication was acquired from the patients included in this study.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Data and materials of this study are accessible anytime during review.

Authors' contributions

Yang Yu, Yizhou Xie and Qun Zhou contributed equally to this work and should be considered to be the First Authors. Yizhou Xie and XH Fan are jointly responsible for the project and should be considered to be the Corresponding Authors. Yizhou Xie and XH Fan organized and monitored the case report. Yang Yu and Qun Zhou collected the literature and wrote the article. Chengzhi Feng and Yongtao Wang performed recorded and audited the article.

Acknowledgements

Not applicable.

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Table.1 Basic Data of Fourteen Cases

Parameters	Mean±SD or No%
Age (years)	51.07±6.40
BMI (kg/m²)	20.86±3.82
Sex (male/total)	71.4% (10:14)
Duration of disease before definite diagnosis(months)	15.07±1.73
Anemia	71.4% (10:14)
Hypoproteinemia	57.1% (8:14)
Concurrent extra-pulmonary TB	35.7% (5:14)
TB toxic symptoms	57.1% (8:14)
Back pain	100% (14:14)
Lower limb radiating pain	21.4% (3:14)
Neurological deficit	14.3% (2:14)
Proportion of number of affected vertebras (2 Vertebras: 3 Vertebras: 4 and more Vertebras)	57.1%: 28.6%: 14.3% (8: 4: 2)
Proportion of Abscess (None: Small amount: Large amount)	35.7%: 35.7%: 28.6% (5: 5: 4)

Table.2 Preoperative clinical evaluation index

Clinical evaluation index	Mean±SD
VAS	5.86±0.86
ODI	74.29±6.26
JOA	10.29±2.58
ESR (mm/1h)	73.36±8.18
CRP (mg/L)	71.28±8.58
KA (°)	21.40±2.22

Table. 3 Surgical related index

Parameters	Mean±SD or No%
Operation time	223.4±94.4
Blood loss (cc)	235.0±190.5
Fusion rate	90%
Complication rate	7.5%

Table. 4 Clinical evaluation index analysis for VAS, ODI and JOA

Schedule	VAS	ODI	JOA
Pro	5.86±0.86	74.29±6.26	10.29±2.58
Po	3.14±0.86^#	27.07±5.64^#	18.64±1.45^#
FFU	1.57±0.65^#*	8.29±3.05^#*	24.93±1.86^#*

^# p＜0.05, compared to Pro.

^* p＜0.05, compared to Po.

Table. 5 Blood test index for ESR, CRP and KA

Schedule	ESR	CRP	KA
Pro	73.36±8.18	71.28±8.58	21.40±2.21
Po	33.43±7.08^#	22.47±3.28^#	9.72±0.88^#
FFU	13.50±0.54^#*	2.29±0.54^#*	9.86±0.76^#

^# p＜0.05, compared to Pro.

^* p＜0.05, compared to Po.

No competing interests reported.

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Debridement, decompression and interbody fusion by using biportal spine endoscopy on patients diagnosed with lumbar spine tuberculosis: 1 year follow-up

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Abstract

Objectives

Methods

Results

Conclusion

Figures

Background

Methods

Preoperative Management

Surgical Procedure

Postoperative Management

Evaluation Indexes

Statistics

Results

Discussion

Limitations

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

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