Our data demonstrates that spinal TB can be effectively treated using debridement and XLIF during a single operation. The technique made it possible to retain the spine’s stability, while minimizing the length of the operation and blood loss, with few complications. As detailed above, patients had improvements in both their VAS scores and postoperative neurologic recovery.
Compared with laparoscopic or thoracoscopy-assisted approaches for the treatment of mono-segmental spinal TB, the XLIF approach has several advantages. First, XLIF eliminates the need for a general surgical assistant and the steep learning curve associated with laparoscopic or thoracoscopic approaches [8, 11]. Second, the mean length of the operation and blood loss in our patients were significantly minimized compare with previous series of video-assisted thoracoscopic surgery for spinal TB described by Lv et al. and Kapoor et al. [11, 12]. Third, a long period of lung deflation can be avoided, which makes XLIF ideal for use in elderly patients or those with respiratory compromise [13, 14]. Finally, the technique allows direct visualization, which is particularly helpful for removing the infected tissue .
Perhaps most importantly, the stability of the spine was retained. Although there was a decrease in the Cobb angle, the average correction rate of the kyphotic angle was 58.0%. Biomechanical studies [16, 17] indicated that transpedicular fixation conferred better stabilization than lateral fixation, but both methods can provide adequate stability. The major disadvantage of transpedicular fixation combined with XLIF is that it prolongs the operation. Timothy et al.  reported that posterior instrumentation was not necessary, especially in the setting of infection, because of the high bone fusion rate associated with using XLIF. In addition, mono-segmental fixation can retain the spinal motion units and slow the degeneration of adjacent vertebral bodies. The average bone fusion time was 5.6 ± 0.8 months, which was similar to other studies [5–7, 13, 14]. Moreover, the quality of life improved significantly in accordance with the better VAS score and neurological improvement.
Notably, surgeons should be aware of the possible neurological complications associated with XLIF. In the present study, two patients experienced sensory disturbance over the left thigh and iliopsoas muscle weakness after surgery. The patients recovered following three months of physical therapy and oral methylcobalamin. A nationwide survey conducted between March 2013 and April 2015 in Japan reported that the most common complications associated with XLIF were sensory nerve injury (5.1%) and psoas weakness (4.3%) . Tohmeh et al.  proposed the use of dynamically-evoked electromyography (EMG) to detect and prevent neural injury during XLIF. We suggest that surgeons should have accurate knowledge of the spinal nerve rather than relying on EMG to avoid potential neurological complications [20, 21].
Based on our clinical experience, we recommend using a combination of debridement and XLIF for the treatment of mono-segmental spinal TB without a large abscess or severe bone defects. The operating area and the guide needle puncture should be in front of the psoas muscle and vertebra, respectively. Standardized anti-TB treatment and regular follow up are very important. Patients should be made aware of potential complications, including delayed pneumothorax or hemothorax, vascular injury, and non-pulmonary complications, so that they can be carefully monitored postoperatively [13, 14].
This study has several potential limitations. First, the results are from a relatively small sample size and there was no control group. Second, the follow-up was relatively short. Third, the indications for the procedure were based on our experience. Additional multicenter prospective studies with a longer follow-up are necessary to better characterize the efficacy and safety of XLIF for the treatment of spinal TB.