General information
Between January 2005 and January 2015, 302 cases with thoracolumbar junction (T12-L1) TB from six hospitals across China were hospitalized; 125 were excluded because of chemotherapy lonely, poor compliance or tolerance, complicated with active lung TB or spinal tumours, HIV co-infection and lost to follow-up (Figure 1). The remaining 177 cases were included, comprising 88 males and 89 females with a mean age of 35.2 ± 10.0 years (range 14–62). 45 patients were treated by the anterior-only procedure (Group A), 52 by the combined anterior and posterior procedure (Group B) and 80 by the posterior-only procedure (Group C) (Table 1).
patients were diagnosed as spinal TB by clinical symptoms, signs, laboratory test, radiological examination and histopathology. Neurological function of the cases was evaluated by American Spinal Injury Association (ASIA) score. 6 cases were grade A, 14 were grade C, 47 were grade D and 108 were grade E. The back pain was evaluated by visual analogue scale (VAS) for all patients, and the local kyphotic angle was assessed by Cobb technique.
Preoperative management
All cases underwent chemotherapy regimens HREZ (rifampicin 450 mg/day, isoniazid 300 mg/day, pyrazinamide 750 mg/day and ethambutol 750 mg/day) for more than 2 weeks preoperatively.
Operation technique
Operations at each centre were performed by senior surgeons. All cases were treated by general endotracheal anaesthesia, then placed in the appropriate position. (1) In the anterior-only approach, thoracoabdominal procedure was adopted. After the lesion site was completely debrided, the defect area of vertebrae was inserted with a suitable cage or autologous or allograft iliac bone. Then the screw-rods were inserted in lateral anterior of the vertebrae. (2) In the anterior–posterior approach, the prone position was used initially. Dorsal midline incision was performed. The lamina and articular process were exposed, then pedicle screws were implanted in the right places. After correction of the kyphosis angle, bone grafting was performed, and the incision was closed. Then, patients were transferred to the lateral position, and a correctly placed incision was made. The thoracoabdominal approach was used to debride the lesion, decompress spinal cord and graft cage or iliac bone. (3) In the posterior-only approach, the prone position was used. Dorsal midline incision was performed and the lamina and articular process were exposed. After the screws were placed in the right places, the transpedicular space was used to debride lesion tissues, such as abscesses, necrotic discs and endplates. Then, suitable size autograft iliac bone or titanium cage containing cancellous bone was inserted into intervertebral body. At last, installed the rods and rectified the kyphosis and/or scoliosis. Before the surgery of each group was over, isoniazid (0.3 g) and streptomycin (1.0 g) were administered locally, and tubes were placed routinely near the incision.
Postoperative care
Preventive antibiotic treatment was used within 48 hours postoperatively. All cases were advised to use a bracing apparatus till bony fusion. Patients were administered oral HREZ chemotherapy for 6 months after the surgery, then received HRE chemotherapy for 9-12 months. When the drug sensitivity test indicated drug-resistant TB, sensitive drugs would be adjusted. Patients’ ESR rates, liver and kidney function were re-examined regularly. Follow-up was performed at 1, 3, 6, 12 and 18 months, then conducted once each year.
Statistical analysis
Continuous data were expressed as 一 X ± S.D. The LSD or Dunnett T3 test was used to evaluate differences in operation time, blood loss, kyphosis angle, ESR, VAS score. SPSS version 22 (SPSS, Inc., Chicago, USA) was used for statistical analysis. Values of 𝑃 less than 0.05 were considered to indicate significant differences.