Lumbar is the only bony structure in the human body that connects the thorax to the pelvis and plays a crucial role in various physical activities as it bears most of the bodyweight. With the aid of discs’ elastic function, lumbar can effectively buffer shock transmitted from the lower limbs, which prevents neural tissue injury in the spinal canal from sudden trauma. Inconspicuous manifestations can delay the diagnosis of lower lumbar TB; therefore, an effective surgery can shorten the duration of anti-TB drug treatment, fasten the patients’ rehabilitation and reduce the occurrence of anti-TB drug resistance [5].
In this respect, most patients with lower lumbar TB can also be cured via regular anti-TB drug chemotherapy; however, surgical intervention is mandatory in critical cases. Several surgical approaches are implemented for the treatment of lower lumbar TB, such as, single anterior approach for STB which was first reported by Hodgson in Hong Kong in the 1960s [6]. Radical lesion debridement and anterior spine column construction are easily obtainable using a single anterior approach. With the introduction of pedicle screw fixation, many scholars reported stability to be an essential part of STB healing.
Wang et al. [7] reported that STB patients who underwent only posterior instrumentation and posterolateral fusion without anterior debridement could obtain lesion healing and solid bony fusion without TB recurrence during a mean follow-up of 68.8 months. Zhang et al. [8] suggested that spinal stability should be prioritized as TB lesion could not be radically eliminated at the microbiological level. Qian et al. [9] compared the clinical outcomes between the patients who underwent the procedure of radical debridement, bone graft, instrumentation, and the patients who underwent the procedure of isolated posterior instrumentation without debridement. No significant differences of VAS, kyphotic angle and neurological function improvement were observed between the two groups.
Despite such evidence, most experts deemed that radical debridement played a decisive role in the treatment of STB. Jin et al. [10] studied 289 patients who underwent complete debridement, interbody fusion anterior, or posterior fixation. They reported that debridement should not only include pus, caseous necrotic tissue and pathological granular tissue but also include the sclerotic bone and bony bridges adjacent to the lesions because these tissues possibly prevented anti-TB drugs from entering the unhealthy bony tissues. Wang et al. [11] found that except for kyphotic deformity correction, single anterior debridement, interbody fusion, and fixation were useful for some cases of STB. Huang et al. [12] found that one-stage surgical management of anterior lesion removal, bone grafting, posterior instrumentation and fusion were effective for children with STB. Liang et al. [13] found that chemotherapy for an average duration of 4.5 months was effective for STB patients who underwent a combined posterior and anterior approach of posterior infixation (including fixation of the affected vertebrae) including anterior debridement and interbody fusion. Nevertheless, some experts consider such an approach as time-consuming [14, 15].
Postoperative debridement was first reported by a Chinese orthopedic pioneer Fang Xianzhi in the 1950s [16]. Yusof et al. [17] reported that the proportion of posterior column involvement in spinal TB was highly underestimated,and therefore, lots of patients were suitable for posterior surgery. Zhou et al. [18] reported that one-stage posterior surgery coordinated with continuous local chemotherapy and postural drainage were useful for lumbar STB. Pang et al. [19] indicated that the clinical results of one-stage posterior transforaminal lumbar debridement, 360° interbody fusion, and posterior instrumentation were favorable for STB in lower lumbar and lumbosacral junction. Few studies also compared the clinical results of a single posterior approach with a combined posterior-anterior approach for the patients of lumbar STB. Wang et al. [20] compared the clinical results of lumbar STB utilizing a single posterior approach with a combined posterior and anterior approach.
Although both approaches provided excellent clinical results for thoracic and lumbar STB, a single posterior approach demanded the less operation time (blood loss), hospitalization duration and obtained superior kyphotic deformity correction. According to results, the single posterior approach provided a reasonable ESR, CRP, VAS, JOA score and kyphosis Cobb’s correction but at the expense of prolonged abscess disappearance and time return to regular activity as opposed combined posterior-anterior approach (less operation time and blood loss). No significant differences in surgical complication and cure rate between the single posterior approach and combined posterior-anterior approach were found during the follow-up period of patients. So, we believe that a single posterior approach might be suitable for most cases of lower lumbar STB; however, for the patients with big iliopsoas abscess, the combined posterior-anterior approach might be appropriate due to fast recovery.