The autologous bundled multi-segment rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XU Shuang ¹ , WANG Gaoju ¹ , YANG Jin ¹ , LI Jun ¹ , DUAN Yi ¹ , XIONG Yilin ² ,  WANG Qing ¹

1. Department of Spinal Surgery, Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China;
2. Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China;

Corresponding author：

WANG Qing, Email: wqspine2004@163.com

Keywords：

Thoracic tuberculosis; debridement; rib graft; internal fixation

DOI：

10.7507/1002-1892.201612117

Video：

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Objective To investigate the effectiveness of bundled multi-segment autologous rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement. Methods The anterior debridement, multi-segment autologous rib interbody fusion, anterior or posterior internal fixation were used for treating the bone defect after thoracic spinal tuberculosis debridement in 36 cases between January 2006 and December 2013. There were 20 males and 16 females with an average age of 50.5 years (range, 21-60 years), and an average disease duration of 6.8 months (range, 5-11 months). The thoracic vertebral tuberculosis located at T_{4, 5} in 1 case, T_{5, 6} in 4 cases, T_{6, 7} in 4 cases, T_{7, 8} in 4 cases, T_{8, 9} in 9 cases, T_{9, 10} in 8 cases, T_{10, 11} in 5 cases, and T_{11, 12} in 1 case. Neurological impairment of 34 patients was assessed as grade B in 2 cases, grade C in 8 cases, and grade D in 24 cases according to Frankel classification. The pre- and post-operative erythrocyte sedimentation rate (ESR), C reactive protein (CRP), visual analogue scale (VAS) score, and kyphosis Cobb angle were evaluated. The fusion rate was analysed based on CT three-dimensional reconstruction. Results The cross-sectional area of the bundled multi-segment rib graft was 136.8-231.2 mm² (mean, 197.1 mm²); the endplate surface area of adjacent upper and lower vertebral bodies was 425.0-677.6 mm² (mean, 550.6 mm²); and the cross-sectional area of rib graft accounted for 29%-50% (mean, 33.6%) of the endplate surface area. The operation time was 95-160 minutes (mean, 125 minutes) and the intraopeartive blood loss was 280-850 mL (mean, 450 mL). All the patients were followed up 2-8 years (mean, 4.4 years). The postoperative complications included intercostals neuralgia in 2 cases, pleural effusion in 1 case, and liver function damage caused by antituberculosis drugs in 2 cases, who were all cured after symptomatic treatment. The rest patients had no respiratory complications and wound infection; and there was no fracture, displacement, absorption of rib support, tuberculosis recurrence, internal fixation loosening, and kyphosis occurred in all patients. CT three-dimensional reconstruction showed that the fusion rate was 86.1 (31/36) at 6 months after operation and was 97.2% (35/36) at 12 months after operation. The ESR, CRP, VAS scores, and kyphosis Cobb angle at 3 months after operation and last follow-up were significantly improved when compared with preoperative values (P<0.05), but there was no significant difference between at 3 months after operation and last follow-up (P>0.05). Neurological deficits were all improved at last follow-up according to Frankel classificaiton, including 2 cases with grade B recovered to grade D, 8 cases with grade C to grade D in 1 case and to grade E in 7 cases, 24 cases with grade D all to grade E. Conclusion Bundled multi-segment autologous rib graft reconstruction is an alternative method for less than 2 discs and vertebral bone defect created by radical debridement for thoracic spinal tuberculosis.

Citation： XU Shuang, WANG Gaoju, YANG Jin, LI Jun, DUAN Yi, XIONG Yilin, WANG Qing. The autologous bundled multi-segment rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(10): 1225-1230. doi: 10.7507/1002-1892.201612117 Copy

1.	Qureshi MA, Khalique AB, Afzal W, et al. Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis. Eur Spine J, 2013, 22 Suppl 4: 618-623.
2.	Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg (Am), 1989, 71(9): 1314-1323.
3.	刘国辉, 张鹏, 杨述华, 等. 前后路一期手术治疗多节段胸椎结核并截瘫. 中华骨科杂志, 2008, 28(12): 983-987.0.
4.	Li M, Du J, Meng H, et al. One-stage surgical management for thoracic tuberculosis by anterior debridement, decompression and autogenous rib grafts, and instrumentation. Spine J, 2011, 11(8): 726-733.
5.	Dai LY, Jiang LS, Wang W, et al. Single-stage anterior autogenous bone grafting and instrumentation in the surgical management of spinal tuberculosis. Spine (Phila Pa 1976), 2005, 30(20): 2342-2349.
6.	丁真奇, 康两期, 翟文亮, 等. 前路一期植骨内固定治疗上胸椎结核合并瘫痪. 中华骨科杂志, 2004, 24(7): 399-402.0.
7.	Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions. J Neurosurg, 1998, 88(2): 255-265.
8.	Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976), 2003, 28(2): 134-139.
9.	Koptan W, Elmiligui Y, Elsharkawi M. Single stage anterior reconstruction using titanium mesh cages in neglected kyphotic tuberculous spondylodiscitis of the cervical spine. Eur Spine J, 2011, 20(2): 308-313.
10.	Kamat AS, Freeman BJ, Cain CM, et al. Laminated multi-segment rib graft in anterior column reconstruction. Eur Spine J, 2002, 11(5): 465-466.
11.	Zhang HQ, Guo CF, Xiao XG, et al. One-stage surgical management for multilevel tuberculous spondylitis of the upper thoracic region by anterior decompression, strut autografting, posterior instrumentation, and fusion. J Spinal Disord Tech, 2007, 20(4): 263-267.
12.	Cavuşoğlu H, Kaya RA, Türkmenoğlu ON, et al. A long-term follow-up study of anterior tibial allografting and instrumentation in the management of thoracolumbar tuberculous spondylitis. J Neurosurg Spine, 2008, 8(1): 30-38.
13.	Hodgson AR, Stock FE. Anterior spinal fusion: a preliminary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. Clin Orthop Relat Res, 1994, (300): 16-23.
14.	Kubosch D, Milz S, Sprecher CM, et al. Effect of graft size on graft fracture rate after anterior lumbar spinal fusion in a sheep model. Injury, 2010, 41(7): 768-771.
15.	Closkey RF, Parsons JR, Lee CK, et al. Mechanics of interbody spinal fusion. Analysis of critical bone graft area. Spine (Phila Pa 1976), 1993, 18(8): 1011-1015.
16.	Vieweg U, Kaden B, Schramm J. Vertebral body replacement with a rib segmentblock in transthoracic intervention. Zentralbl Neurochir, 1996, 57(3): 136-142.
17.	Justinger C, Slotta JE, Schilling MK. Incisional hernia after abdominal closure with slowly absorbable versus fast absorbable, antibacterial-coated sutures. Surgery, 2012, 151(3): 398-403.

1. Qureshi MA, Khalique AB, Afzal W, et al. Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis. Eur Spine J, 2013, 22 Suppl 4: 618-623.
2. Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg (Am), 1989, 71(9): 1314-1323.
3. 刘国辉, 张鹏, 杨述华, 等. 前后路一期手术治疗多节段胸椎结核并截瘫. 中华骨科杂志, 2008, 28(12): 983-987.0.
4. Li M, Du J, Meng H, et al. One-stage surgical management for thoracic tuberculosis by anterior debridement, decompression and autogenous rib grafts, and instrumentation. Spine J, 2011, 11(8): 726-733.
5. Dai LY, Jiang LS, Wang W, et al. Single-stage anterior autogenous bone grafting and instrumentation in the surgical management of spinal tuberculosis. Spine (Phila Pa 1976), 2005, 30(20): 2342-2349.
6. 丁真奇, 康两期, 翟文亮, 等. 前路一期植骨内固定治疗上胸椎结核合并瘫痪. 中华骨科杂志, 2004, 24(7): 399-402.0.
7. Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of fusion rates and donor-site morbidity for autogeneic rib and iliac crest bone grafts in posterior cervical fusions. J Neurosurg, 1998, 88(2): 255-265.
8. Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976), 2003, 28(2): 134-139.
9. Koptan W, Elmiligui Y, Elsharkawi M. Single stage anterior reconstruction using titanium mesh cages in neglected kyphotic tuberculous spondylodiscitis of the cervical spine. Eur Spine J, 2011, 20(2): 308-313.
10. Kamat AS, Freeman BJ, Cain CM, et al. Laminated multi-segment rib graft in anterior column reconstruction. Eur Spine J, 2002, 11(5): 465-466.
11. Zhang HQ, Guo CF, Xiao XG, et al. One-stage surgical management for multilevel tuberculous spondylitis of the upper thoracic region by anterior decompression, strut autografting, posterior instrumentation, and fusion. J Spinal Disord Tech, 2007, 20(4): 263-267.
12. Cavuşoğlu H, Kaya RA, Türkmenoğlu ON, et al. A long-term follow-up study of anterior tibial allografting and instrumentation in the management of thoracolumbar tuberculous spondylitis. J Neurosurg Spine, 2008, 8(1): 30-38.
13. Hodgson AR, Stock FE. Anterior spinal fusion: a preliminary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. Clin Orthop Relat Res, 1994, (300): 16-23.
14. Kubosch D, Milz S, Sprecher CM, et al. Effect of graft size on graft fracture rate after anterior lumbar spinal fusion in a sheep model. Injury, 2010, 41(7): 768-771.
15. Closkey RF, Parsons JR, Lee CK, et al. Mechanics of interbody spinal fusion. Analysis of critical bone graft area. Spine (Phila Pa 1976), 1993, 18(8): 1011-1015.
16. Vieweg U, Kaden B, Schramm J. Vertebral body replacement with a rib segmentblock in transthoracic intervention. Zentralbl Neurochir, 1996, 57(3): 136-142.
17. Justinger C, Slotta JE, Schilling MK. Incisional hernia after abdominal closure with slowly absorbable versus fast absorbable, antibacterial-coated sutures. Surgery, 2012, 151(3): 398-403.

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The autologous bundled multi-segment rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement

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