Application of one-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Jin ¹ , WU Xinglin ¹ , LU Tingsheng ² , SONG Hui ³ ,  ZHOU Zhuojia ¹ , LI Bo ¹

1. Department of Orthopedics, Guizhou Provincial People’s Hospital, Guiyang Guizhou, 550002, P.R.China;
2. Department of Spinal Surgery, Guizhou Provincial Orthopedic Hospital, Guiyang Guizhou, 550002, P.R.China;
3. Department of Medical Imaging, Guizhou Provincial People’s Hospital, Guiyang Guizhou, 550002, P.R.China;

Corresponding author：

ZHOU Zhuojia, Email: zhouzhuojia@sina.com

Keywords：

Lumbosacral tuberculosis; posterior approach surgery; musculussacrospinalis iliac flap

DOI：

10.7507/1002-1892.201809090

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Objective To evaluate the safety and effectiveness of one-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis.Methods Between August 2011 and October 2014, 13 patients with lumbosacral tuberculosis were treated by one-stage posterior reserved posterior ligament complex, lesion debridement, bone graft fusion, and internal fixation via unilateral musculussacrospinalis iliac flap approach. There were 8 males and 5 females, aged from 22 to 57 years, with an average age of 35 years. The disease duration ranged from 2 to 19 months, with an average of 6.7 months. According to the American Spinal Injury Association (ASIA) classification criteria, the patients were graded as grade B in 2 cases, grade C in 4 cases, grade D in 5 cases, and grade E in 2 cases before operation. The preoperative Oswestry disability index (ODI) was 36.4±5.7; the preoperative lumbosacral angle was (20.7±0.7)°; the preoperative erythrocyte sedimentation rate (ESR) was (63.4±8.4) mm/1 h; and the preoperative C-reactive protein (CRP) was (38.8±5.2) mmol/L. The operation time and intraoperative blood loss were recorded. The ODI, ASIA grade, lumbosacral angle, and ESR were recorded at last follow-up. Bridwell criterion was used to judge the interbody fusion.Results The operation time was 150-240 minutes (mean, 190 minutes), and the intraoperative blood loss was 420-850 mL (mean, 610 mL). No major blood vessel, dural sac, nerve root, and lumbosacral plexus injuries occurred during the operation. Delayed wound healing occurred in 3 cases, and primary wound healing achieved in the other patients. No wound infection or sinus formation was found. All 13 patients were followed up 1.5-6.1 years (mean, 2.8 years). During the follow-up period, there was no tubercular symptom, cerebrospinal fluid leakage, loosening and rupture of internal fixator; and no complications such as retrograde ejaculation and erectile dysfunction occurred in 8 male patients. Solid spinal fusion obtained in all patients with the mean fusion time of 6.4 months (range, 4.2-9.9 months); and all iliac osteotomies healed. At last follow-up, the ODI was 7.2±3.5, the lumbosacral angle was (31.2±0.5)°, and ESR was (9.8±2.5) mm/1 h, all of which improved significantly when compared with pre-operative ones (P<0.05). The patients were classified as grade D in 2 cases and grade E in 11 cases, which improved significantly when compared with preoperative ones (Z=–3.168, P=0.002).Conclusion One-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis is effective and safe.

Citation： ZHANG Jin, WU Xinglin, LU Tingsheng, SONG Hui, ZHOU Zhuojia, LI Bo. Application of one-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(3): 296-301. doi: 10.7507/1002-1892.201809090 Copy

1.	Laura A, Annabel B, Hannah MD, et al. Global tuberculosis report 2018. World Health Organization, 2018: 1.
2.	Trecarichi EM, Di Meco E, Mazzotta V, et al. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. Eur Rev Med Pharmacol Sci, 2012, 16(Suppl 2): 58-72.
3.	Mor Z, Pinsker G, Cedar N, et al. Epidemiology of extra-pulmonary tuberculosis in Israel, 1999-2010. Int J Tuberc Lung Dis, 2013, 17(2): 229-233.
4.	García-Rodríguez JF, Álvarez-Díaz H, Lorenzo-García MV, et al. Extrapulmonary tuberculosis: epidemiology and risk factors. Enferm Infecc Microbiol Clin, 2011, 29(7): 502-509.
5.	Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J, 2013, 22(Suppl 4): 556-566.
6.	Rajasekaran S. Kyphotic deformity in spinal tuberculosis and its management. Int Orthop, 2012, 36(2): 359-365.
7.	Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg (Br), 2010, 92(7): 905-913.
8.	Shah SP, Kulkarni AG. S1 tuberculosis treated with segmental lumbopelvic fixation: a case report. Spine (Phila Pa 1976), 2012, 37(14): E866-E869.
9.	Rajasekaran S, Shanmugasundaram TK, Prabhakar R, et al. Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy. Spine (Phila Pa 1976), 1998, 23: 1163-1167.
10.	彭琪琪, 欧云生, 朱勇, 等. 后路病灶清除植骨内固定联合不同入路腰大肌脓肿清除局部化疗治疗胸腰椎结核. 中国修复重建外科杂志, 2018, 32(7): 912-919.
11.	Zhang H, Sheng B, Tang M, et al. One-stage surgical treatment for upper thoracic spinal tuberculosis by internal fixation, debridement, and combined interbody and posterior fusion via posterior-only approach. Eur Spine J, 2013, 22(3): 616-623.
12.	Rawall S, Mohan K, Nene A. Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases. Musculoskelet Surg, 2013, 97(1): 67-75.
13.	Wu P, Wang XY, Li XG, et al. One-stage posterior procedure in treating active thoracic spinal tuberculosis: a retrospective study. Eur J Trauma Emerg Surg, 2015, 41(2): 189-197.
14.	Zhang HQ, Lin MZ, Li JS, et al. One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg, 2013, 133(3): 333-341.
15.	Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
16.	Hodgson AR, Stock FE, Fang HS, et al. Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg, 1960, 48: 172-178.
17.	Song JF, Jing ZZ, Chen B, et al. One-stage anterolateral surgical treatment for lumbosacral segment tuberculosis. Int Orthop, 2012, 36(2): 339-344.
18.	Li JH, Zhang ZH, Shi T, et al. Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach. J Orthop Surg Res, 2015, 10: 62.
19.	Hirano T, Hasegawa K, Takahashi HE, et al. Structural characteristics of the pedicle and its role in screw stability. Spine (Phila Pa 1976), 1997, 22(21): 2504-2509.
20.	Weinstein JN, Rydevik BL, Rauschning W. Anatomic and technical considerations of pedicle screw fixation. Clin Orthop Relat Res, 1992, (284): 34-46.
21.	Bateman DK, Millhouse PW, Shahi N, et al. Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications. Spine J, 2015, 15(5): 1118-1132.
22.	Lindley EM, McBeth ZL, Henry SE, et al. Retrograde ejaculation after anterior lumbar spine surgery. Spine (Phila Pa 1976), 2012, 37(20): 1785-1789.
23.	廖烨晖, 叶入裴, 李广州, 等. 一期后前联合入路与单纯后路手术治疗下腰椎结核的疗效比较. 中国修复重建外科杂志, 2017, 31(5): 534-540.
24.	Ekinci S, Akyildiz F, Ersen O, et al. Tuberculosis of ultralong segmental thoracic and lumbar vertebrae treated by posterior fixation. Spine J, 2015, 15(10): 2298-2299.
25.	He Q, Xu J. Comparison between the antero-posterior and anterior approaches for treating L5-S1 vertebral tuberculosis. Int Orthop, 2012, 36(2): 345-351.
26.	Zhang H, Zeng K, Yin X, et al. Debridement, internal fixation, and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach: a 4-year follow-up of 28 patients. J Orthop Surg Res, 2015, 10: 150.
27.	Jain A, Jain R, Kiyawat V. Evaluation of outcome of posterior decompression and instrumented fusion in lumbar and lumbosacral tuberculosis. Clin Orthop Surg, 2016, 8(3): 268-273.
28.	Sahoo MM, Mahapatra SK, Sethi GC, et al. Posterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis: a retrospective study. J Spinal Disord Tech, 2012, 25(7): E217-E223.
29.	Lee BH, Lee HM, Kim TH, et al. Transpedicular curettage and drainage of infective lumbar spondylodiscitis: technique and clinical results. Clin Orthop Surg, 2012, 4(3): 200-208.
30.	Sun L, Song Y, Liu L, et al. One-stage posterior surgical treatment for lumbosacral tuberculosis with major vertebral body loss and kyphosis. Orthopedics, 2013, 36(8): e1082-e1090.
31.	Xu Z, Wang X, Shen X, et al. One-stage lumbopelvic fixation in the treatment of lumbosacral junction tuberculosis. Eur Spine J, 2015, 24(8): 1800-1805.
32.	Wang YX, Zhang HQ, Liao W, et al. One-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of lumbo-sacral spinal tuberculosis in the aged. Int Orthop, 2016, 40(6): 1117-1124.
33.	Li W, Liu J, Gong L, et al. Posterior intervertebral space debridement, annular bone grafting and instrumentation for treatment of lumbosacral tuberculosis. BMC Surg, 2017, 17(1): 124.
34.	Campbell PG, Malone J, Yadla S, et al. Early complications related to approach in thoracic and lumbar spine surgery: a single center prospective study. World Neurosurg, 2010, 73(4): 395-401.
35.	Hirakawa A, Miyamoto K, Masuda T, et al. Surgical outcome of 2-stage (posterior and anterior) surgical treatment using spinal instrumentation for tuberculous spondylitis. J Spinal Disord Tech, 2010, 23(2): 133-138.
36.	Zeng H, Wang X, Pang X, et al. Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults. Eur J Trauma Emerg Surg, 2014, 40(5): 607-616.
37.	Xu Z, Wang X, Shen X, et al. Posterior only versus combined posterior and anterior approaches for lower lumbar tuberculous spondylitis with neurological deficits in the aged. Spinal Cord, 2015, 53(6): 482-487.
38.	周焯家, 简月奎, 李波, 等. 腰骶椎结核治疗的方法选择 (附 65 例分析). 中国矫形外科杂志, 2008, 16(15): 1141-1143.

1. Laura A, Annabel B, Hannah MD, et al. Global tuberculosis report 2018. World Health Organization, 2018: 1.
2. Trecarichi EM, Di Meco E, Mazzotta V, et al. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. Eur Rev Med Pharmacol Sci, 2012, 16(Suppl 2): 58-72.
3. Mor Z, Pinsker G, Cedar N, et al. Epidemiology of extra-pulmonary tuberculosis in Israel, 1999-2010. Int J Tuberc Lung Dis, 2013, 17(2): 229-233.
4. García-Rodríguez JF, Álvarez-Díaz H, Lorenzo-García MV, et al. Extrapulmonary tuberculosis: epidemiology and risk factors. Enferm Infecc Microbiol Clin, 2011, 29(7): 502-509.
5. Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J, 2013, 22(Suppl 4): 556-566.
6. Rajasekaran S. Kyphotic deformity in spinal tuberculosis and its management. Int Orthop, 2012, 36(2): 359-365.
7. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg (Br), 2010, 92(7): 905-913.
8. Shah SP, Kulkarni AG. S1 tuberculosis treated with segmental lumbopelvic fixation: a case report. Spine (Phila Pa 1976), 2012, 37(14): E866-E869.
9. Rajasekaran S, Shanmugasundaram TK, Prabhakar R, et al. Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy. Spine (Phila Pa 1976), 1998, 23: 1163-1167.
10. 彭琪琪, 欧云生, 朱勇, 等. 后路病灶清除植骨内固定联合不同入路腰大肌脓肿清除局部化疗治疗胸腰椎结核. 中国修复重建外科杂志, 2018, 32(7): 912-919.
11. Zhang H, Sheng B, Tang M, et al. One-stage surgical treatment for upper thoracic spinal tuberculosis by internal fixation, debridement, and combined interbody and posterior fusion via posterior-only approach. Eur Spine J, 2013, 22(3): 616-623.
12. Rawall S, Mohan K, Nene A. Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases. Musculoskelet Surg, 2013, 97(1): 67-75.
13. Wu P, Wang XY, Li XG, et al. One-stage posterior procedure in treating active thoracic spinal tuberculosis: a retrospective study. Eur J Trauma Emerg Surg, 2015, 41(2): 189-197.
14. Zhang HQ, Lin MZ, Li JS, et al. One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg, 2013, 133(3): 333-341.
15. Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine (Phila Pa 1976), 1995, 20(12): 1410-1418.
16. Hodgson AR, Stock FE, Fang HS, et al. Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg, 1960, 48: 172-178.
17. Song JF, Jing ZZ, Chen B, et al. One-stage anterolateral surgical treatment for lumbosacral segment tuberculosis. Int Orthop, 2012, 36(2): 339-344.
18. Li JH, Zhang ZH, Shi T, et al. Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach. J Orthop Surg Res, 2015, 10: 62.
19. Hirano T, Hasegawa K, Takahashi HE, et al. Structural characteristics of the pedicle and its role in screw stability. Spine (Phila Pa 1976), 1997, 22(21): 2504-2509.
20. Weinstein JN, Rydevik BL, Rauschning W. Anatomic and technical considerations of pedicle screw fixation. Clin Orthop Relat Res, 1992, (284): 34-46.
21. Bateman DK, Millhouse PW, Shahi N, et al. Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications. Spine J, 2015, 15(5): 1118-1132.
22. Lindley EM, McBeth ZL, Henry SE, et al. Retrograde ejaculation after anterior lumbar spine surgery. Spine (Phila Pa 1976), 2012, 37(20): 1785-1789.
23. 廖烨晖, 叶入裴, 李广州, 等. 一期后前联合入路与单纯后路手术治疗下腰椎结核的疗效比较. 中国修复重建外科杂志, 2017, 31(5): 534-540.
24. Ekinci S, Akyildiz F, Ersen O, et al. Tuberculosis of ultralong segmental thoracic and lumbar vertebrae treated by posterior fixation. Spine J, 2015, 15(10): 2298-2299.
25. He Q, Xu J. Comparison between the antero-posterior and anterior approaches for treating L5-S1 vertebral tuberculosis. Int Orthop, 2012, 36(2): 345-351.
26. Zhang H, Zeng K, Yin X, et al. Debridement, internal fixation, and reconstruction using titanium mesh for the surgical treatment of thoracic and lumbar spinal tuberculosis via a posterior-only approach: a 4-year follow-up of 28 patients. J Orthop Surg Res, 2015, 10: 150.
27. Jain A, Jain R, Kiyawat V. Evaluation of outcome of posterior decompression and instrumented fusion in lumbar and lumbosacral tuberculosis. Clin Orthop Surg, 2016, 8(3): 268-273.
28. Sahoo MM, Mahapatra SK, Sethi GC, et al. Posterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis: a retrospective study. J Spinal Disord Tech, 2012, 25(7): E217-E223.
29. Lee BH, Lee HM, Kim TH, et al. Transpedicular curettage and drainage of infective lumbar spondylodiscitis: technique and clinical results. Clin Orthop Surg, 2012, 4(3): 200-208.
30. Sun L, Song Y, Liu L, et al. One-stage posterior surgical treatment for lumbosacral tuberculosis with major vertebral body loss and kyphosis. Orthopedics, 2013, 36(8): e1082-e1090.
31. Xu Z, Wang X, Shen X, et al. One-stage lumbopelvic fixation in the treatment of lumbosacral junction tuberculosis. Eur Spine J, 2015, 24(8): 1800-1805.
32. Wang YX, Zhang HQ, Liao W, et al. One-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of lumbo-sacral spinal tuberculosis in the aged. Int Orthop, 2016, 40(6): 1117-1124.
33. Li W, Liu J, Gong L, et al. Posterior intervertebral space debridement, annular bone grafting and instrumentation for treatment of lumbosacral tuberculosis. BMC Surg, 2017, 17(1): 124.
34. Campbell PG, Malone J, Yadla S, et al. Early complications related to approach in thoracic and lumbar spine surgery: a single center prospective study. World Neurosurg, 2010, 73(4): 395-401.
35. Hirakawa A, Miyamoto K, Masuda T, et al. Surgical outcome of 2-stage (posterior and anterior) surgical treatment using spinal instrumentation for tuberculous spondylitis. J Spinal Disord Tech, 2010, 23(2): 133-138.
36. Zeng H, Wang X, Pang X, et al. Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults. Eur J Trauma Emerg Surg, 2014, 40(5): 607-616.
37. Xu Z, Wang X, Shen X, et al. Posterior only versus combined posterior and anterior approaches for lower lumbar tuberculous spondylitis with neurological deficits in the aged. Spinal Cord, 2015, 53(6): 482-487.
38. 周焯家, 简月奎, 李波, 等. 腰骶椎结核治疗的方法选择 (附 65 例分析). 中国矫形外科杂志, 2008, 16(15): 1141-1143.

Chinese Journal of Reparative and Reconstructive Surgery

Application of one-stage posterior surgery via unilateral musculussacrospinalis iliac flap approach in treatment of lumbosacral tuberculosis

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