orthopedic paper I
A surgical treatment of spinal tuberculosis
Report of Three Cases
Spinal tuberculosis accounts for 47.28% of all bone and joint tuberculosis and is commonly seen in clinical settings (1). Conservative treatment, even with the advent of anti-tuberculosis drugs, often takes many years and is difficult to cure. Surgical treatment, although significantly improved, usually requires 2-3 major surgeries, costing time and money and causing additional pain. A one-time surgical cure is, therefore, ideal. This paper reports on one case each of cervical, thoracic, and lumbar spinal tuberculosis that were treated with a single planned surgery at our hospital in the years 1975 and 1976.
Case Presentation
Case One
Male, 18 years old, a farmer from Fanchang County. Case number: 12179.
He has experienced neck pain for a year and limited movement for half a year. He has had a fever, neck swelling, and difficulty swallowing for two weeks. He cannot eat or drink, speak, and has had breathing difficulties for four days. X Hospital diagnosed him with tuberculosis of the 3rd and 4th cervical vertebrae and a large abscess behind the pharynx, compressing the trachea and esophagus, following a puncture that drained white, thin pus. He was admitted to our hospital as an emergency case on October 26, 1975. Examination: His neck is immobile, and there is fullness and fluctuation below the jaw. He breathes through his mouth, does not speak, sweats profusely, and is dehydrated but not cyanotic. No other special findings. Quick fluid replacement of 1000cc was done, and emergency surgery was performed two hours after admission under local anesthesia. Through the left anterolateral approach of the neck, 600cc of pus was drained, and the pus cavity wall was scraped off. The cervical vertebrae's periosteum was cut open along the midline, and a pus plug at the lower edge of the 3rd cervical vertebra was removed under direct vision. A 0.5x0.6 cm bone hole was visible. The external opening was enlarged, and tuberculous granulation tissue, cheesy material, and granular fragments were carefully scraped off. The pus cavity was flushed. No bone grafting was done as the intervertebral space had already disappeared and fused naturally. Gentamycin and streptomycin were placed, and rubber pieces were used for drainage. The surgery went smoothly. After the surgery, his breathing stabilized, he could eat and speak. His neck was immobilized postoperatively, and anti-tuberculosis treatment was administered. Sutures were removed on the sixth day, and the incision healed. He was discharged after ten days. A total of 60 grams of streptomycin was injected, and rimifon was taken for half a year. He resumed light labor two months after surgery and full labor a year later. Follow-up after three and a half years showed everything to be normal; his neck movement was unimpeded. An X-ray on August 14, 1979, showed bony fusion of the 3rd and 4th cervical vertebrae, with no necrotic bone, abscess, or bone destruction (X-ray number 2090).
Case Two
Male, 23 years old, from Nanling, a farmer. Case number: 2875.
Admitted to the hospital on May 31, 1976, due to tuberculosis of the 9th and 10th thoracic vertebrae and an adjacent abscess. After pre-operative preparation and ensuring no contraindications to surgery, the procedure was performed under endotracheal ether anesthesia on June 19, 1976. The approach was through the 9th intercostal space on the right side. The mediastinal pleura was incised to enter the thorax and reach the abscess on the vertebrae. The pus was aspirated, and after dealing with the two intercostal veins, the exposure was expanded. Direct vision to the opposite lesion up to the rib-transverse process joint was achieved. Tuberculous granulation tissue, cheesy material, necrotic intervertebral discs, and dead bone were scraped off and flushed. Bone grooves were chiseled above and below the diseased vertebrae, and four rib grafts were implanted tightly. Antibiotics were placed and the area was sutured meticulously. The thoracic cavity was thoroughly rinsed, closed, and a drain was put in place. The post-operative recovery was smooth. The thoracic tube was removed after 26 hours, and a thorax radiograph after 72 hours showed a sharp costophrenic angle. On the fifth post-operative day, the patient's temperature returned to normal, and he was discharged on June 29, 1976, after a 29-day hospital stay. He was advised bed rest for four months and anti-tuberculosis treatment for nine months. Follow-up: The patient started moving around one month after surgery and gradually resumed light work, but developed kyphosis. A year later, he returned to regular labor. Three years post-surgery, an X-ray showed no abscess shadow or dead bone adjacent to the vertebrae. The 9th and 10th thoracic vertebrae had fused, but the bone grafts were absorbed. The 10th vertebra had collapsed, leading to a hump (X-ray number 2104).
Case Three
Male, 50 years old, married, a farmer from Nanling. Case number: 1462.
He suffered from tuberculosis of the 2nd and 3rd lumbar vertebrae, which led to a psoas abscess. He had already been administered 20 grams of streptomycin. He was admitted to the hospital on August 8, 1976. On August 9, 1976, under spinal anesthesia, he underwent lesion removal and anterior bone grafting via a left lumbar incision. The 12th rib was removed and set aside for later use. After extraperitoneal dissection, the lumbar muscle was incised to access the abscess. Subsequently, two lumbar transverse vessels nearby were safely dealt with. This allowed for an expanded exposure and clearing of the abscess from the opposite lumbar muscle. Granulation tissue from the abscess wall was fully scraped off. Immediate pressing with a hot saline-soaked gauze for 5 minutes was done to minimize extensive bleeding. The exposure to the bony hole in the vertebrae was expanded, and necrotic bone, intervertebral disc, and substantial tuberculous tissue were thoroughly removed. After cleaning, the site was deemed satisfactory. A bone groove was chiseled between the affected vertebrae and the removed 12th rib was embedded, completing the lesion removal and anterior bone grafting in one go. Post-operative recovery was smooth, and the incision healed without complications. He was discharged on March 24, 1978, after a 21-day hospital stay. He was advised bed rest for four months and resumed work half a year later. Currently, he works at 90% of his capacity, can walk 50 kilometers without discomfort, and is in good mental and physical health. Three years post-surgery, an examination on August 15, 1979, revealed no palpable masses in both lumbar muscles, no tenderness upon percussion on the spine, and good spinal mobility. A thorax X-ray showed the upper right lung tuberculosis in the absorption and recovery phase. Lumbar X-ray revealed bony fusion from L1 to L4 with no signs of dead bone or abscess (X-ray number 2101).
Discussion
(1) The treatment of spinal tuberculosis has undergone a long evolutionary process. From prolonged bed rest, full-body anti-tuberculosis treatment to palliative abscess incision; from abscess scraping, fistula shortening surgery to radical lesion removal with fusion surgery, and even recently, there has been an attempt to resolve the issue with one operation. However, because of the complex anatomical relationships of the spine and the difficulty of exposure, the high surgical risk hinders a "complete clearance". Thus, curing this type of disease with one surgery has not yet become widespread. By improving external and internal exposure, making complete clearance possible, we went through the three cases mentioned, all of which were cured within half a year, showing superiority compared to other treatment schemes.
(2) In the surgical treatment of spinal tuberculosis, in addition to clearing the abscess and vertebral lesions, the "tuberculosis barrier" is also broken, allowing anti-tuberculosis drugs to reach the lesion, significantly increasing the cure rate compared to conservative treatment alone [3]. During the same period, our hospital treated five other cases, including two cases of thoracic spine tuberculosis with paralysis. These cases underwent one-sided lesion clearance or simple fusion surgery and were all cured, though it took about a year. The cases in this study were cured more quickly due to more thorough clearance.
(3) Treatment of spinal tuberculosis requires both lesion recovery and the restoration of the spine's support and stability, making bone graft fusion an essential part of treatment. Posterior grafting faces tensile stress, which is not conducive to graft growth; anterior grafting, however, is under compressive forces, favoring graft growth. It can be done simultaneously with lesion clearance, using autologous grafts from the external exposure site. Embedding the graft is more effective than covering or filling, providing both temporary and permanent support, making it more reasonable. Still, thorough lesion clearance without mixed infection is a prerequisite, or the graft is easily absorbed or necrosed [3]. Cases two and three in this study had no mixed infections, and the clearances were "satisfactory", hence they underwent anterior grafting.
Bone grafting between vertebrae is susceptible to displacement and absorption due to pressure, so it's imperative to ensure the patient is on bed rest for more than three months. Rural patients often are unwilling to be hospitalized for extended periods. If they move prematurely at home, it can lead to graft failure. In case two, the patient got out of bed just one-month post-op, leading to graft displacement, absorption, vertebral collapse, and a hunched back. In contrast, case three followed medical advice and achieved the expected results, serving as a valuable lesson.
(4) Cervical spine tuberculosis with a retropharyngeal abscess can cause compressive symptoms, leading to difficulties in swallowing, speech, and even breathing, constituting an emergency situation. Given its convenient surgical approach, the operation can be carried out under local anesthesia, with minimal blood loss and damage, making the procedure relatively straightforward. Moreover, the abscess stretches the surrounding tissue, exposing a broad area in front of the diseased vertebra. By adhering to the "midline incision" principle [1], the vertebral lesion can be thoroughly removed under direct vision. Given the rich blood supply in the neck, rapid absorption of the lesion, and strong repair capability, satisfactory outcomes can be easily achieved, as seen in Case 1. Whether to graft, apply traction, or fixate depends on the stability of the affected vertebrae. However, precautions must be taken to prevent cervical cord trauma and avoid serious accidents like high-level paralysis (① Avoid using a bone chisel; ② Do not go beyond the posterior longitudinal ligament during removal).
(5) For thoracic spine tuberculosis, especially between the 3rd to 10th vertebrae, if conditions permit, the thoracic approach can be used to clear lesions on both sides and perform anterior grafting in a single operation. This is preferred by patients and also saves bed space. Although there's the inconvenience of thoracotomy and the risk of infection, it's still considered safe under modern anesthesia, asepsis, and the use of antibiotics. Case 2 was discharged 10 days after the operation for recuperation.
(6) The lumbar spine is deeply situated, surrounded by numerous vital structures, making it hard to expose and the surgery more invasive. Thoroughly removing the lesion isn’t easy, and typically, 2-3 operations are needed. However, given the patient's physical condition, with special handling of the lumbar vessels [1], following the sub-periosteal dissection, the diseased vertebrae can be safely and extensively exposed, facilitating the thorough removal of the lesion.
Regarding the clearance of the contralateral lumbar abscess: by compressing the contralateral lumbar region and directly viewing the source of the pus, and then through the broadened internal exposure, using curettes of various curvatures, one can navigate and scrape away the abscess. If necessary, an incision can be made at a safe location on the contralateral side, guided by the curette, to "meet up" and clear out the abscess. It’s essential to note that all vital organs are located outside the lumbar muscles, so "intramuscular" abscess scraping is generally safe. Still, care should be taken to avoid vascular and nerve damage [9]. On this basis, anterior grafting can also be expected to cure, significantly shortening the treatment duration, as seen in Case 3.
Conclusion
Through the clinical practice of the author's three cases, the clinical process and the 3-4 year follow-up results of cervical, thoracic, and lumbar spine tuberculosis being cured with a single surgery are described. Among them, Case 1 was an emergency, while Cases 2 and 3 both involved anterior grafting. It is pointed out that the key lies in proper exposure and thorough removal. Combined with a review of the literature, some technical measures are proposed, and a preliminary discussion on the treatment of spinal tuberculosis is presented.
References
① Tianjin Hospital Orthopedics, Clinical Orthopedics Tuberculosis Volume, P183 People's Health Publishing House 1974
② Fang Xianzhi: Bone and Joint Tuberculosis Lesion Removal Therapy, People's Health Publishing House 1960
③ Guo Juling: The role and issues of anterior grafting in the treatment of spinal tuberculosis, Chinese Journal of Surgery 11:12, 1963
④ Liu Zhong: Thoracic vertebrae tuberculosis lesion removal through the thoracic cavity, Chinese Journal of Surgery 8:531, 1960
⑤ Fan Bingzhe: Open chest procedure for thoracic vertebral tuberculosis lesion removal, Chinese Journal of Surgery 7:20, 1959
⑥ Wang Zhixian: Thoracic surgery for thoracic lesion removal through the chest, Chinese Journal of Surgery:271, 1959
⑦ Luo Xianzheng: Preliminary report on thoracic extrapleural spinal tuberculosis lesion removal, Chinese Journal of Surgery 12:1144, 1964
⑧ Tian Chengrui: Some insights into the lesion removal therapy for spinal tuberculosis, Tianjin Medical Orthopedics Supplement 2:76:1678
⑨ Yu Peili and others: Injury to the external iliac artery during lumbar vertebrae tuberculosis lesion scraping surgery (Clinical case discussion), Chinese Journal of Surgery 11:936, 1963.
This article was originally published in the Proceedings of First Anhui Province Orthopedic Symposium in 1979. Nanling Hospital Orthopedics, Li Mingjie
from 脊椎结核的一次手术治疗
