Objective To summarize clinical characteristics and explore operative strategy of elderly patients with spinal tuberculosis.Methods From December 2005 to December 2010,151 aged patients with spinal tuberculosis were treated with six different surgical procedures.Among 69 patients were followed,including 36 males and 33 females,with the average age of 68.3 (60 to 83) years.62 patients were complicated by other diseases.The clinical manifestations,locations and images of these patients were analyzed.The occurrence of misdiagnosis and mistreatment was counted.The visual analogue scale (VAS) scoring was applied to evaluate the local pain,and the Frankel classification was used to evaluate the improvement of neurological function.The criterion of cure of spinal tuberculosis was used to assess the clinical cure of these patients.Results All patients had different levels of local pain.The preoperative VAS was 8.2±1.4,with 42 (60.9) cases of more than 7.72.5％ patients didn't have obvious toxic symptoms and 43.5％ didn't have paravertebral or psoas abscess,while 68.1％ had spinal nerve damage.Lumbar spine was the most commonly affected area and 2 vertebrae TB got the highest incidence.The Cobb's angle was 20.4°±4.3° preoperatively.The misdiagnose rate was 30.4％ (21/69) and the mistreatment rate was 13.0％ (9/69).The average follow-up period was 27 months.Sixty-seven patients were clinically cured.The average union segments were 4.1 ±0.6 and the average time of union was 5.9± 1.7 months.The correction of kyphosis was 9.5°±3.6° after surgery but lost 7.2°±2.3° at the last follow-up time.5 patients with neurological deficits were clinically improved at least one grade after surgery,according to the Frankel grading system.One patient died from pulmonary infection.Other complications included cardiac dysfunction in 5 patients,pulmonary infection in 4 patients,cerebral infarction in 2 patients,internal fixation loosening in 2 patients,sinus formation in 5 patients,drug-induced liver dysfunction in 5 patients,drug rash in 6 patients and aggravation of neurological function in 1 patient.Conclusion Spinal tuberculosis in elderly patients usually concealed onset and combined with other diseases,which could lead to misdiagnosis and mistreatment.Surgical procedures should be chosen individually and in minimal-invasive way.The segments should be fixed longer to avoid loosening.

Objective To investigate operative approach,immobilization manner,and surgical effect of multiple-level contiguous thoracic spinal tuberculosis.Methods Between January 2001 and December 2010,112 patients with thoracic spinal tuberculosis were treated with 5 different surgical procedures.Among them,81 adults with multiple-level contiguous thoracic spinal tuberculosis were followed up for 17 to 75 months (average,39 months).Twenty three patients suffered from spinal cord dysfunction; according to the Frankel classification,there were 3 cases of type A,4 cases of type B,7 cases of type C,and 9 cases of type D.The double vertebral bodies were commonly affected areas,especially T10 and T11-Results Local symptoms of all patients were relieved significantly 1 to 3 weeks postoperatively.Erythrocyte sedimentation rates (ESR) returned to normal level in all patients 8 to 12 weeks postoperatively.Three sinuses were found 0.5 month,1 month and 1.5 months postoperatively,respectively,which were cured by changing dressing for 1 to 2 months.The average correction of kyphotic deformity was 10.2°±2.1° in anterior fixation group,while 12.6°±2.7° in posterior fixation group.At final follow-up,the average loss of correction was 6.9°±1.9° in anterior fixation group,while 5.8°±1.4° in posterior fixation group.At least one Frankel grade improvement was observed in 23 patients.Conclusion The surgical methods should be chosen according to the location and degree of the lesion.Correct surgical procedures can obtain good results in correction and maintenance of the deformity,clearance of the foci,decompression of the spinal cord and pain relief for thoracic spinal tuberculosis.The posterior fixation is better than the anterior fixation with regard to correction and maintenance of the kyphotic deformity.

OBJECTIVE:To compare the outcomes of anterior verus posterior instrumentation under different surgical procedures in the surgical management of thoracolumbar spinal tuberculosis (TB). METHODS:Between January 2004 and December 2009, 241 adult patients with thoracolumbar spinal TB underwent radical debridement and strut grafting plus anterior or posterior instrumentation in single-stage or two-stages. The mean age was 39 years (range: 16 - 67). The mean follow-up period for 189 patients was 37 months (range: 22 - 72). Among them, 157 cases underwent > 3 weeks of chemotherapeutic regimen of isoniazid, rifampin, pyrazinamide and ethambutol and the remaining 32 were operated for neurological impairment after 6-18 h with the same chemotherapeutic regimen. Except for 8 patients with skip lesions undergoing hybrid anteroposterior instrumentation, anterior instrumentation was utilized in 74 patients (Group A) and posterior instrumentation in 107 patients (Group B). RESULTS:In both groups, local symptoms of all patients were relieved significantly 1-3 weeks postoperatively. And 10/14 cases (71%) in Group A and 14/19 cases (74%) in Group B with neurological deficits had excellent or good clinical outcomes (P > 0.05). The levels of erythrocyte sedimentation rates (ESR) returned from 43.6 mm/h and 42.4 mm/h preoperatively to normal at 8-12 weeks postoperatively. Kyphosis degrees were corrected by a mean of 11.5° in Group A and 12.6° in Group B (P < 0.01). The correction loss was 6.8° in Group A and 6.1° in Group B at the last follow-up (P < 0.01). Fusion rates of the grafting bone were 92.5% and 91.8% respectively at the final follow-up (P > 0.05). Severe complications did not occur. CONCLUSION:Either anterior or posterior instrumentation can obtain good results in correction and maintenance of deformity, clearance of foci, decompression of spinal cord and pain relief in the treatment of thoracolumbar spinal TB as long as the surgical indications are properly selected. Posterior instrumentation may be superior to anterior instrumentation in the correction and maintenance of deformity.

OBJECTIVE:To evaluate the surgical indications and clinical effectiveness of different operative procedures in the treatment of lower lumbar tuberculosis.METHODS:From June 2001 to Oct 2008, 72 patients with lower lumbar tuberculosis were treated by different operative procedures. Including 38 males and 34 females, with an average age of 38.5 years old ranging from 16 to 70 years. The average duration of symptom was 6.8 months (ranging from 4 months to 2 years). A single vertebrae was involved in 10 patients,two contiguous vertebrae in 50 cases and three vertebrae in 12 cases. The average preoperative lordotic angle was 13.1 degree (ranging from -5.0 degrees to 34.0 degrees). Three different operative procedures included: (1) posterior debridement and posterolateral fusion and posterior instrumentation in 28 patients; (2) anterior radical debridement and anterior fusion and anterior instrumentation in 32 patients; (3) image-guided percutaneous drainage (PCD) of tuberculous abscesses in 12 patients. The selection of the procedure was made according to the degree of the lesions. The resolution of inflammatory process, bony fusion, correction of sagittal angles and JOA scores were used for evaluating the result of the surgery and the complications were analyzed.RESULTS:All patients were followed up from 1.5 to 8.0 years (means 3.6 years). PCD was an effective treatment in 11 out of the 12 patients, one required surgical debridement and fusion. Among them, 57 (95%, 57/60) patients were treated by open operation showed successful bony fusion. The complications maily included common iliac vein injury in 3 patients, dural tear in 2 patients, they were all cured by intro-or postoperative treatment. The average immediate post-operative lordotic angle was 27.3 degree (35.0 degrees to 16.0 degrees), the average lordotic angle was 25.6 degree (33.0 degrees to 15.0 degrees) at final follow-up. Preoperatively and at final follow-up, JOA scores were respectively (15.2 +/- 3.4), (25.6 +/- 2.4) (P<0.01).CONCLUSION:Different operative procedures should be selected to treat lower lumbar tuberculosis according to the degree of lesions. Aggressive surgical treatment was found helpful in the resolution of inflammatory process and correcting the loss of lordosis, preventing progression of kyphosis.

Objective To investigate clinical outcome of short-course chemotherapy in retreating spinal tuberculosis after radical operation. Methods Forty-six retreating patients with spinal tuberculosis were included in this series, 29 males, 17 females with the age from 27 to 61 years (average of 43.7 years). All patients were treated with radical operation and short-course anti-tuberculous chemotherapy from March 2005 to March 2008. The tuberculous focus located thoracic spine in 17 cases, thoracic-lumbar in 13 and lumbosacral vertebrae in 16 cases. Of them, 5 cases had sinuses of tuberculosis and 7 cases had incomplete palsy in lower limbs (Frankel C-D). CT or MRI showed obvious sequestra, cold abscess within spinal focus. Surgical procedures including debridement, auto-bone grafting, and one-stage internal fixation, was performed at the 4 to 6 weeks after chemotherapy. Chemotherapy regimes were 3HRZ/6-9HRE in majority of patients. Clinical effect and focus healing were evaluated at follow-up period. Results Tuberculous symptoms and local pain of vertebral volume were obvious in all patients before chemotherapy,with average ESR 65.3 mm/h and average CRP 37.4 mg/L. After 4-6 weeks chemotherapy, tuberculosis symptoms and vertebral pain improved in all patients, and the average ESR decreased to 38.3 mm/1h, the average CRP decreased to 17.2 mg/L. Two to three months after operation, tuberculous symptoms and local pain relived in all patients,ESR and CRP became normal in 37 cases. Six to twelve months after operation, bonegraft complex in each patient became stable and there were no instrument loosening or deformity correction loss. Six patients with incomplete palsy recovered and 1 case improved from Frankel C to D grade. Focus healing was achieved in 44 cases (95.7%) after short-course chemotherapy (3HRZ/6-9HRE), and there were no resurgence in 2 to 4 years follow-up period. Drug fast 2 cases for RFP+INH cured at the 15 months after chemotherapy. Conclusions Removed tubercular focus for the treatment of retreating spinal tuberculosis can improve clinical effect and shorten chemotherapy course.

OBJECTIVE To investigate the clinical significance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the treatment of spinal tuberculosis. METHODS Sixty-seven patients (41 males and 26 females, ranging in age from 23 to 61 years) with active spinal tuberculosis in our hospital (from Mar. 2004 to Mar. 2007) were included in this study. The tuberculosis focus were located either in cervical spine, thoracic spine or in lumbar spine. After 4 to 6 weeks anti-tuberculosis chemotherapy, all the patients underwent one-stage operation (focus debridment) and auto-bone graft combined with internal fixation. Blood test for ESR and CRP were carried out at different times before and after operation. RESULTS The average ESR was (79.4 +/- 35.6) mm/h, and the average CRP was (44.3 +/- 17.5) mg/L before chemotherapy, indicating active tuberculosis focus. After 4 to 6 weeks chemotherapy, the average ESR was (45.3 +/- 21.0) mm/h,and the average CRP was (26.7 +/- 11.8) mg/L, the differences were statistically (P < 0.05), and the clinical symptoms of spinal tuberculosis relieved in all patients. Four weeks after operation, the average ESR dropped to (42.8 +/- 16.5)mm/h, the average CRP dropped to (23.8 +/- 10.0) mg/L statistically (P < 0.05). Eight weeks after operation, the average value of ESR and CRP were at normal level in 47 cases, indicating inactive tuberculosis focus. Focus healing was achieved in 65 patients after short-term chemotherapy. CONCLUSION The level of ESR and CRP are high in active spinal tuberculosis and low when focus controlled. ESR and CRP are reliable parameters in evaluation the treatment and prognosis of spinal tuberculosis.

OBJECTIVE:To evaluate the exploratory development of bone graft by titanium mesh with bone allograft in treatment of cervical spinal tuberculosis. METHODS:Thirty two cases of cervical spinal tuberculosis treated with anterior radical debridement, decompression and inter fixation from January 2002 to January 2007 were included (at least two years follow-up). 18 male and 14 female, age from 18 to 72, mean 41.3 years old. 0.5 - 15.0 months before visit, mean 6.9 months. There were 13 cases in initial treatment group and 19 cases in retreatment group. All cases were divided into two groups (group A and group B) by resource of bone graft. Group A, titanium mesh with bone allograft, 17 cases. Group B, autograft with ilium, 15 cases. Operation time, blood loss, curing conditions, cervical curvature (absolute rotation angle, ARA), function of spinal cord and the rate for bone graft fusions in two groups were compared. The mean follow-up was 3.5 years (range 2 - 5 years). RESULTS:The primary healing rate of incisions was 93.8% (30/32), and total healing rate was 96.9% (31/32). There were no significant differences in operation time or in blood loss between two groups (P > 0.05). Operation time and blood loss, 72 min/121 ml in group A and 90 min/198 ml in group B, there were significant differences between two groups (P < 0.05). In each group, there were significant differences in the function of spinal cord between preoperative and immediately post operative, between preoperative and follow-up, and between immediately post operative and follow-up (P < 0.05), and there were significant differences in ARA between preoperative and immediately post operative, and between preoperative and follow-up (P < 0.05), and there were no significant differences between immediately post operative and follow-up (P > 0.05). On preoperative, immediately post operative and follow-up, there were no significant differences in the function of spinal cord or in ARA between two groups (P > 0.05). CONCLUSION:For cervical spinal tuberculosis followed by effective individual chemotherapy, a good effect can be obtained by treated with radical debridement and bone allograft with titanium mesh.

OBJECTIVE:To evaluate the mid- or long-term clinical results and the factors that influence the outcomes of prosthetic disc nucleus (PDN) replacement in the treatment of lumbar disc disease.METHODS:Thirty-four patients who underwent the PDN replacement from March 2002 to October 2003 were followed for an average of 52.6 months (range from 48 to 66 months). Twenty patients were discogenic low back pain, 14 patients were lumbar disc herniation. The follow-up results were evaluated by using the Oswestry disability index (ODI) and the visual analogue scales (VAS) through direct examinations and questionnaires. ODI was 58.4% preoperatively, and VAS was 7.4. Radiography was also used to measure the range of motion (ROM) and disc height of the operative segment, and findings were compared with those on preoperative radiographs.RESULTS:Twelve months after operation, a significant proportion of patients recovered from low back pain or leg pain, ODI decreased to averaged 18.2%. VAS decreased to 1.8, the average increase of the postoperative disc height was 17.6%, ROM was 9.2 degrees. At the final followup, all patients with deteriorated leg radicular symptoms improved, ODI increased from 18.2% 12 months after operation to averaged 31.2%. Low back pain became more serious in 18 patients. VAS increased from 1.8 to 3.1, the average decrease of the postoperative to preoperative disc height was 13.5%, ROM decreased to 6.8 degrees. The rate of degeneration or breakages of the end plates was 64.7% (22/34), implant device migrations were observed in 25 patients.CONCLUSIONS:The mid- or long-term outcome of PDN replacement in the treatment of degenerative lumbar disc disease is not as encouraging as that of the short-term follow-up. It is neither effective in term of restoration of the intervertebral disc height nor increase of the ROM of the operative segment, complication rates are significantly higher, and inferior results are to be expected. The selection of suitable surgical candidates and determination of valid indications for operative treatment are very important.

OBJECTIVE:To evaluate the surgical outcomes of spinal tuberculosis treated with transpedicular instrumentation and interbody auto-grafting.METHODS:Thirty-four patients of thoracolumbar tuberculosis were treated with transpedicular instrumentation, radical focus resection and interbody auto-grafting, combined with 6- or 9-month antituberculous medication from October 1996 to November 1998. All patients were followed-up prospectively for 3 to 5 years postoperatively.RESULTS:The back pain and tuberculous symptoms were relieved about one week postoperatively. The erythrocyte sedimentation rate came back to normal level from 4 to 6 weeks postoperatively. The solid interbody arthodesis was achieved from 4 to 6 months postoperatively. All patients were cured of tuberculous lesions in spinal column or in other region, and there were no tuberculous recurrence. In 12 patients, average preoperative kyphosis angle was 24 degrees (range 10 degrees approximately 32 degrees ), and that was 9 degrees (range 5 degrees approximately 13 degrees ) immediately after surgery. The average correction of kyphotic deformity was 15 degrees and was maintained unchanged in follow-up period postoperatively. Nine patients who had type-C or type-D neurological lesions, according to Frankel gradation, had complete recovery one year postoperatively.CONCLUSION:In spinal tuberculous operation, transpedicular instrumentation and interbody fusion are essential in providing rigid stabilization of spinal column, correcting or preventing kyphotic deformity, accelerating focus healing up and shortening chemotherapy period. Transpedicular instrumentation is necessary in short segments fixation and preserving functional unit of spine.