Risk factors and interventions for surgical failure of spinal tuberculosis / 中华骨科杂志

ABSTRACT

Objective:To investigate the risk factors and interventions for surgical failure of spinal tuberculosis (STB).Methods:A total of 317 STB patients aged from 11 to 86 years with an average age of 53.5±16.7 years, who received debridement and fusion with bone grafting from January 2013 to December 2019, were retrospectively analyzed, including 206 males and 111 females. The follow-up duration was at least 1 year. During the follow-up, any one of the following 1)-3) was defined as surgical failure, namely 1) the same tubercular lesion treated by surgery more than 2 times, 2) the number of unplanned readmissions related to tubercular lesion≥1, 3) drug-resistant STB or delayed healing, recurrent lesion with cold abscess/sinus tract, combined with other bacterial infection, or loosening of internal fixation. The other cases were regarded as "curative" cases. Patients' symptoms, medication history, auxiliary examination and surgical plan were collected for univariate analysis. Further, the potential risk factors for surgical failure were analyzed by binary Logistic regression. Failed cases were treated with etiological intervention, such as puncture pumping pus or debridement or revision. The necrosis or granulation tissue was collected and further detected by tuberculosis culture, metagenomic next-generation sequencing (mNGS) and real-time fluorescent quantitative PCR (RT-qPCR).Results:There were 27 cases with surgical failure. Abscess or sinus tract formation was developed in 17 cases, which accounted for 63% (17/27). Among these patients, there were 3 cases of resistance to isoniazid or rifampicin and 2 cases of resistance to isoniazid and rifampicin (multidrug resistance, MDR). Seventeen cases were treated by anti-tuberculosis treatment, while 14 cases by puncture drainage (or puncture catheter irrigation) and 3 cases by debridement and suturing. Seven cases with wound infection or poor healing accounted for 26% (7/27). Among them, 5 kinds of pathogens were detected, none of which showed tuberculosis drug resistance. All of them were treated by anti-infection and debridement suturing, while 2 of them were treated with internal fixation removal. Three cases (11%, 3/27) with internal fixation loosening were treated by revision surgery. There was statistically significant difference between the failed group and the cured group in involved multi-/jumping segment, history of type 2 diabetes, a history of more than three basic diseases, CRP at one week after surgery, WBC at one week after surgery, time of first dose, operation duration and intraoperative blood loss ( P<0.10). Binary Logistic regression analysis showed that multi-/jumping segment ( OR= 3.513, P=0.047), CRP at one week after surgery ( OR=1.021, P=0.005), first dose time ≥20 weeks ( OR=2.895, P=0.039), blood loss ≥800 ml ( OR=5.950, P=0.001) and more than three basic diseases involved ( OR=3.671, P=0.027) were independent risk factors for surgical failure. Conclusion:Early diagnosis, especially the diagnosis of drug-resistant STB and standardized anti-tubercular treatment, should be carried out effectively. Puncture and drainage of abscess is an effective therapy to treat the cases with abscess/sinus tract formation. Some cases involved multi-/jumping segments could be with higher risk of failure after internal fixation. Thus, they should be treated individually with emphasis on the segmental stability reconstruction.