Clinical Value of Metagenomic Next-Generation Sequencing Using Spinal Tissue in the Rapid Diagnosis of Spinal Tuberculosis.

Purpose: To evaluate the accuracy of metagenomic next-generation sequencing (mNGS) for rapid diagnosis of spinal tuberculosis using spinal tissue specimens. Methods: Medical data regarding suspected spinal tuberculosis were retrospectively analyzed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of mNGS were calculated to determine its diagnostic efficacy, and these values were compared with culture and composite reference standard (CRS). Results: Two hundred and three cases of spinal tuberculosis were included for analysis. The sensitivity, specificity, PPV, NPV, and AUC of mNGS compared with culture were all very good. When CRS was used for the comparison, the sensitivity of mNGS and culture were 71.2% and 73.0%; the specificity and PPV were 100% in all cases; the NPV were 74.2% and 75.4%; the AUCs were all 0.86. The sensitivity and NPV of culture were slightly higher than that of mNGS; however, the diagnostic efficacy of mNGS and culture was consistent (P > 0.05). Conclusion: Spinal tissue specimens for mNGS testing had very good accuracy for diagnosing spinal tuberculosis.

Unilateral biportal endoscopic foraminotomy and diskectomy combined with piezosurgery for treating cervical spondylotic radiculopathy with neuropathic radicular pain.

Objective: Unilateral biportal endoscopy (UBE) represents a relatively recent development in minimally invasive spine surgery. This study aimed to evaluate the efficacy and safety of UBE foraminotomy and diskectomy combined with piezosurgery for treating cervical spondylotic radiculopathy (CSR) with neuropathic radicular pain. Methods: We retrospectively analyzed the outcomes in 12 patients with CSR who underwent UBE foraminotomy and diskectomy combined with piezosurgery. The intraoperative blood loss, operative time, visual analog scale (VAS) scores for the neck and arm, neck disability index (NDI) scores, and complications were recorded. Results: Postoperative VAS scores of the neck and arm and NDI scores were significantly improved. Additionally, a postoperative CT scan revealed adequate enlargement of the cervical canal and nerve root. No specific complications occurred during surgery and the immediate postoperative period. Conclusions: This primary study indicated that the UBE foraminotomy and diskectomy with piezosurgery is a promising technique for treating cervical spondylotic radiculopathy with neuropathic radicular pain.

Comparison of Affected-Vertebra Fixation of Cortical Bone Trajectory Screw and Pedicle Screw for Lumbar Tuberculosis: A Minimum 3-Year Follow-Up.

Purpose: This study is aimed at comparing the clinical efficacy of cortical bone trajectory (CBT) screw fixation and pedicle screw (PS) fixation of the affected vertebrae in lumbar tuberculosis. Methods: We retrospectively analyzed the outcomes in 52 patients (27 cases in the CBT group, 25 cases in the PS group) with lumbar TB who underwent posterior affected-vertebra fixation combined with anterior debridement and bone grafting. The intraoperative blood loss, operative time, visual analog scale (VAS) scores for incision pain and leg pain, Japanese Orthopedic Association (JOA) score, bone grafting fusion, and complications were recorded. Results: All patients were followed up for 35-52 months and achieved good clinical outcomes. There were no differences between the two groups in the operative time, intraoperative blood loss, JOA score, bone grafting fusion, and complications. However, there was a significant difference between the two groups in VAS scores for incision pain on the 1st day and 3rd day after surgery. At the last follow-up, JOA scores were significantly improved in both groups compared to the preoperation. Conclusion: This retrospective study confirmed that both the affected-vertebra CBT screw fixation and PS fixation for lumbar TB via posterior and anterior approaches could achieve satisfactory outcomes, while the former resulted in better improvement for postoperative VAS scores.

[A preliminary study on the surgical timing of spinal tuberculosis].

OBJECTIVE: To observe the changes of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and nerve function in patients with spinal tuberculosis before and after surgery, explore the timing of surgical intervention, and evaluate its influence on surgical safety. METHODS: A retrospective analysis was conducted on 387 patients with spinal tuberculosis who received surgical treatment from March 2012 to March 2017, including 278 males and 109 females, aged 12 to 86 years old with an average of (49.9±19.1) years. There were 64 cases of cervical tuberculosis, 86 cases of thoracic tuberculosis, 76 cases of thoracolumbar tuberculosis and 161 cases of lumbar tuberculosis. There were 297 patients with single segmental involvementand 90 patients with multiple segmental involvement. Among them, 62 cases presented neurological damage, and preoperative spinal cord neurological function depended on ASIA grade, 5 cases of grade A, 8 cases of grade B, 39 cases of grade C, and 10 cases of grade D. According to the duration of preoperative antituberculosis treatment, the patients were divided into group A (256 cases, receiving conventional quadruple antituberculosis treatment for 2-4 weeks before surgery) and group B (131 cases, receiving conventional quadruple antituberculosis treatment for more than 4 weeks before surgery). The two groups were compared in terms of gender, age, preoperative complicated pulmonary tuberculosis, lesion site, lesion scope, surgical approach, drug resistance and other general clinical characteristics. ESR, CRP, visual analogue scale(VAS), Oswestry Disability Index (ODI), Frankel grade and postoperative complications were observed. RESULTS: All 387 patients were followed up for 12 to 36 (18.3±4.5) months. There were no significant differences in gender, age, preoperative pulmonary tuberculosis, lesion site, lesion range, surgical approach, preoperative drug resistance and other characteristics between two groups. A total of 32 patients in two groups did not heal after surgery, with an incidence rate of 8.27%. The VAS and spinal cord dysfunction index of the two groups were significantly improved after surgery (P<0.05), but there was no significant difference between two groups at the same time point (P>0.05) . From 1 to 14 days after operation, the neurological function began to gradually recover, and the neurological function grade was increased by 1 to 3 grades. From 3 months after operation to the final follow up, 52 cases recovered completely, 8 cases partially recovered, and 2 cases did not improve. There was no significant difference in ESR and CRP between two groups before admission, 1 month after surgery, and final follow-up (P>0.05). CONCLUSION: After 2-4 weeks of anti tuberculosis treatment before operation, patients with spinal tuberculosis could be operated upon with ESR and CRP in a descending or stable period. In principle, patients with spinal tuberculosis and paraplegia should be treated as soon as possible after active preoperative management of the complication without emergency surgery.

[Comparative analysis of binding multi-fold rib graft, iliac bone graft and titanium mesh graft during surgery of tuberculosis of thoracic vertebra].

OBJECTIVE: To compare the clinical effects of three different methods of binding multi-fold rib graft, iliac bone graft and titanium mesh graft in tuberculosis of thoracic vertebra by approach of transverse rib process. METHODS: A hundred and seven patients with tuberculosis of thoracic vertebra received surgical treatment from January 2010 to December 2016 were retrospectively analyzed. The patients were divided into three groups according different methods of bone graft. The surgical approach of the transverse rib process was used in all 107 patients, after thoroughly remove the necrotic tissue of tuberculosis, three different bone grafts were used respectively including iliac bone graft (36 cases, group A), binding multi-fold rib graft (35 cases, group B), titanium mesh bone graft (36 cases, group C). Perioperative indexes, the time required for bone graft during operation, intraoperation blood loss, the loss rate of the anterior edge of the lesion, Cobb angle, postoperative bone graft fusion time, spinal nerve recovery and Oswestry Disability Index were compared among three groups. RESULTS: All the patients were followed up for 13 to 24 months, and the operation time required for bone graft was (23.2±4.1) min in group A, (23.8± 4.4)min in group B, and (25.5±4.2) min in group C, with no statistically significant difference among three groups (P>0.05). Intraoperative blood loss was (541.6±35.3) ml in group A, (546.8±27.8) ml in group B, and (540.1±34.5) ml in group C, withno statistically significant difference among three groups(P>0.05). Preoperative anterior vertebral height loss rate was (46.0± 3.1)% in group A, (46.4±3.3)% in group B, and (45.3±3.6)% in group B;at the final follow up, the loss rate of anterior vertebral height among three groups was (8.6±5.0)%, (8.1±4.2)%, (9.4±4.3)%, respectively. There were no statistically significant differences before operation and final follow-up among three groups (P>0.05). Preoperative Cobb angle was (35.1±4.8)° in group A, (35.2±4.5)° in group B and (35.2±4.5)° in group C, with no statistically significant difference among three groups (P>0.05);postoperative at 3 days, Cobb angle in three groups was (15.1±3.6)°, (15.3±3.1)° and (15.2±3.4)°, respectively, there was no statistically significant difference among three groups (P>0.05);at the final follow-up, the Cobb angle among three groups was (17.7±3.3)°, (17.9±3.9)°, (18.6±3.6)°, respectively, with no statistically significant difference among three groups (P>0.05). The time of bone graft fusion was (5.6±0.5) months in group A, (5.6±0.6) months in group B and (5.8±0.6)months in group C, with no statistically significant difference among three groups (P>0.05). Frankel classification at the final follow up, 4 cases were grade B, 7 cases were grade C, 10 cases were grade D, and 86 cases were grade E. Spinal nerve function in all three groups recovered to a certain extent after treatment, with no statistically significant difference among three groups (P> 0.05). Oswestry Disability Index at the final follow-up showed no statistically significant difference among three groups (P> 0.05). CONCLUSION: The approach of transverse rib process for debridement of lesions can effectively treat tuberculosis of thoracic vertebra by binding multi-fold rib graft, iliac bone graft and titanium mesh graft, but binding multi-fold rib graft can effectively avoid iliac bone donor complications, and is an effective alternative to iliac bone graft, which is worth popularizing.

Application of 3-dimensional printing technology combined with guide plates for thoracic spinal tuberculosis.

BACKGROUND: To explore the accuracy and security of 3-dimensional (3D) printing technology combined with guide plates in the preoperative planning of thoracic tuberculosis and the auxiliary placement of pedicle screws during the operation. METHODS: Retrospective analysis was performed on the data of 60 cases of thoracic tuberculosis patients treated with 1-stage posterior debridement, bone graft fusion, and pedicle screw internal fixation in the Department of Orthopedics, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital from March 2017 to February 2019. There were 31 males and 29 females; age: 41 to 52 years old, with an average of (46.6 ±â€Š2.0) years old. According to whether 3D printing personalized external guide plates are used or not, they are divided into 2 groups: 30 cases in 3D printing group (observation group), and 30 cases in pedicle screw placement group (control group). A 1:1 solid model of thoracic spinal tuberculosis and personalized pedicle guide plates was created using the 3D printing technology combined with guide plates in the observation group. Stability and accuracy tests were carried out in vitro and in vivo. 30 patients in the control group used conventional nail placement with bare hands. The amount of blood loss, the number of fluoroscopy, the operation time, and the occurrence of adverse reactions related to nail placement were recorded. After the operation, the patients were scanned by computed tomography to observe the screw position and grade the screw position to evaluate the accuracy of the navigation template. All patients were followed up for more than 1 year. Visual Analogue Scale scores, erythrocyte sedimentation rate, and C-reactive protein were evaluated before surgery, 6 months after surgery, and 12 months after surgery. RESULTS: Sixty patients were followed up for 6 to 12 months after surgery. One hundred seventy-five and 177 screws were placed in the 3D printing group and the free-hand placement group, respectively. The rate of screw penetration was only 1.14% in the 3D-printed group (all 3 screws were grade 1) and 6.78% in the free-hand nail placement group (12 screws, 9 screws were grade 1 and 3 screws were grade 2). The difference was statistically significant (P = .047). The operation time of the 3D printing group ([137.67 ±â€Š9.39] minutes), the cumulative number of intraoperative fluoroscopy ([4.67 ±â€Š1.03] times), and the amount of intraoperative blood loss ([599.33 ±â€Š83.37] mL) were significantly less than those in the manual nail placement group ([170.00 ±â€Š20.48] minutes, [9.38 ±â€Š1.76] times, [674.6 ±â€Š83.61] mL). The differences were statistically significant (P < .05). There was no significant difference in VAS score and Oswestry disability index score between the 2 groups of patients before operation, 3 and 6 months after operation (P > .05). CONCLUSION: The 3D printing technology combined with guide plate is used in thoracic spinal tuberculosis surgery to effectively reduce the amount of bleeding, shorten the operation time, and increase the safety and accuracy of nail placement.

Treatment of single-segment suppurative spondylitis with the transforaminal endoscopic focal cleaning and drainage.

Objective: To evaluate the clinical value of the transforaminal endoscopic focal cleaning and drainage for suppurative spondylitis.Design: Retrospective study.Participants: Twenty-one patients with single-segment suppurative spondylitis.Interventions: All patients were treated with the transforaminal endoscopic focal cleaning and drainage.Outcome Measures: The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured before and after the operation. Visual analogue scale (VAS) was used to evaluate the relief of pain symptoms. Neurological function American Spinal Injury Association (ASIA) grade was used to evaluate the recovery of neurological function. The postoperative clinical efficacy of the patients was evaluated using the Kirkaldy-Willis functional scoring criteria. The stability of the spine and the recurrence of infection were evaluated by imaging data.Results: Postoperative bacteriological culture results showed positive in 15 cases and no bacteria growth in 6 cases. Besides, 16 cases were pathologically diagnosed. The ESR, CRP, and VAS scores at 2 weeks postoperatively and at the last follow-up were significantly improved compared with those at pre-operation. At the last follow-up, the clinical outcome was excellent in 17 cases, good in 3 cases, and fair in 1 case, according to the Kirkaldy-Willis functional scoring criteria; and the ASIA grade returned to normal. There was no significant difference in the Cobb angle between the last follow-up and the pre-operation. There was no recurrence of infection during the follow-up period.Conclusion: The transforaminal endoscopic focal cleaning and drainage is a minimally invasive, effective and safe surgical procedure for suppurative spondylitis.

[Application of cortical bone trajectory screw in elderly patients with lumbar tuberculosis].

OBJECTIVE: To explore the clinical effect of cortical bone trajectory screw technology combined with anterior mini-open debridement and prop graft for lumbar tuberculosis in elderly. METHODS: The clinical data of 22 patients with lumbar tuberculosis treated by cortical bone trajectory screw technology combined with anterior mini-open debridement and prop graft from February 2015 to December 2016 were retrospectively analyzed. There were 13 males and 9 females with an average age of (73.3±7.1) years old. The pre-operative Frankel grading showed that 2 cases were grade B, 5 cases were grade C, 6 were grade D, and 9 were grade E. Pre- and post-operative kyphosis Cobb angle, visual analogue scale (VAS), erythrocyte sedimentation rate(ESR) and the Frankel grade were analyzed, the conditions of complication, stability of internal plants, graft fusion were observed. RESULTS: All 22 patients were follow-up for 12 to 24 months with an average of (18.7±4.6) years. Two patients with contralateral psoas major muscle abscess enlarged at 3 months after operation and were cured by drainage under the guidance of type-B ultrasonic. Other 20 cases got primary healing without sinus formation and recurrence of spinal tuberculosis. At the final follow-up, the Frankel grading showed that 3 cases was grade C, 5 cases were grade D, and 14 cases were grade E. The Cobb angle, visual analogue scale (VAS), ESR were respectively decreased from preoperative(17.68±3.86)°, (6.95±2.26) points, (47.14±20.85)mm/h to (4.77±2.47)°, (2.18±1.59) points, (16.77±11.42) mm/h at final follow-up. X-ray and CT scan showed bone union for 3 to 8 months after operation, with a mean time of(4.9±1.2) months. CONCLUSIONS: It is effective method to treat lumbar tuberculosis with cortical bone trajectory screw technology combined with anterior mini-open debridement and prop graft.

Application of Cortical Bone Trajectory Screws in Elderly Patients with Lumbar Spinal Tuberculosis.

OBJECTIVE: To investigate the clinical efficacy of cortical bone trajectory (CBT) screws in the treatment of elderly patients with lumbar spinal tuberculosis. METHODS: A total of 45 elderly patients with lumbar spinal tuberculosis were allocated to 1 groups based on different surgical methods: 22 patients in group A received posterior CBT screw fixation combined with anterior debridement with a small incision and bone grafting, and 23 patients in group B underwent posterior pedicle screw fixation combined with anterior debridement with a small incision and bone grafting. The intraoperative blood loss, postoperative drainage volumes, Cobb angles, visual analogue scale scores, erythrocyte sedimentation rates (ESRs), and Frankel grades before and after surgery were analyzed. The surgical complications and spinal fusion were also assessed. RESULTS: After a 3-month follow-up, 2 patients in group A and 3 patients in group B experienced anterior psoas muscle abscesses, which were cured by a second surgery. The remaining patients were healed by the first surgery. Spinal fusion after bone graft required 3 to 8 months (average, 4.9 months). There were no significant differences in surgery time, blood loss, drainage volume, and hospital stay between the 2 groups. The visual analogue scale scores, Cobb angles, ESRs, and Frankel grades were significantly improved after surgery in both groups. CONCLUSION: The CBT screws were not inferior to traditional pedicle screws. The application of CBT- screws fixation combined with anterior debridement with a small incision and bone grafting was an effective and safe method to treat elderly patients with lumbar spinal tuberculosis.

[Eearly clinical effects of percutaneous endoscopic focal cleaning and drainage in the treatment of single-level suppurative spondylitis].

OBJECTIVE: To evaluate the clinical value of percutaneous endoscopic focal cleaning and drainage in the treatment of single-level suppurative spondylitis. METHODS: The clinical data of 18 patients with single-level suppurative spondylitis treated by percutaneous endoscopic focal cleaning and drainage from June 2014 to December 2015 were retrospectively analyzed. There were 11 males and 7 females, aged from 46 to 75 years old with an average of (58.89±9.46) years. According to the patient's diagnosis and drug sensitivity results to anti-infection therapy after operation. All the patients were followed up for 12 to 24 months with an average of(15.50±3.45) months. Disease control status was evaluated by laboratory examination of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) before and after operation. Relief of pain was evaluated using visual analogue scale(VAS). Nerve function was assessed by ASIA classification. Clinical effects were evaluated by Kirkaldy-Willis standard. Spinal stability and recurrence of infection were observed by imaging data. RESULTS: All the operations were successful, and no complication as hematoma, nerve injury, infection, cerebrospinal fluid leakage, sinus formation at the site of tube placement, or mixed infection were found. Postoperative bacteriological report was positive in 12 cases, while 6 cases showed no bacterial growth, and the infection status in 13 cases were confirmed by pathological examination. ESR, CRP, VAS at 2 weeks, 3 months after surgery and at the final follow-up were obviously improved(P<0.05). Clinical symptoms were improved significantly at 1 week to 3 months after operation. According to Kirkaldy-Willis standard to evaluate the clinical effect, 14 cases obtained excellent results, 3 good, and 1 fair. Nerve function recovery was based on ASIA grading at the final follow-up. The lost Cobb angles were (1.11±1.18)° on average, with no statistically significant difference before and after operation (P>0.05). During the follow-up, no recurrent infection has occurred. CONCLUSIONS: Percutaneous endoscopic focal cleaning and drainage is a minimally invasive, effective and safe surgical method, which serves as a new choice for surgical treatment of suppurative spondylitis.

Association between TLR-9 gene rs187084 polymorphism and knee osteoarthritis in a Chinese population.

Osteoarthritis (OA) is a complex disease that is induced by many genetic risk variants and other factors. To examine the role of toll-like receptor 9 (TLR-9) in OA patients, we conducted a case-control study involving 215 knee OA (KOA) patients and 215 controls in a Chinese population. Genotyping with a custom-by-design 48-Plex single nucleotide polymorphism Scan™ Kit showed the TLR-9 gene rs187084 polymorphism was associated with an increased risk of KOA. Stratification analyses further validated this finding among old people (age ≥ 55 years). In conclusion, TLR-9 gene rs187084 polymorphism is positively correlated with susceptibility to KOA, especially among old people. Nevertheless, this finding should be confirmed by larger size studies with more ethnic populations.

Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation.

BACKGROUND The aim of this study was to evaluate the efficiency and clinical outcomes of mini-open anterior approach focal cleaning combined with posterior internal fixation compared to conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in the treatment of lumbar tuberculosis (TB). MATERIAL AND METHODS Medical records from 124 patients were collected from February 2010 to April 2015; patients were divided into two groups: group A (mini-open anterior approach focal cleaning combined with posterior internal fixation) and group B (conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in period I). The data on postoperative mechanical ventilation time, preoperative, postoperative, and last follow-up Cobb angle, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and Frankel classification were collected and analyzed. Operative complications, internal stability, and bone graft fusion were also observed. RESULTS All patients were followed-up for 12 to 36 months (average 22.5 months). Seven cases (five in group A and two in group B) had side psoas abscess and were cured after secondary drainage surgery. The rest of the cases were all cured after primary surgery, with no formation of sinus, incisional hernia, cerebrospinal fluid leakage, or recurrence of spinal TB, with no TB symptoms. Bone graft fusion ranged from 3 to 8 months (average 4.7 months). Compared to group B, group A, which had less time on postoperative mechanical ventilation, had a higher VAS score. Both groups had distinct improvements in Cobb angle, ESR, and Frankel classification after surgery. CONCLUSIONS Treating lumbar TB by mini-open anterior approach focal cleaning combined with posterior internal fixation was safe and effective.

[Application value of Xpert MTB/RIF in diagnosis of spinal tuberculosis and detection of rifampin resistance].

OBJECTIVE: To investigate the application value of Xpert MTB/RIF in diagnosis of spinal tuberculosis and detection of rifampin resistance. METHODS: The 109 pus specimens were obtained from patients who were primaryly diagnosed as spinal tuberculosis. All of the pus specimens were detected by acid-fast stain, liquid fast culturing by BACTEC MGIT 960 and Xpert MTB/RIF assay to definite the differences in sensitivity and specificity of mycobacterium tuberculosis among detecting methods. Pus specimens obtained by different methods were deteceded by MTB/RIF test to analyze the self-influence on Xpert MTB/RIF test. The result of liquid fast culturing by BACTEC MGIT 960 was used as the gold standard; and the value of Xpert MTB/RIF assay in detecting rifampin resistance was analyzed. RESULTS: The sensitivity of acid-fast stain, liquid fast culturing by BACTEC MGIT 960 and Xpert MTB/RIF assay were 25.92%, 48.15%, 77.78%, respectively. The sensitivity of pus specimens obtained from open surgery, ultrasound positioning puncture and biopsy the sensitivity were 83.78%, 76.47%, 44.68% respectively deteceded by MTB/RIF test. According to the gold standard of the results of liquid fast culturing by BACTEC MGIT 960 assay, the sensitivity and specificity of Xpert MTB/RIF assay in detecting rifampin resistance were 80%(4/5) and 90.70%(39/43), respectively. CONCLUSIONS: Xpert MTB/RIF assay has higher value in diagnosis of spinal tuberculosi, and also can detect rifampin resistance. The number of mycobacterium tuberculosis in pus specimens has a great influence in the sensitivity of Xpert MTB/RIF assay.