[Application of multimodal neuroelectrophysiological monitoring technology in surgical treatment of thoracic tuberculosis].

OBJECTIVE: To explore the value of multimodal neuroelectrophysiological monitoring technology in the evaluation of spinal cord and nerve root function for the treatment of thoracic tuberculosis with debridement and bone grafting and posterior internal fixation by transcostal transverse process approach. METHODS: The clinical data of 25 patients with thoracic tuberculosis underwent debridement and bone grafting and posterior vertebral arch internal fixation by transcostal transverse process approach from December 2018 to September 2019 was retrospectively analyzed. Among these 25 patients, including 14 males and 11 females;aged from 20 to 83 years old, with a mean of (63.45±9.65) years;there were 3 cases of single vertebral body destruction, 13 cases of 2 vertebral bodies destruction, and 9 cases of 3 or more vertebral bodies destruction. All surgical patients underwent intraoperative detection of somatosensory evoked potential(SEP) and transcranial electric stimulation-motor evoked potential(TES-MEP);and electromyography (EMG) was used to monitor the pedicle screw placement and lesion removal. The erythrocyte sedimentation rate(ESR) was used to evaluate the decline of inflammatory indexes, the visual analogue scale (VAS) was used to evaluate the thoracic spine pain, and the Cobb angle and Oswestry Disability Index(ODI) were used to evaluate the improvement of function. RESULTS: All 25 patients were successfully monitored. Five patients had abnormal SEP waveforms during operation, 3 cases were caused by intraoperative clearing of lesions and spinal cord compression during irrigation, timely replacement of instruments and gestures, and adjustment of irrigation water flow rate returned the waveform to normal; one case was caused by a decrease in systolic blood pressure, and the waveform returned to normal after timely treatment of increased blood pressure;after 1 case of SEP waveform abnormality, the operation was suspended for 10 minutes and recovered spontaneously, and the waveform abnormality did not reappear until the end of the operation. Seven patients had abnormal TES-MEP waveforms, 5 cases occurred when the pedicle screw was inserted, the nail path was adjusted in time, and the waveform recovered after nail repositioning;one case was caused by tilting the operation bed during operation, and the waveform gradually recovered after adjusting the tilt angle of operation bed; one case occurred during the correction of the pedicle screw and rod system, and the waveform gradually returned to normal after the contralateral screw and rod correction were completed during operation. In 5 cases, the EMG burst potential was detected at the same time when the TES-MEP waveform was abnormal. After adjustment, the EMG burst potential disappeared. There was no abnormality in the TES-MEP and SEP waveforms at the same time. Postoperative VAS, ESR, Cobb angle, and ODI were improved compared with preoperatively (P<0.05). CONCLUSION: In patients with thoracic tuberculosis, the use of debridement and bone grafting and posterior internal fixation by transcostal transverse process approach combined with intraoperative SEP, TES-MEP and EMG monitoring can timely reflect the spinal cord and nerve root function, avoid intraoperative injuries while achieving good fixation and lesion removal.

Multi-modal Neuroelectrophysiological Monitoring in the Treatment of Thoracic Tuberculosis with Debridement and Bone Grafting and Posterior Pedicle Screw Fixation via Costal Transverse Process Approach.

OBJECTIVE: To explore the value of multi-mode neuroelectrophysiological monitoring (MIOM) in evaluating spinal cord and nerve root function in the treatment of thoracic tuberculosis via costal transverse process approach. METHODS: From December 2017 to September 2019, a retrospective study of thoracic tuberculosis patients in our hospital was conducted. This study included 25 patients (14 men and 11 women). The average age of patients at the time of surgery was 63.3 years (range, 20-83 years). All patients (three cases with the destruction of a single vertebral body, 13 cases with the destruction of two vertebral bodies, and nine cases with the destruction of three or more vertebral bodies) underwent costal transverse process approach with debridement and bone grafting and internal fixation combined with intraoperative multimodal neuroelectrophysiological monitoring. During the operation, somatosensory evoked potential (SEP), transcranial electrical stimulation motor evoked potential (TES-MEP), and spontaneous electromyography (EMG) were used to monitor progress. ESR, visual analogue scale (VAS), Cobb angle, and Oswestry disability index (ODI) were statistically analyzed to evaluate the treatment effects and patient satisfaction. RESULTS: All 25 patients were successfully monitored. The follow-up time ranged from 12 to 21 months, with an average of 15.3 months. SEP waveform abnormalities occurred in five patients during the operation, the incidence rate was 28%. Of these five patients, three patients changed their instruments and postures, and adjusted the flushing water flow in time; one patient received pressure therapy in time; the operation was suspended for 10 min for one patient. There were seven cases with abnormal TES-MEP waveform, the incidence rate was 28%. Among these seven cases, five cases adjusted the nail path during the operation and adjusted the nail position in time. One case adjusted the inclination angle of the operating table in time; one case completed the contralateral nail stick correction in time; five of them had abnormal TES-MEP waveforms, and EMG burst potential was also detected, the incidence rate was 20%. After prompt treatment, the abnormal waveforms of all patients returned to normal; no abnormal waveforms, recurrence of tuberculosis, loosening of internal fixation, nerve and spinal cord dysfunction, etc. The VAS score, erythrocyte sedimentation rate (ESR), Cobb angle, and ODI scores of the patients 1 year after operation were significantly improved compared with 1 week after operation (P < 0.05). CONCLUSION: Multi-mode intraoperative electrophysiological detection combined with costal transverse process approach for the treatment of thoracic tuberculosis could avoid intraoperative nerve and blood vessel damage, reduce surgical risk, improve surgical efficiency, and ensure curative effect.

[Clinical study of movable external fixation for elbow tuberculosis].

OBJECTIVE: To compare clinical effect of movable external fixation and fusion fixation for the treatment of elbow tuberculosis. METHODS: From October 2013 to June 2019, 52 patients with elbow tuberculosis treated with standard antituberculosis therapy were divided into movable external fixation group and fusion fixation group according to treatment methods. In group A, there were 25 patients, including 11 males and 14 females, aged from 24 to 75 years old with an average of (42.81± 9.01) years old; the courses of diseases ranged from 2 to 9 months with an average of (3.96±1.45) months. In group B, there were 27 patients, including 15 males and 12 females, aged from 23 to 77 years old with an averageof (44.08±7.44) years old; the courses of diseases ranged from 2 to 7 months with an average of (3.88±1.67) months. All patients were performed focus debridement. Intraoperative blood loss, operative time were compared between two groups. VAS score before operation, 2 weeks and 12 months after operation were applied to evaluate pain relieve;Mayo elbow performance score (MEPS) before operation, 1 and 12 months after operation were used to evaluate clinical effect;changes of erythrocyte sedimentation rate (ESR) and Creactive protein, CRP) before operation, 3 weeks after antituberculosis therapy, 1 week and 6 months after operation were compared between two groups. RESULTS: All patients were followed up from 12 to 20 months with an average of (13.50±4.85) months. No mixed infection and recurrence of tuberculosis occurred. There were no statistical differences in intraoperative blood loss and operative time(P>0.05). There was difference in postoperative VAS score at 2 weeks between movable external fixation group (5.15±0.95) and fusion fixation group (4.04±0.84)(P<0.01);while no difference in postoperative VAS score at 12 months between two groups (P>0.05). No difference in ESR and CRP level between two groups before and after operation (P>0.05). Postoperative Mayo score at 1 and 12 months in movable external fixation group were (78.15±7.83) and (90.19±7.13);in fusion fixation group were (70.40±7.61) and (82.60±8.38);there were differences in Mayo score at different time points between two groups(P<0.01). CONCLUSION: For elbow tuberculosis, movable external fixation and fusion fixation have equal effect in operative time, amount of bleeding and control of tuberculosis infection indicator. Movable external fixation need earlier functional exercise, not conducive to pain relief at early stage, which may be better than fusion fixation, it is worth clinical promoting.

[One-stage posterior debridement combined with lumbar-ilium fixation and bone graft fusion for the treatment of lumbosacral tuberculosis].

OBJECTIVE: To investigate the clinical effect of One-stage posterior debridement combined with lumbar-ilium fixation and bone graft fusion for the treatment of lumbosacral tuberculosis. METHODS: The clinical data of 31 patients with lumbosacral tuberculosis treated by one-stage posterior debridement combined with lumbar-ilium fixation and bone graft fusion from January 2013 to February 2018 were retrospectively analyzed. There were 18 males and 13 females, aged from 18 to 77 years old with an average of (45.9±9.1) years. The lesion segment was form L4 to S2. The preoperative ASIA grading showed that 2 cases were grade B, 17 cases were grade C, 12 were grade D. Pre- and post-operative C reactive protein (CRP), visual analogue scale (VAS), erythrocyte sedimentation rate (ESR), ASIA grade, lumbosacral angle and intervertebral space height were analyzed, the surgery complications, stability of internal fixation, bone fusion were observed. RESULTS: All the 31 patients were followed up for 10 to 24 months with an average of (16.0±3.1) months. One patient with local infection and subcutaneous hydrops was cured by dressing change. Other 30 cases got primary healing without sinus formation and no recurrence of spinal tuberculosis. All the patients were cured, no internal fixation loosening and breakage were found. All bone fusion was successful with an average fusion time of (4.7±1.1) months. At the final follow-up, ESR and CRP were normal, the VAS was decreased from (6.13±1.21) points preoperatively to (1.92±0.57) pioints, the ASIA grading showed that 2 cases were grade C, 6 cases were grade D, and 23 cases were grade E. The lumbosacral angle and intervertebral space height was increased from preoperative (21.42±3.75) °, (7.84±0.41) mm to (27.21±3.12) °, (9.80±0.38) mm at the final follow-up, respectively. CONCLUSION: One-stage posterior debridement combined with lumbar-ilium fixation and bone graft fusion is a practicable, effective and safe method for the treatment of lumbosacral tuberculosis. It can be recommended in clinical application.