Application of a modified thoracoabdominal approach that avoids cutting open the costal portion of diaphragm during anterior thoracolumbar spine surgery.

PURPOSE: In the present prospective randomized controlled study, we compared the feasibility and effectiveness of our modified thoracoabdominal approach to anterior thoracolumbar spine surgery without cutting open the costal portion of diaphragm (extradiaphragmatic approach) with the traditional transdiaphragmatic thoracoabdominal approach. The traditional combined thoracoabdominal approach in anterior thoracolumbar surgery for spine tuberculosis is effective but seriously damages the diaphragm and causes various lung complications. We used an extradiaphragmatic approach for complete anterior debridement, bone grafting, and nerve decompression and compared its efficacy and complications with those of the traditional transdiaphragmatic thoracolumbar approach. METHODS: The study included 106 patients with spinal tuberculosis. After a standard preoperative chemotherapy regimen, all patients underwent posterior deformity correction and internal fixation, anterior debridement, decompression, and bone grafting. Patients were divided into the modified extradiaphragmatic thoracolumbar approach group (the modified group) and the traditional transdiaphragmatic thoracolumbar approach group (the traditional group). During the treatment, we strictly followed the standard chemotherapy regimen. RESULTS: The mean follow-up duration was 36.2 months (range 25-38 months). There were significant differences between the two groups in intraoperative blood loss, length of incision, recovery time, and postoperative complications but no significant differences in preoperative and postoperative erythrocyte sedimentation rates and C-reactive protein values, kyphosis, and neurologic function, recovery of ability to live and work, and postoperative healing of bone grafts. CONCLUSION: The modified extradiaphragmatic thoracolumbar approach for anterior thoracolumbar spine surgery is as effective as the traditional approach. However, associated surgical trauma is minimal, and the incidence of pulmonary complications is low.

A comparative study of a rabbit spinal tuberculosis model constructed by local direct infection via the posterior lateral approach.

The present study aims to establish a method of constructing a New Zealand rabbit spinal tuberculosis model by direct local infusion of M. tuberculosis H37Rv strain into the intervertebral disc space through the posterior lateral approach. Sixty-six New Zealand rabbits were pretreated with complete Freund's adjuvant and randomly divided into 4 group: the posterolateral approach model group (Group A, 25), ventral transverse process approach model group (Group B, 25), control group (Group C, 10), and blank group (Group D, 6). In Groups A and B, the bone holes were filled with gelatin sponge after drilling, and the local area was directly infused with 0.1 ml of M. tuberculosis H37Rv strain suspension. In Group C, the gelatin sponge was filled through the posterolateral approach and the local area was infused with 0.1 ml of normal saline suspension. In Group D, No specific treatment was performed. The general conditions of the experimental rabbits in each group were compared to those of a control group; the degree of vertebral body exposure, incision length, and complications of the two methods were compared; and the tuberculosis models were evaluated by imaging, histopathology, and bacterial culture. In Group A, the lateral side of the vertebral body was well exposed, the damage was mild, and no peritoneal rupture or gastrointestinal complications were observed. In Group B, the ventral side of the vertebral body and the intervertebral disc were exposed, and abdominal complications were more likely to occur. The survival rates of the experimental rabbits at 8 weeks after surgery were 92.0% in Group A, 88.00% in Group B, 90.0% in Group C, and 100% in Group D. MRI examinations showed that in Group A, the positive rate of radiographic bone findings was 86.9% at 4 weeks after surgery and 100% at 8 weeks after surgery; in Group B, the positive rate of radiographic bone findings was 78.2% at 4 weeks after surgery and 95.4% at 8 weeks after surgery. There was no significant difference between Groups A and B in the radiographic bone findings rate detected by the same imaging method at the same time point (P > 0.05). Eight weeks after surgery, bone destruction, paravertebral abscess, and caseous necrosis occurred in the vertebral bodies of surviving rabbits in Groups A and B. The BacT/ALERT 3D rapid culture system was used to culture the pus in the lesion, and the results showed that the positive rate of tuberculosis was 52.17% in Group A and 54.54% in Group B, and the difference was not statistically significant (P > 0.05). After pretreatment with complete Freund's adjuvant, direct infusion of the H37Rv strain of M. tuberculosis into the intervertebral disc space of New Zealand rabbits via the posterolateral approach and the ventral transverse process approach can successfully establish rabbit spinal tuberculosis models.

[COMBINED POSTERIOR AND ANTERIOR APPROACHES FOR RESECTION OF THORACOLUMBAR SPINAL HUGE DUMBBELL-SHAPED TUMOR].

OBJECTIVE: To investigate the surgical outcome of combined posterior and anterior approaches for the resection of thoracolumbar spinal canal huge dumbbell-shaped tumor. METHODS: Between January 2009 and March 2015, 12 patients with thoracolumbar spinal canal huge dumbbell-shaped tumor were treated by posterior approach and anterolateral approach through diaphragmatic crura and thoracoabdominal incision for complete resection. There were 9 males and 3 females, with an average age of 45 years (range, 30-65 years). The disease duration was 8-64 weeks (mean, 12.7 weeks). The tumor was located at T(12), L1 in 6 cases, at L(1,2) in 5 cases, and at L(2,3) in 1 case. The tumor size ranged from 4.3 cm x 4.0 cm x 3.5 cm to 7.5 cm x 6.3 cm x 6.0 cm. According to tumor outside the spinal involvement scope and site and based on the typing of Eden, 5 cases were rated as type b, 2 cases as type d, 4 cases as type e, and 1 case as type f in the transverse direction; two segments were involved in 8 cases, and more than two segments in 4 cases. The degree of tumor excision, tumor recurrence, and the spine stability were observed during follow-up. The verbal rating scale (VRS) was used to evaluate pain improvement. RESULTS: The average surgical time was 170 minutes (range, 150-230 minutes); the average intraoperative blood loss was 350 mL (range, 270-600 mL). All incisions healed by first intention, and no thoracic cavity infection and other operation related complication occurred. Of 12 cases, 10 were histologically confirmed as schwannoma, and 2 as neurofibroma. The patients were followed up 6 months to 6 years (mean, 31 months). Neurological symptoms were significantly improved in all patients, without lower back soreness. The thoracolumbar X-ray film and MRI showed no tumor residue. No tumor recurrence, internal fixator loosening, scoliosis, and other complications were observed during follow-up. VRS at last follow-up was significantly improved to grade 0 (10 cases) or grade 1 (2 cases) from preoperative grade 1 (2 cases), grade 11 (8 cases), and grade III (2 cases) (Z = -3.217, P=0.001). CONCLUSION: Combined posterior approach and anterolateral approach through diaphragmatic crura and thoracoabdominal incision for complete resection of thoracolumbar spinal canal huge dumbbell-shaped tumor is feasible and safe, and can protect the stability of thoracolumbar spine and paraspinal muscle function. It can obtain satisfactory clinical result to use this method for treating the complex type of thoracolumbar spinal canal dumbbell-shaped tumor.