Mid- and Long-Term Efficacy of Surgical Treatment of L1-2 Vertebral Tuberculosis with Subdiaphragmatic Extraperitoneal Approach

Abstract

BACKGROUND The L1-2 vertebral segment is the most common site of spinal tuberculosis. Traditional thoracoabdominal surgery in this segment risks trauma and complications. This study analyzed the surgical efficacy of the subdiaphragmatic extraperitoneal approach in the treatment of L1-2 spinal tuberculosis. MATERIAL AND METHODS Retrospective analysis of 67 patients with L1-2 vertebral tuberculosis who underwent posterior internal fixation was performed: 35 patients underwent the subdiaphragmatic extraperitoneal approach (group A) and 32 underwent the thoracoabdominal approach (group B). Operation time, intraoperative blood loss, postoperative hospital stay, postoperative nerve function recovery, deformity correction, bone graft fusion, lesion healing, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complications were observed. RESULTS In group A and group B, intraoperative blood loss was 712.00±64.66 mL and 1104.38±131.34 mL; average operation time was 3.16±0.67 h and 5.16±1.07 h; and postoperative hospital stay was 9.60±2.64 days and 13.69±3.87 days, respectively. At 6 months and 5 years after surgery, neurological function, visual analog scale score, and Cobb angle of all patients were significantly improved compared with those before surgery; ESR and CRP decreased to normal levels; lesions completely cured; and all patients had good bone graft fusion. Pulmonary complications occurred in 2 patients in group A and in 14 patients in group B. CONCLUSIONS The efficacy of subdiaphragmatic extraperitoneal approach was similar to that of the thoracoabdominal approach for L1-2 spinal tuberculosis, but the former has the advantages of less surgical trauma, shorter operation time, less intraoperative bleeding, and fewer postoperative pulmonary complications.

Figure 1

The subdiaphragmatic extraperitoneal approach: (A) expose and remove the 12^th rib; (B) cut the abdominal wall muscles at the end of the ribbed bed and enter the extraperitoneum; (C) expose the psoas and square muscles; (D) cut the diaphragm and psoas attachment points lateral-anterior of the affected vertebra, push the crura of diaphragm upward, push the psoas away from the vertebra, and expose the L1–2 vertebral body and disc.

Figure 2

The thoracoabdominal approach: (A) expose and cut the 11^th rib; (B) cut the rib bed and abdominal wall muscles, enter the extraperitoneal cavity and the thoracic cavity, expose the diaphragm; (C) cut the diaphragm muscle 2 cm away from the 11^th rib attachment point; (D) expose L1–2 vertebral body and disc.

Figure 3

A 30-year-old male patient diagnosed with L1–2 vertebral tuberculosis was treated with posterior affected-vertebrae fixation, anterior subdiaphragmatic extraperitoneal approach for thorough lesion removal, and autologous iliac bone graft fusion. (A, B) Preoperative computed tomography (CT) showed obvious bone destruction. (C, D) Enhanced magnetic resonance imaging before surgery showed vertebral signal changes, vertebral bone destruction, and paravertebral abscess. (E–H) X-ray and CT at 6 months after surgery showed pedicle screw fixation and good bone graft fusion. (I–L) X-ray and CT 5 years after surgery showed that the pedicle screw had been completely removed, the lesion had completely cured, and the bone graft had completely fused.