Efficacy of single-stage posterior surgery for HIV-positive patients with thoracolumbar tuberculosis

According to the WHO Global Tuberculosis Report 2020 [18], an estimated 10 million people (8.9–11 million) were infected with tuberculosis in 2019. Tuberculosis is one of the most critical complications of HIV/AIDS. Previous studies have reported that the infection rate of HIV with tuberculosis was 25.20% [19], and some studies have reported up to 50% of HIV patients with tuberculosis [20].

Currently, there are no global or national epidemiological studies on spinal tuberculosis. However, it was found that spinal tuberculosis accounted for 69.11% of osteoarticular tuberculosis [6, 21], and elderly patients over 60 years accounted for 44.08%. 24.30% of the patients were 20–39 years old. 2.34% of patients were younger than 20 years old. Shi et al. [22] suggested that the most common site of spinal tuberculosis was the thoracic vertebra and lumbar vertebra, accounting for 47.47% and 59.57 respectively.

Bakhsh et al. [23] reported that the cure rate of spinal tuberculosis, especially in the early stage, could reach 85% with drug therapy alone, but the indications are relatively narrow, and kyphosis and other conditions may occur in the late stage, requiring surgical treatment. At present, it has been widely accepted that surgery should be performed timely in the treatment of spinal tuberculosis. Researchers reported that surgical treatment at the right time relieves pain quickly and can clear lesions and correct deformities. Unfortunately, there were few reports on the surgical treatment of HIV-positive spinal tuberculosis patients [24]. Risk assessment of surgical treatment and the choice of surgical timing is critical [12,13,14,15].

In this study, the nutritional status of patients in the two groups was evaluated preoperatively according to the clinical malnutrition assessment criteria. After nutritional support treatment, hemoglobin and albumin in 4 patients in the observation group were significantly increased. No statistical differences existed between the observation and control groups in hemoglobin, albumin, operative site, operative time, and blood loss. In the observation group, 7 patients had postoperative complications, including 4 with delayed wound healing due to malnutrition. In the control group, only 2 patients developed complications. However, there were no statistically significant differences in the incidence of postoperative complications between the two groups. At the same time, there were statistically significant differences in the count of CD4+T lymphocytes, hemoglobin, and albumin in the observation group with postoperative complications compared with those without complications. Nutritional support is vital in the perioperative management of HIV patients. Therefore, proper nutritional support, such as supplementing amino acids, albumin, and blood transfusion, is necessary.

In this study, one opportunistic infection, candida Albicans occurred in a patient with CD4+T lymphocyte count < 150 cells/ul. Due to surgical stress, the cellular immune function of HIV-positive patients may be impaired. When CD4+T lymphocyte count < 200 cells/ul, the probability of fatal opportunistic infections increases significantly [25]. We should evaluate the risk of surgery by combining the level of CD4+T lymphocytes before surgery. Non-healing wounds and infection may occur when CD4+T lymphocytes are lower than 200 cells/ul, leading to severe consequences [12, 26,27,28]. Therefore, patients undergoing surgery should receive antiviral therapy before surgery.

So far, the commonly used surgical treatment methods include the anterior approach, posterior approach, anterior and posterior approach combined with debridement, and bone graft fusion. However, there were still controversies about surgical methods [7,8,9,10,11].

Since spinal tuberculosis mainly involves the anterior and medial columns of the vertebral body, the anterior approach has apparent advantages in exposing the surgical field and directly entering the lesion site. Therefore, the anterior approach for debridement, bone graft, and instrumentation is primarily used in treating thoracolumbar tuberculosis and has achieved sound therapeutic effects. However, the anterior approach also has certain disadvantages. In addition to extensive exposure to lesions, cutting off a large number of initially healthy tissues is necessary, resulting in more incredible trauma than the posterior approach, which may result in relatively more complications [29]. At the same time, correcting severe kyphosis by anterior approach is often challenging to achieve the same satisfying effect as the posterior approach and may even lead to the decline of spinal stability after decompression [30, 31].

With the recent improvement of MRI, CT, and ultrasound techniques, posterior surgery has gradually achieved satisfactory results in debridement. At the same time, because of the excellent effect of posterior instrumentation in the correction of kyphosis, the choice of posterior surgery for spinal tuberculosis is more common. In contrast, the posterior approach has a simple anatomical structure, short operative time, less intraoperative blood loss, and a significantly reduced possibility of anterior organ injury. As the most common technique in spinal surgery, it is much easier to master this technique with the assistance of an X-ray or surgical navigation system than to be familiar with the complex anatomical relationship between the anterior approach and the risk of injury to vital organs, blood vessels, and nerves in the thoracic and abdominal cavity. Lee et al. [32] proposed that posterior debridement, bone graft fusion, and instrumentation are effective methods for treating thoracolumbar tuberculosis. Zhang et al. [33,34,35,36] reported the clinical efficacy of single-stage posterior debridement and interbody fusion and instrumentation in treating thoracolumbar spinal tuberculosis in several studies, believing that this operation has the advantages of minor trauma, good orthopedic effect, and good efficacy. Zhao et al. [37] believed that compared with the anterior approach, the posterior approach could better correct kyphosis. The most significant disadvantage of this method is that the lesion is not cleared, and the firmness of the bone graft is not as good as that of the anterior approach. Zeng et al. [38] reviewed 177 cases of thoracolumbar tuberculosis. They pointed out that the correction rate of kyphosis and spinal stability of the posterior approach was significantly better than that of the anterior approach, comparable to that of the combined anterior and posterior approach. In addition, the amount of intraoperative blood loss and operative time were significantly less/shorter than that of the anterior and combined anterior and posterior approaches, suggesting that the posterior approach is superior to the other two methods and plays an essential role in thoracolumbar tuberculosis.

In this study, 26 patients with thoracolumbar tuberculosis underwent single-stage posterior debridement, interbody bone graft fusion, and instrumentation. Symptoms in patients had significantly improved, and recovery of neurological function and correction rate of kyphosis was satisfactory. Long-term follow-up showed good bone graft fusion, no significant angle loss, and no tuberculosis recurrence. In addition, there were no significant differences in the time of bone graft fusion, VAS score, ASIA scale, correction rate of kyphosis, and angle loss between the two groups. Therefore, we believe that the posterior approach is safe, effective, and feasible in treating HIV-positive thoracolumbar tuberculosis. However, the sample size of this study is small, which requires further observation and clinical evaluation of long-term efficacy with large sample size.

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