Abstract
Introduction
Osteotomized debridement (OD) is increasingly used in the treatment of active thoracolumbar tuberculosis (TB). So far, no nomenclature has been established to describe the patterns of OD, and thus the surgical outcomes cannot be directly analyzed and compared among the patients treated with different extents of OD. The purpose of this study was to establish a reliable classification of OD for further study of spinal TB.
Materials and Methods
This was a multicenter retrospective study. The proposed classification included 6 grades of OD based on sagittal range of vertebral body destruction: grade 0 involves single-level intervertebral disc and adjacent superficial endplates; grade 1 involves adjacent endplates and vertebral bodies, but no pedicle is involved; grade 2 involves adjacent endplates, vertebral bodies, and a lower or upper pedicle; grade 3 involves adjacent endplates, vertebral bodies, and both of lower and upper pedicles; grade 4 involves an entire vertebral body and an adjacent lower or upper pedicle; grade 5 involves two continuous entire vertebral bodies. Two hundred and five patients with active thoracolumbar TB who underwent OD surgery were included, and all ODs were classified. The reliability of this classification was evaluated twice by 10 readers, and Fleiss kappa coefficients were calculated.
Results
In the 205 patients, 208 ODs were performed. Grade 2 OD was the commonest type (98/208, 47.1%), followed by grade 1 (50/208, 24.0%), grade 3 (26/208, 12.5%), grade 0 (20/208, 9.6%), grade 4 (8/208, 3.8%), and grade 5 (6/208, 2.9%). The average accuracy of the two readings was 86.2% and 90.1%, respectively. The intra-rater reliability for the classification was “almost perfect agreement” with a Fleiss kappa coefficient average of 0.92. The inter-rater reliability was “almost perfect agreement” with a coefficient average of 0.89 for two readings.
Conclusions
This classification proved to be intuitive and reliable. The graded OD provides a platform for preoperative evaluation and allows comparative analysis of clinical outcomes in different extents of OD.
Similar content being viewed by others
Data availability
All data gathered can be requested from the corresponding author.
References
Dunn RN, Ben HM (2018) Spinal tuberculosis. The Bone and Joint Journal 100:425–431
Klöckner C, Valencia R (2003) Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine 28:1036–1042
Rajasekaran S (2012) Kyphotic deformity in spinal tuberculosis and its management. Int Orthop 36:359–365. https://doi.org/10.1007/s00264-011-1469-2
Wang YX, Zhang HQ, Li M, Tang MX, Guo CF, Deng A, Gao Q, Wu JH, Liu JY (2017) Debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only. Injury 48:378–383. https://doi.org/10.1016/j.injury.2016.12.025
Wang X, Pang X, Wu P, Luo C, Shen X (2014) One-stage anterior debridement, bone grafting and posterior instrumentation vs. single posterior debridement, bone grafting, and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis. Eur Spine J 23:830–837. https://doi.org/10.1007/s00586-013-3051-7
Pang X, Wu P, Shen X, Li D, Luo C, Wang X (2013) One-stage posterior transforaminal lumbar debridement, 360 degrees interbody fusion, and posterior instrumentation in treating lumbosacral spinal tuberculosis. Arch Orthop Trauma Surg 133:1033–1039. https://doi.org/10.1007/s00402-013-1751-4
Turgut M (2001) Spinal tuberculosis (Pott’s disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurg Rev 24:8–13. https://doi.org/10.1007/pl00011973
Ma S, Zhou Z, Wan Z, Duan P, Huang S, Xu J, Deng W, Wu C, Cao K (2022) Osteotomized debridement versus curetted debridement in posterior approach in treating thoracolumbar tuberculosis: a comparative study. Eur Spine J 31:473–481. https://doi.org/10.1007/s00586-021-07075-w
Garg B, Kandwal P, Nagaraja UB, Goswami A, Jayaswal A (2012) Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: a retrospective analysis. Indian J Orthop 46:165–170. https://doi.org/10.4103/0019-5413.93682
Zhang HQ, Li JS, Zhao SS, Shao YX, Liu SH, Gao Q, Lin MZ, Liu JY, Wu JH, Chen J (2012) Surgical management for thoracic spinal tuberculosis in the elderly: posterior only versus combined posterior and anterior approaches. Arch Orthop Trauma Surg 132:1717–1723. https://doi.org/10.1007/s00402-012-1618-0
Demirel M, Akgul T, Pehlivanoglu T, Karademir G, Bayram S, Dikici F, Sar C (2019) Posterior approach alone versus combined anterior and posterior approach in the management of vertebral tuberculosis. Turk Neurosurg 29:724–733. https://doi.org/10.5137/1019-5149.JTN.25968-19.3
Zhou Y, Li W, Liu J, Gong L, Luo J (2018) Comparison of single posterior debridement, bone grafting and instrumentation with single-stage anterior debridement, bone grafting and posterior instrumentation in the treatment of thoracic and thoracolumbar spinal tuberculosis. BMC Surg 18:71. https://doi.org/10.1186/s12893-018-0405-4
Li L, Xu J, Ma Y, Tang D, Chen Y, Luo F, Li D, Hou T, Zhou Q, Dai F, He Q, Zhang Z, (2014) Surgical strategy and management outcomes for adjacent multisegmental spinal tuberculosis: a retrospective study of forty-eight patients. Spine (Phila Pa 1976) 39:E40-48. https://doi.org/10.1097/BRS.0000000000000053
Feng Y, Wang YS, Lv J, Lv Z, Zhao B, Zhao S, Cheng CT (2020) Treatment of spinal tuberculosis of GATA Type III: primary posterior debridement combined with osteotomy parallel to the endplates for reconstruction. Orthop Surg 12:997–1004. https://doi.org/10.1111/os.12650
Ma S, Zhou Z, Yu H, Zhong J, Xiong J, Xu J, Deng W, Cao K (2022) Posterior approach with osteotomized debridement versus combined anterior and posterior approach in treating thoracolumbar tuberculosis: a retrospective cohort study. Global Spine J. https://doi.org/10.1177/21925682221123321
Ma S, Zhou Z, Yu H, Zhong J, Xiong J, Xu J, Deng W, Cao K (2022) Global spinal realignment after osteotomized debridement in active lumbar spinal tuberculosis: correlation with patient-reported outcomes. World Neurosurg 164:e1153–e1160. https://doi.org/10.1016/j.wneu.2022.05.120
Lee C, Vessa P, Lee J (1995) Chronic disabling low back pain syndrome caused by internal disc derangements. the results of disc excision and posterior lumbar interbody fusion. Spine 20:356–361. https://doi.org/10.1097/00007632-199502000-00018
Landis J, Koch G (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174. https://doi.org/10.2307/2529310
Ames CP, Smith JS, Scheer JK, Shaffrey CI, Lafage V, Deviren V, Moal B, Protopsaltis T, Mummaneni PV, Mundis GM Jr, Hostin R, Klineberg E, Burton DC, Hart R, Bess S, Schwab FJ, International Spine Study G (2013) A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction: clinical article. J Neurosurg Spine. https://doi.org/10.3171/2013.5.SPINE121067
Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, Ames C, Smith JS, Shaffrey CI, Glassman S, Farcy JP, Lafage V (2014) The comprehensive anatomical spinal osteotomy classification. Neurosurgery 74:112–120. https://doi.org/10.1227/NEU.0000000000000182o
Jin W, Wang Q, Wang Z, Geng G (2014) Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation. Spine J 14:964–970. https://doi.org/10.1016/j.spinee.2013.07.466
Qureshi MA, Khalique AB, Afzal W, Pasha IF, Aebi M (2013) Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis. Eur Spine J 22(Suppl 4):618–623. https://doi.org/10.1007/s00586-012-2459-9
Swanson AN, Pappou IP, Cammisa FP, Girardi FP (2006) Chronic infections of the spine: surgical indications and treatments. Clin Orthop Relat Res 444:100–106. https://doi.org/10.1097/01.blo.0000203447.44146.55
Wang LJ, Zhang HQ, Tang MX, Gao QL, Zhou ZH, Yin XH (2017) Comparison of three surgical approaches for thoracic spinal tuberculosis in adult: minimum 5-year follow up. Spine (Phila Pa 1976 https://doi.org/10.1097/BRS.0000000000001955
Wu P, Wang XY, Li XG, Shen XJ, Pang XY, Luo CK, Xu ZQ, Zeng H, Zhang PH, Peng W (2015) One-stage posterior procedure in treating active thoracic spinal tuberculosis: a retrospective study. Eur J Trauma Emerg Surg 41:189–197. https://doi.org/10.1007/s00068-014-0421-8
Hodgson A, Stock F, Fang H, Ong G (1960) Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. British J Surg 48:172–178. https://doi.org/10.1002/bjs.18004820819
Benli IT, Acaroglu E, Akalin S, Kis M, Duman E, Un A (2003) Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis. Eur Spine J 12:224–234. https://doi.org/10.1007/s00586-002-0403-0
Ma YZ, Cui X, Li HW, Chen X, Cai XJ, Bai YB (2012) Outcomes of anterior and posterior instrumentation under different surgical procedures for treating thoracic and lumbar spinal tuberculosis in adults. Int Orthop 36:299–305. https://doi.org/10.1007/s00264-011-1390-8
Pu X, Zhou Q, He Q, Dai F, Xu J, Zhang Z, Branko K (2012) A posterior versus anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis. Int Orthop 36:307–313. https://doi.org/10.1007/s00264-011-1329-0
Cui X, Li LT, Ma YZ (2016) Anterior and posterior instrumentation with different debridement and grafting procedures for multi-level contiguous thoracic spinal tuberculosis. Orthop Surg 8:454–461. https://doi.org/10.1111/os.12288
Kim BJ, Ko HS, Lim Y, Seo JG, Jeon TH (1993) The clinical study of the tuberculous spondylitis. J Korean Orthopaedic Association 28:2221
Zeng H, Shen X, Luo C, Xu Z, Zhang Y, Liu Z, Wang X (2015) Comparison of three surgical approaches for cervicothoracic spinal tuberculosis: a retrospective case-control study. J Orthop Surg Res 10:100. https://doi.org/10.1186/s13018-015-0238-0
Liu J, Wan L, Long X, Huang S, Dai M, Liu Z (2015) Efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal tuberculosis: a meta-analysis. World Neurosurg 83:1157–1165. https://doi.org/10.1016/j.wneu.2015.01.041
Funding
This work was funded by National Natural Science Foundation of China (No.81860473, 81460405), Key project of Natural Science Foundation of Jiangxi Provincial (No. 20202ACB206004), Major Discipline Academic and Technical Leaders Training Program of Jiangxi Province (No. 20204BCJ22026) and the Program of Health Commission of Jiangxi Province (No.20191029).
Author information
Authors and Affiliations
Contributions
KC and SM contributed to the study conception and design. Material preparation, data collection and analysis were performed by ZZ, ZG, WW, YW and RZ. The first draft of the manuscript was written by SM and ZZ and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
The data does not compromise anonymity or confidentiality or breach local data protection laws, and it is approved for publication by The First Affiliated Hospital of Nanchang University, General Hospital of Ningxia Medical University, The Second Affiliated Hospital of Kunming Medical University, and The Second Affiliated Hospital of Nanchang University.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Consent to publish
All participants gave their informed consent for the publication of all the figures and data.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Ma, S., Zhou, Z., Ge, Z. et al. A novel classification of osteotomized debridement based on the range of focus in treating active thoracolumbar tuberculosis: a multicenter study. Arch Orthop Trauma Surg 143, 5565–5574 (2023). https://doi.org/10.1007/s00402-023-04869-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-023-04869-z