PEER-REVIEW REPORTS
Efficacy and Safety of Posterior Versus Combined Posterior and Anterior Approach for the Treatment of Spinal Tuberculosis: A Meta-Analysis Jiaming Liu1, Linyue Wan2, Xinhua Long1, Shanhu Huang1, Min Dai1, Zhili Liu1
Key words Meta-analysis - Posterior approach - Posterior and anterior approach - Spinal tuberculosis -
Abbreviations and Acronyms CI: Confidence interval MD: Mean difference OR: Odds ratio TB: Tuberculosis
- OBJECTIVE:
Surgical treatment is an important strategy for the treatment of spinal tuberculosis (TB). Several approaches have been reported for the surgery. However, no single study has had a large enough sample population to definitively determine whether the single posterior approach is as effective and safe as the combined posterior and anterior approach for the treatment of spinal TB. A meta-analysis was conducted to evaluate the clinical efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal TB.
- METHODS:
Available online: www.sciencedirect.com
In this meta-analysis, electronic databases, such as PubMed, MEDLINE, EMBASE, Google scholar, and Cochrane library, were searched to select the potentially relevant reports that compared the outcomes of the posterior approach (group A) with the combined posterior and anterior approach (group B) in the treatment of spinal TB. Relevant journals and references were also searched manually. Data extraction and quality assessment were according with Cochrane Collaboration guidelines. Outcome assessments were operation time, blood loss, correction of angle, loss of correction, hospital stay, fusion time of the grafting bone, neurological improvement, and complications after surgery. Results were expressed as odds ratio for dichotomous outcomes and mean difference for continuous outcomes with 95% confidence interval.
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
- RESULTS:
From the 1Department of Orthopedics Surgery, the First Affiliated Hospital of Nanchang University and 2Scientific Research Department, Jiangxi Vocational and Technical College of Information Application, Nanchang, People’s Republic of China To whom correspondence should be addressed: Zhili Liu, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:1157-1165. http://dx.doi.org/10.1016/j.wneu.2015.01.041 Journal homepage: www.WORLDNEUROSURGERY.org
INTRODUCTION Spinal tuberculosis (TB) is a common extrapulmonary manifestation of the disease, which is found in approximately 50% of the bone and joint of patients with spinal TB, with 75% of cases accompanied by paraspinal abscess (11). It is generally accepted that spinal TB is the most dangerous of any bone and joint TB because of its ability to cause bone destruction, deformity, and paraplegia (9). At present, potent antituberculous chemotherapy remains an irreplaceable treatment for TB spondylitis. However, in some cases surgical treatment is an essential strategy (12, 16, 22). Various surgical interventions have been reported in patients with spinal TB. The anterior approach to the spine allows direct access to the infected focus and is convenient for debriding/reconstructing the defect (1, 8). However, it may reduce the biomechanical stability of the spine and it is common to find residual kyphosis at the end of treatment (17). The combined anterior and
Five controlled clinical trials published between 2012 and 2014, involving 253 patients (group A, 129; group B, 124) with spinal TB were retrieved in this study. The overall meta-analysis showed that there were significant differences (P< 0.01) between groups A and B in operation time, blood loss, hospital stay, and complications after surgery. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after surgery between groups A and B.
- CONCLUSIONS:
The posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of sinal TB. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making.
posterior approach helps overcome the stability-related drawbacks of the anterior approach and recently has been popular (7, 13, 23). The single posterior approach is an effective and safe method in treatment of spinal TB (15). Whether the clinical outcomes of the single posterior approach for the treatment of spinal TB are superior to the combined posterior and anterior approach
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
still remains a subject of controversy (20, 24-27). To achieve an integrative understanding of the clinical response of patients who underwent the posterior approach (group A) or the combined posterior and anterior approach (group B), a systematic review of relevant controlled trials and a meta-analysis was conducted to clarify the differences in these 2 approaches.
www.WORLDNEUROSURGERY.org
1157
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Table 1. Characteristics of Studies Included in the Meta-Analysis Study
Country
Type of Study
Sample Size Age (year)
Follow-up Location of (month) Tuberculosis
Medical Treatment
Bone Graft
Zhang et al., 2012 (26)
China Retrospective cohort study
20/16 68.4 (65e76) 35.1 (26e45) Thoracic spine
Wang et al., 2013 (24)
China Retrospective study
60/55 48.6 (18e76) 21.3 (12e36) Thoracic and Chemotherapy 2e4 weeks before Strut grafts lumbar spine surgery, 9e12 months after surgery
Soares do Brito et al., 2013 (20)
Portugal Retrospective study
Zhang et al., 2013 (28)
China Retrospective study
19/18 41.2 (6e63) 46.6 16.7 Lumbar spine Chemotherapy 3 weeks before 47.5 15.0 surgery, 12e15 months after surgery
Zeng et al., 2014 (26)
China Retrospective study
19/20
11/15
46.7
4e24
QAS
Chemotherapy 3e5 weeks before Bicortical iliac bone allograft surgery, 12e15 months after surgery
Thoracic and 14 months lumbar spine
41 (20e75) 39.1 12.0 Lumbosacral 38.5 (19e67) 40.7 12.4 spine
18
16
—
12
Titanium mesh cage filled with bicortical iliac bone allograft/ allograft
17
Chemotherapy 2e4 weeks before Allogeneic iliac bone/allograft surgery, 9e12 months after bone surgery
18
QAS, Quality assessment score.
Table 2. The Clinical Outcomes in Group A Versus Group B of Studies Included Study
Operation Time (minutes)
Blood Loss (mL)
Correction of Angle ( )
Loss of Hospital Stay Fusion Time Correction ( ) (days) (months)
Fusion Rate (%)
Neurological Improvement
Complications
Zhang et al., 2012 (26) Group A
262.1 43.5
632.5 227.0
9 3.4
2.7 1.9
18.8 2.7
8.1 1.8
100
7/14
3
Group B
445.6 91.4
1159.4 349.4
9.4 4.2
3.2 1.4
22.9 3.5
7.8 1.7
100
7/11
12
Wang et al., 2013 (24) Group A
160.4 20.5
760.7 146.2
14.1 6.4
1.7 0.8
13.6 3.2
9.72.5
95
36/45
1
Group B
231.4 27.3
1023.8 197.9
14.7 9.1
2.1 0.9
18.7 3.6
7.82.1
100
34/44
5
Soares do Brito et al., 2013 (20) Group A
—
—
12.7 4.7
4.9 2.1
—
10.6 2.1
100
2/3
1
Group B
—
—
8.7 3.6
2.6 1.4
—
10.6 2.2
100
1/2
1
Zhang et al., 2013 (28) Group A
207.9 30.9
409.5 107.9
22.7 6.8
1.6 0.6
—
8.3 1.7
100
15/17
0
Group B
349.7 38.9
840.0 168.7
21.1 5.9
1.3 0.5
—
7.9 1.9
100
15/16
0
1.2 0.82
14.2 1.3
6.6 1.8
100
16/17
4
17.5 4.3
6.4 1.4
100
17/18
10
Zeng et al., 2014 (26) Group A
163.7 72.9
283.0 80.5
7.9 3.5
Group B
347.5 76.2
380.0 252.5
7.3 3.1
1158
www.SCIENCEDIRECT.com
1.06 0.7
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS
Identification
JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Records identified through database searching (n = 855)
Additional records identified through other sources (n = 0)
Eligibility
Screening
Records after duplicates removed (n = 267)
Records screened (n = 267)
Records excluded (n = 233)
Full-text articles assessed for eligibility (n = 34)
Full-text articles excluded, with reasons (n = 29)
Included
Studies included in qualitative synthesis (n = 5)
Studies included in quantitative synthesis (meta-analysis) (n = 5) Figure 1. Flow chart showing identification and selection of studies.
METHODS Search Strategy The public databases including PubMed (1966epresent), MEDLINE (1966epresent), EMBASE (1974epresent), Springer (1996epresent), Cochrane Library (most recent edition), and Google Scholar were
searched for relevant reports published up to March 2014, according to the Cochrane Collaboration guidelines. The search terms were “posterior,” “posterior and anterior,” “spinal tuberculosis,” “thoracic and lumbar tuberculosis,” “study,” and “trial.” Relevant journals and references from retrieved articles were also searched manually. Gray or
unpublished articles reported as a result of a meeting, website, and internal journal were also reviewed. There was no restriction on language. Inclusion and Exclusion Criteria of the Studies Trials with the following characteristics were included: 1) randomized, quasirandomized, or controlled clinical trials, 2) the subjects were patients with spinal TB, 3) the studies compared the clinical outcomes of the posterior approach with the combined posterior and anterior approach, and 4) full-text articles. The studies were excluded if they met the following criteria: 1) duplicate reports of earlier trials, 2) were reviews, letters, or comments. and 3) the data required was not clear in the studies. Quality Assessment and Data Extraction To assess the methodologic quality of the included studies, we used a modification of the generic evaluation tool used by the Cochrane Bone, Joint and Muscle Trauma Group (3). The methodologic quality of each trial was scored from 0e24. Initially, study titles and abstracts were read and then the full texts of potential relevant studies were screened to identify the finally eligible ones according to the inclusion criteria. Two authors (X.H.L. and S.H.H.) independently reviewed the literature. Disagreements were resolved by consensus or consultation with the senior reviewer (M.D. and Z.L.L.). Two authors (J.M.L. and L.Y.W.) independently extracted data from the included articles. Information regarding the study design, country of origin, patient demographics, outcomes, and follow-up
Figure 2. Forest plot of operation time of the surgery in group A versus group B.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
www.WORLDNEUROSURGERY.org
1159
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 3. Forest plot of blood loss during the surgery in group A versus group B.
duration for each treatment group was extracted. Data were managed using the Review Manager (RevMan) 5.2 software (The Cochrane Collaboration, Oxford, United Kingdom). We attempted to contact authors for supplementary information when the reported data were inadequate. Statistical Analysis The meta-analysis was undertaken using RevMan 5.2 (Cochrane Collaboration). We assessed the statistical heterogeneity of each study by using a standard c2 test (statistical heterogeneity was considered significant at P> 0.1) and the I2 statistic (4). An I2 value of 50% or more was considered to indicate substantial heterogeneity. When heterogeneity existed, pooled data were meta-analyzed using a random-effects model (10). Otherwise, a fixed-effects model was used for the analysis. Odds ratio (OR) and 95% confidence interval (CI) were calculated for dichotomous outcomes, whereas mean difference (MD) and 95% CI were used for continuous
outcomes. A P value < 0.05 was considered to be statistically significant. The funnel plot was used to test the publication bias of the literatures involved in the metaanalysis.
the studies are from China. The smallest sample size was 26 and largest was 115. The follow-up time of the included studies was from 4e47.5 months. Their quality assessment scores ranged from 12e18. Individual patient data were available from these articles.
RESULTS Study Characteristics A total of 855 titles, potentially relevant to the search terms, were identified initially. Most of the articles were excluded after review of the abstract and title for being unrelated to the topic at hand, not comparative studies, duplicate report, or for being case reports or review articles. Finally, only 5 articles satisfied the predefined inclusion criteria for data extraction and meta-analysis (20, 24-27) (Tables 1 and 2). The flow chart of the study selection and inclusion process is shown in Figure 1. The eligible studies were published between 2012 and 2014. These studies involved 129 patients in the posterior approach group (group A) and 124 patients in the combined posterior and anterior approach group (group B). Four of
Results of Data Analysis Operation Time. The data on operation time of the surgery was available in 4 studies (24-27), consisting of 237 patients (group A, 118; group B, 119). The randomeffects model was applied to determine the operation time between the 2 groups due to the evidence of heterogeneity (c2 ¼ 67.5, I2 ¼ 96%, P< 0.01). The pooled MD is 142.0 (95% CI 201.9 to 82.2; P< 0.01) for patients in group A compared with group B (Figure 2). It revealed that there was significant difference in the operation time between group A and group B, suggesting that the posterior approach group had less operation time than that of the combined posterior and anterior approach group.
Figure 4. Forest plot of correction of angle after surgery in group A versus group B.
1160
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 5. Forest plot of loss of correction at the final follow-up in group A versus group B.
Blood Loss. Four separate studies (24-27), consisting of 237 patients (group A, 118; group B, 119), were included in this metaanalysis. Because of heterogeneity among the literatures (c2 ¼ 25.7, I2 ¼ 88%, P< 0.01), the random-effects model was used and blood loss during surgery was found to be significantly different between group A and group B (MD ¼ 318.1, 95% CI 470.6 to 165.6; P< 0.01) (Figure 3). The result suggested that there was less blood loss using the posterior approach than that the combined posterior and anterior approach. Correction of Angle After Surgery. The summary of the meta-analysis for correction of angle after surgery is shown in Figure 4. The data of effect on correction of angle were available in all studies (2427), consisting of 253 patients (group A, 129; group B, 124). Homogeneity was observed among studies (c2 ¼ 5.48, I2 ¼ 27%, P ¼ 0.24), therefore the fix-effects model was applied to pool the results. No statistical significant difference was found in the correction of angle after
surgery between group A and group B (MD ¼ 0.71, 95% CI 0.43 to 1.94; P ¼ 0.26). Loss of Correction at the Final Follow-Up. All of the studies (24-27), consisting of 253 patients (group A, 129; group B, 124), were included to assess the overall effects of the loss of correction at the final follow-up. The random-effects model was used to determine the overall effects between the 2 groups because of heterogeneity among the literature (c2 ¼ 20.12, I2 ¼ 80%, P< 0.01) (Figure 5). The pooled MD is 0.16 (95% CI 0.38 to 0.70; P ¼ 0.57) for patients in group A compared with group B. The result suggested that there was no significant difference in the loss of correction between these two treatment groups at the final follow-up. Hospital Stay. Three studies (24-26), consisting of 190 patients (group A, 99; group B, 91), were included in this meta-analysis. No heterogeneity was observed among studies (c2 ¼ 2.45, I2 ¼ 18%, P ¼ 0.29), therefore the fix-effects model was applied
to pool the results. Significance difference was found in the hospital stay between group A and group B (MD ¼ 4.49, 95% CI 5.43 to 3.54; P< 0.01) (Figure 6). It indicated that the posterior approach group spent less time in the hospital than the combined posterior and anterior approach group.
Fusion Time and Fusion Rate of the Grafting Bone After Surgery. All of the studies reported the data on fusion time and fusion rate of the grafting bone after surgery (24-27). A total of 253 patients (group A, 129; group B, 124) were included to assess the overall effects of fusion time. Testing of heterogeneity was significant (c2 ¼ 9.97, I2 ¼ 60%, P ¼ 0.04), therefore the random-effects model was valid to conduct the meta-analysis. There was no significant difference in the fusion time of the grafting bone after surgery between group A and group B (MD ¼ 0.65, 95% CI 0.14 to 1.45; P ¼ 0.11) (Figure 7). The fusion rate of the grafting bone was 100% in both of groups in the studies, except for
Figure 6. Forest plot of hospital stay in group A versus group B.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
www.WORLDNEUROSURGERY.org
1161
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 7. Forest plot of the fusion time of the grafting bone in group A versus group B.
the Wang et al. (24) study (95% in group A and 100% in group B). Neurological Improvement After Surgery. The meta-analysis for neurological improvement after surgery is shown in Figure 8. Five studies (24-27), consisting of 187 patients (group A, 96; group B, 91), were included in this analysis. The fixedeffects model was used (c2 ¼ 0.96, I2 ¼ 0%, P ¼ 0.92) and neurological improvement was not found to be significantly different between groups A and B (OR ¼ 0.93, 95% CI 0.43 e 1.97; P ¼ 0.84). Complications After Surgery. Five studies (24-27), consisting of 253 patients (group A, 129; group B, 124), were included in this meta-analysis. No heterogeneity was observed among studies (c2 ¼ 3.96, I2 ¼ 24%, P ¼ 0.27), therefore the fixed-effects model was applied to pool the results. Significant different was found in
complications after the surgery between groups A and B (OR ¼ 0.19, 95% CI 0.08 e 0.45; P< 0.01). The result revealed that less complication occurred with the posterior approach than with the combined posterior and anterior approach. The meta-analysis is shown in Figure 9. Test of Publication Bias The funnel plot of the studies involved in this meta-analysis is shown in Figure 10. According to the funnel plot, the points representing the studies are nearly symmetrical. It is suggested that there was no significant publication bias among the studies involved in this meta-analysis. DISCUSSION Spinal TB can be treated by different approaches: anterior, combined anterior and posterior, or single posterior approaches (12, 16, 22). During the past 3 years, many
studies (24-27) have reported the clinical outcomes of the posterior approach versus the combined anterior and posterior approach for the treatment of spinal TB. However, these studies have shown contradictory results due to small sample sizes or low statistical power. In this metaanalysis, we combined 5 studies that compared the clinical outcomes of the posterior approach with the combined anterior and posterior approach in treating for 253 patients with spinal TB. The results indicated that there were significant differences (P< 0.01) in operation time, blood loss, hospital stay, and complications after the surgery between the 2 groups. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after the surgery between groups A and B. These results demonstrated that the
Figure 8. Forest plot of neurological improvement after surgery in group A versus group B.
1162
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 9. Forest plot of complications after the surgery in group A versus group B.
posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of spinal TB. Since Hodgson et al. (5) first reported their “Hong Kong operation” to treat spinal TB in 1960, various methods of surgical management in patients with spinal TB spondylitis have been reported (12, 16, 22). The aims of such procedures were debridement, spinal cord decompression, stability reconstruction, deformity correction, and late onset deformity prevention (12). Although the anterior approach has some advantages in allowing adequate debridement of the
infected focus, thorough decompression, and direct reconstruction of the vertebrae (1, 8), the disadvantages of increasing difficulty in performing internal instrumentation and the complicated anatomy anterior to the vertebrae present a significant challenge for surgeons (21). Some surgeons recommended the combined anterior and posterior approach in the treatment of spinal TB because of the advantages of a wider surgical field, the ability to thoroughly debride, the high rate of bone fusion, and the effective deformity correction (6, 28). However, longer operation time, greater blood loss, and double the surgical trauma for patients compared with the anterior approach were reported in this approach.
Figure 10. The funnel plot of the studies involved in the meta-analysis. The points that represented the studies included in the meta-analysis are nearly symmetrical according to the plot.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
With the development in treating spinal TB, the posterior approach has been proposed and has become popular. A posterior approach in combination with internal fixation and posterior or posterolateral fusion may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with spinal TB spondylitis (18). Pang et al. (14) and and Sahoo et al. (19) reported considerable success using one-stage posterior approach in the treatment of spinal TB. Guven et al. (2) also reported satisfactory function of stabilization and kyphosis prevention after posterior transpedicular debridement and instrumented fusion without anterior debridement. In a meta-analysis, Yang et al. (25) suggested that posterior instrumentation may have the same clinical outcome compared with anterior instrumentation in the treatment of spinal TB. However, controversy remains on whether the single posterior or the combined anterior and posterior approach is superior to be applied in the treatment of spinal TB. Huang et al. (6) reported that the onestage surgical management for children with spinal TB by anterior decompression, bone grafting, posterior instrumentation, and fusion was feasible and effective. Soares do Brito et al. (20) believed that the combined anterior and posterior or only the posterior surgical approach is similar in deformity correction and bone fusion for treating spinal TB. Zeng et al. (26) found that posterior surgery is feasible and effective, resulting in better clinical outcomes than combined posterior-anterior
www.WORLDNEUROSURGERY.org
1163
PEER-REVIEW REPORTS JIAMING LIU ET AL.
surgeries, especially in surgical time, blood loss, hospital stay, and complications. However, because of the small sample sizes and low statistical power, the evidence level of these studies was low. Therefore, we reviewed the literatures and combined 5 studies to compare the clinical outcomes of the posterior approach with the combined anterior and posterior approach in treating spinal TB. The results of our meta-analysis showed that the posterior approach appeared to have the same clinical efficacy than the combined posterior and anterior approach in the treatment of spinal TB. Although only published studies were included in the present meta-analysis, the funnel plot showed that the points were nearly symmetrical, suggesting that there was no significant publication bias among the involved studies. However, more studies are needed to decrease the publication bias. All the included studies compared group A to group B for the baseline clinical data. No significant differences were found between the 2 groups on the baseline data. Therefore, we believed that the selection bias in the included studies was low and the metaanalysis can be conducted. Some limitations of this study should be discussed. First, the recruited studies were not randomized controlled trials. The number of the included studies and the sample size of the patients were small, therefore there are still need more and high-quality randomized controlled trials to test and verify the results of this metaanalysis. Second, significant heterogeneities among studies were detected in the current meta-analysis, which may distort the pooled results. Third, the location of the TB lesion were different among the 5 studies. This may affect the surgical strategies and the outcomes. Four of the studies are published from China. We should interpret these results with caution because the population from each country was not uniform. Fourth, the use of variable outcome measures and different bone graft substitute may affect the outcomes and undermine informed decisionmaking.
META ANALYSIS OF APPROACH FOR TB
TB, the posterior approach appears to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complication rates compared with the combined posterior and anterior approach. However, the quality of the studies included was not satisfactory. More high-quality, randomized controlled trials are required to guide the selection of the surgical approach in patients with spinal TB. REFERENCES 1. Benli IT, Kaya A, Acaroglu E: Anterior instrumentation in tuberculous spondylitis: is it effective and safe? Clin Orthop Relat Res 460:108-116, 2007. 2. Guven O, Kumano K, Talcin S, Karahan M, Tsuji S: A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of spinal tuberculosis. Spine 19: 1039-1043, 1994. 3. Handoll HH, Gillespie WJ, Gillespie LD, Madhok R: The Cochrane Collaboration: a leading role in producing reliable evidence to inform healthcare decisions in musculoskeletal trauma and disorders. Indian J Orthop 42:247-251, 2008. 4. Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ 327:557-560, 2003. 5. Hodgson AR, Stock FE, Fang HS, Ong GB: Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 48:172-178, 1960. 6. Huang QS, Zheng C, Hu Y, Yin X, Xu H, Zhang G, Wang Q: One-stage surgical management for children with spinal tuberculosis by anterior decompression and posterior instrumentation. Int Orthop 33:1385-1390, 2009. 7. Jain AK, Dhammi IK, Jain S, Kumar J: Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions. Indian J Orthop 44:409-416, 2010. 8. Jain AK, Dhammi IK, Prashad B, Sinha S, Mishra P: Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. J Bone Joint Surg Br 90:1477-1481, 2008. 9. Jin D, Qu Dongbin, Chen J, Zhang H: One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J 13: 114-121, 2004.
manifestations in 63 patients. Acta Radiol 37: 506-511, 1996. 12. Mak KC, Cheung KM: Surgical treatment of acute TB spondylitis: indications and outcomes. Eur Spine J 22 (Suppl 4):603-611, 2013. 13. Masuda T, Miyamoto K, Hosoe H, Shimizu K: Comparative study on the efficacy of two-staged (posterior followed by anterior) surgical treatment using spinal instrumentation on pyogenic and tuberculotic spondylitis. Arch Orthop Trauma Surg 131:765-772, 2011. 14. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X: Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765-772, 2013. 15. Pang X, Wu P, Shen X, Li D, Luo C, Wang X: One-stage posterior transforaminal lumbar debridement, 360 interbody fusion, and posteriorinstrumentation in treating lumbosacral spinal tuberculosis. Arch Orthop Trauma Surg 133: 1033-1039, 2013. 16. Pola E, Rossi B, Nasto LA, Colangelo D, Logroscino CA: Surgical treatment of tuberculous spondylodiscitis. Eur Rev Med Pharmacol Sci 16 (Suppl 2):79-85, 2012. 17. Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T: Morphological changes during growth in healed childhood spinal tuberculosis. J Pediatr Orthop 26: 716-724, 2006. 18. Rawall S, Mohan K, Nene A: Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases. Musculoskelet Surg 97:67-75, 2013. 19. Sahoo MM, Mahapatra SK, Sethi GC, Dash SK: Posterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis: a retrospective study. J Spinal Disord Tech 25:E217-223, 2012. 20. Soares do Brito J, Batista N, Tirado A, Fernandes P: Surgical treatment of spinal tuberculosis: an orthopedic service experience. Acta Med Port 26:349-356, 2013. 21. Sansalone CV, Soldano S, Poli C, Tripepi M, D’Aliberti GA, Rossetti O: Anterior approach to the spine. Role of the general surgeon, techniques and surgicalcomplications. The 10-year experience of the Niguarda Hospitals. J Neurosurg Sci 55: 357-363, 2011. 22. Varatharajah S, Charles YP, Buy X, Walter A, Steib JP: Update on the surgical management of Pott’s disease. Orthop Traumatol Surg Res 100: 229-235, 2014.
CONCLUSIONS
10. Lau J, Ioannidis JP, Schmid CH: Quantitative synthesis in systematic reviews. Ann Intern Med 127:820-826, 1997.
23. Wang Z, Yuan H, Geng G, Shi J, Jin W: Posterior mono-segmental fixation, combined with anterior debridement and strut graft, for treatment of the mono-segmental lumbar spine tuberculosis. Int Orthop 36:325-329, 2012.
The results of this meta-analysis showed that in the surgical management of spinal
11. Lindahl S, Nyman RS, Brismar J, Hugosson C, Lundstedt C: Imaging of tuberculosis. IV. Spinal
24. Wang X, Pang X, Wu P, Luo C, Shen X: One-stage anterior debridement, bone grafting and posterior
1164
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
instrumentation vs. single posterior debridement, bone grafting, and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis. Eur Spine J 23:830-837, 2014. 25. Yang P, He X, Li H, Zang Q, Yang B: Clinical efficacy of posterior versus anterior instrumentation for the treatment of spinal tuberculosis in adults: a meta-analysis. J Orthop Surg Res 9:10, 2014. 26. Zeng H, Wang X, Pang X, Luo C, Zhang P, Peng W, Wu P, Xu Z: Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults. Eur J Trauma Emerg Surg 40:607-616, 2014.
META ANALYSIS OF APPROACH FOR TB
27. Zhang HQ, Li JS, Zhao SS, Shao YX, Liu SH, Gao Q, Lin MZ, Liu JY, Wu JH, Chen J: Surgical management for thoracic spinal tuberculosis in the elderly: posterior only versus combined posteriorand anterior approaches. Arch Orthop Trauma Surg 132:1717-1723, 2012. 28. Zhang HQ, Lin MZ, Li JS, Tang MX, Guo CF, Wu JH, Liu JY: One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg 133:333-341, 2013.
commercial or financial relationships that could be construed as a potential conflict of interest. This work is supported by Department of Science and Technology Program Funds of Jiangxi Province, P.R.China (No. 20122BBG70121-2) and the Youth Science Fund of Jiangxi Provincial Education Development, P.R. China (No. GJJ13028). Received 28 August 2014; accepted 19 January 2015; published online 16 February 2015 Citation: World Neurosurg. (2015) 83, 6:1157-1165. http://dx.doi.org/10.1016/j.wneu.2015.01.041 Journal homepage: www.WORLDNEUROSURGERY.org
Jiaming Liu and Linyue Wan are joint first authors. Conflict of interest statement: The authors declare that the article content was composed in the absence of any
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
1165
Efficacy and Safety of Posterior Versus Combined Posterior and Anterior Approach for the Treatment of Spinal Tuberculosis: A Meta-Analysis Jiaming Liu1, Linyue Wan2, Xinhua Long1, Shanhu Huang1, Min Dai1, Zhili Liu1
Key words Meta-analysis - Posterior approach - Posterior and anterior approach - Spinal tuberculosis -
Abbreviations and Acronyms CI: Confidence interval MD: Mean difference OR: Odds ratio TB: Tuberculosis
- OBJECTIVE:
Surgical treatment is an important strategy for the treatment of spinal tuberculosis (TB). Several approaches have been reported for the surgery. However, no single study has had a large enough sample population to definitively determine whether the single posterior approach is as effective and safe as the combined posterior and anterior approach for the treatment of spinal TB. A meta-analysis was conducted to evaluate the clinical efficacy and safety of posterior versus combined posterior and anterior approach for the treatment of spinal TB.
- METHODS:
Available online: www.sciencedirect.com
In this meta-analysis, electronic databases, such as PubMed, MEDLINE, EMBASE, Google scholar, and Cochrane library, were searched to select the potentially relevant reports that compared the outcomes of the posterior approach (group A) with the combined posterior and anterior approach (group B) in the treatment of spinal TB. Relevant journals and references were also searched manually. Data extraction and quality assessment were according with Cochrane Collaboration guidelines. Outcome assessments were operation time, blood loss, correction of angle, loss of correction, hospital stay, fusion time of the grafting bone, neurological improvement, and complications after surgery. Results were expressed as odds ratio for dichotomous outcomes and mean difference for continuous outcomes with 95% confidence interval.
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
- RESULTS:
From the 1Department of Orthopedics Surgery, the First Affiliated Hospital of Nanchang University and 2Scientific Research Department, Jiangxi Vocational and Technical College of Information Application, Nanchang, People’s Republic of China To whom correspondence should be addressed: Zhili Liu, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:1157-1165. http://dx.doi.org/10.1016/j.wneu.2015.01.041 Journal homepage: www.WORLDNEUROSURGERY.org
INTRODUCTION Spinal tuberculosis (TB) is a common extrapulmonary manifestation of the disease, which is found in approximately 50% of the bone and joint of patients with spinal TB, with 75% of cases accompanied by paraspinal abscess (11). It is generally accepted that spinal TB is the most dangerous of any bone and joint TB because of its ability to cause bone destruction, deformity, and paraplegia (9). At present, potent antituberculous chemotherapy remains an irreplaceable treatment for TB spondylitis. However, in some cases surgical treatment is an essential strategy (12, 16, 22). Various surgical interventions have been reported in patients with spinal TB. The anterior approach to the spine allows direct access to the infected focus and is convenient for debriding/reconstructing the defect (1, 8). However, it may reduce the biomechanical stability of the spine and it is common to find residual kyphosis at the end of treatment (17). The combined anterior and
Five controlled clinical trials published between 2012 and 2014, involving 253 patients (group A, 129; group B, 124) with spinal TB were retrieved in this study. The overall meta-analysis showed that there were significant differences (P< 0.01) between groups A and B in operation time, blood loss, hospital stay, and complications after surgery. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after surgery between groups A and B.
- CONCLUSIONS:
The posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of sinal TB. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making.
posterior approach helps overcome the stability-related drawbacks of the anterior approach and recently has been popular (7, 13, 23). The single posterior approach is an effective and safe method in treatment of spinal TB (15). Whether the clinical outcomes of the single posterior approach for the treatment of spinal TB are superior to the combined posterior and anterior approach
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
still remains a subject of controversy (20, 24-27). To achieve an integrative understanding of the clinical response of patients who underwent the posterior approach (group A) or the combined posterior and anterior approach (group B), a systematic review of relevant controlled trials and a meta-analysis was conducted to clarify the differences in these 2 approaches.
www.WORLDNEUROSURGERY.org
1157
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Table 1. Characteristics of Studies Included in the Meta-Analysis Study
Country
Type of Study
Sample Size Age (year)
Follow-up Location of (month) Tuberculosis
Medical Treatment
Bone Graft
Zhang et al., 2012 (26)
China Retrospective cohort study
20/16 68.4 (65e76) 35.1 (26e45) Thoracic spine
Wang et al., 2013 (24)
China Retrospective study
60/55 48.6 (18e76) 21.3 (12e36) Thoracic and Chemotherapy 2e4 weeks before Strut grafts lumbar spine surgery, 9e12 months after surgery
Soares do Brito et al., 2013 (20)
Portugal Retrospective study
Zhang et al., 2013 (28)
China Retrospective study
19/18 41.2 (6e63) 46.6 16.7 Lumbar spine Chemotherapy 3 weeks before 47.5 15.0 surgery, 12e15 months after surgery
Zeng et al., 2014 (26)
China Retrospective study
19/20
11/15
46.7
4e24
QAS
Chemotherapy 3e5 weeks before Bicortical iliac bone allograft surgery, 12e15 months after surgery
Thoracic and 14 months lumbar spine
41 (20e75) 39.1 12.0 Lumbosacral 38.5 (19e67) 40.7 12.4 spine
18
16
—
12
Titanium mesh cage filled with bicortical iliac bone allograft/ allograft
17
Chemotherapy 2e4 weeks before Allogeneic iliac bone/allograft surgery, 9e12 months after bone surgery
18
QAS, Quality assessment score.
Table 2. The Clinical Outcomes in Group A Versus Group B of Studies Included Study
Operation Time (minutes)
Blood Loss (mL)
Correction of Angle ( )
Loss of Hospital Stay Fusion Time Correction ( ) (days) (months)
Fusion Rate (%)
Neurological Improvement
Complications
Zhang et al., 2012 (26) Group A
262.1 43.5
632.5 227.0
9 3.4
2.7 1.9
18.8 2.7
8.1 1.8
100
7/14
3
Group B
445.6 91.4
1159.4 349.4
9.4 4.2
3.2 1.4
22.9 3.5
7.8 1.7
100
7/11
12
Wang et al., 2013 (24) Group A
160.4 20.5
760.7 146.2
14.1 6.4
1.7 0.8
13.6 3.2
9.72.5
95
36/45
1
Group B
231.4 27.3
1023.8 197.9
14.7 9.1
2.1 0.9
18.7 3.6
7.82.1
100
34/44
5
Soares do Brito et al., 2013 (20) Group A
—
—
12.7 4.7
4.9 2.1
—
10.6 2.1
100
2/3
1
Group B
—
—
8.7 3.6
2.6 1.4
—
10.6 2.2
100
1/2
1
Zhang et al., 2013 (28) Group A
207.9 30.9
409.5 107.9
22.7 6.8
1.6 0.6
—
8.3 1.7
100
15/17
0
Group B
349.7 38.9
840.0 168.7
21.1 5.9
1.3 0.5
—
7.9 1.9
100
15/16
0
1.2 0.82
14.2 1.3
6.6 1.8
100
16/17
4
17.5 4.3
6.4 1.4
100
17/18
10
Zeng et al., 2014 (26) Group A
163.7 72.9
283.0 80.5
7.9 3.5
Group B
347.5 76.2
380.0 252.5
7.3 3.1
1158
www.SCIENCEDIRECT.com
1.06 0.7
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS
Identification
JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Records identified through database searching (n = 855)
Additional records identified through other sources (n = 0)
Eligibility
Screening
Records after duplicates removed (n = 267)
Records screened (n = 267)
Records excluded (n = 233)
Full-text articles assessed for eligibility (n = 34)
Full-text articles excluded, with reasons (n = 29)
Included
Studies included in qualitative synthesis (n = 5)
Studies included in quantitative synthesis (meta-analysis) (n = 5) Figure 1. Flow chart showing identification and selection of studies.
METHODS Search Strategy The public databases including PubMed (1966epresent), MEDLINE (1966epresent), EMBASE (1974epresent), Springer (1996epresent), Cochrane Library (most recent edition), and Google Scholar were
searched for relevant reports published up to March 2014, according to the Cochrane Collaboration guidelines. The search terms were “posterior,” “posterior and anterior,” “spinal tuberculosis,” “thoracic and lumbar tuberculosis,” “study,” and “trial.” Relevant journals and references from retrieved articles were also searched manually. Gray or
unpublished articles reported as a result of a meeting, website, and internal journal were also reviewed. There was no restriction on language. Inclusion and Exclusion Criteria of the Studies Trials with the following characteristics were included: 1) randomized, quasirandomized, or controlled clinical trials, 2) the subjects were patients with spinal TB, 3) the studies compared the clinical outcomes of the posterior approach with the combined posterior and anterior approach, and 4) full-text articles. The studies were excluded if they met the following criteria: 1) duplicate reports of earlier trials, 2) were reviews, letters, or comments. and 3) the data required was not clear in the studies. Quality Assessment and Data Extraction To assess the methodologic quality of the included studies, we used a modification of the generic evaluation tool used by the Cochrane Bone, Joint and Muscle Trauma Group (3). The methodologic quality of each trial was scored from 0e24. Initially, study titles and abstracts were read and then the full texts of potential relevant studies were screened to identify the finally eligible ones according to the inclusion criteria. Two authors (X.H.L. and S.H.H.) independently reviewed the literature. Disagreements were resolved by consensus or consultation with the senior reviewer (M.D. and Z.L.L.). Two authors (J.M.L. and L.Y.W.) independently extracted data from the included articles. Information regarding the study design, country of origin, patient demographics, outcomes, and follow-up
Figure 2. Forest plot of operation time of the surgery in group A versus group B.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
www.WORLDNEUROSURGERY.org
1159
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 3. Forest plot of blood loss during the surgery in group A versus group B.
duration for each treatment group was extracted. Data were managed using the Review Manager (RevMan) 5.2 software (The Cochrane Collaboration, Oxford, United Kingdom). We attempted to contact authors for supplementary information when the reported data were inadequate. Statistical Analysis The meta-analysis was undertaken using RevMan 5.2 (Cochrane Collaboration). We assessed the statistical heterogeneity of each study by using a standard c2 test (statistical heterogeneity was considered significant at P> 0.1) and the I2 statistic (4). An I2 value of 50% or more was considered to indicate substantial heterogeneity. When heterogeneity existed, pooled data were meta-analyzed using a random-effects model (10). Otherwise, a fixed-effects model was used for the analysis. Odds ratio (OR) and 95% confidence interval (CI) were calculated for dichotomous outcomes, whereas mean difference (MD) and 95% CI were used for continuous
outcomes. A P value < 0.05 was considered to be statistically significant. The funnel plot was used to test the publication bias of the literatures involved in the metaanalysis.
the studies are from China. The smallest sample size was 26 and largest was 115. The follow-up time of the included studies was from 4e47.5 months. Their quality assessment scores ranged from 12e18. Individual patient data were available from these articles.
RESULTS Study Characteristics A total of 855 titles, potentially relevant to the search terms, were identified initially. Most of the articles were excluded after review of the abstract and title for being unrelated to the topic at hand, not comparative studies, duplicate report, or for being case reports or review articles. Finally, only 5 articles satisfied the predefined inclusion criteria for data extraction and meta-analysis (20, 24-27) (Tables 1 and 2). The flow chart of the study selection and inclusion process is shown in Figure 1. The eligible studies were published between 2012 and 2014. These studies involved 129 patients in the posterior approach group (group A) and 124 patients in the combined posterior and anterior approach group (group B). Four of
Results of Data Analysis Operation Time. The data on operation time of the surgery was available in 4 studies (24-27), consisting of 237 patients (group A, 118; group B, 119). The randomeffects model was applied to determine the operation time between the 2 groups due to the evidence of heterogeneity (c2 ¼ 67.5, I2 ¼ 96%, P< 0.01). The pooled MD is 142.0 (95% CI 201.9 to 82.2; P< 0.01) for patients in group A compared with group B (Figure 2). It revealed that there was significant difference in the operation time between group A and group B, suggesting that the posterior approach group had less operation time than that of the combined posterior and anterior approach group.
Figure 4. Forest plot of correction of angle after surgery in group A versus group B.
1160
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 5. Forest plot of loss of correction at the final follow-up in group A versus group B.
Blood Loss. Four separate studies (24-27), consisting of 237 patients (group A, 118; group B, 119), were included in this metaanalysis. Because of heterogeneity among the literatures (c2 ¼ 25.7, I2 ¼ 88%, P< 0.01), the random-effects model was used and blood loss during surgery was found to be significantly different between group A and group B (MD ¼ 318.1, 95% CI 470.6 to 165.6; P< 0.01) (Figure 3). The result suggested that there was less blood loss using the posterior approach than that the combined posterior and anterior approach. Correction of Angle After Surgery. The summary of the meta-analysis for correction of angle after surgery is shown in Figure 4. The data of effect on correction of angle were available in all studies (2427), consisting of 253 patients (group A, 129; group B, 124). Homogeneity was observed among studies (c2 ¼ 5.48, I2 ¼ 27%, P ¼ 0.24), therefore the fix-effects model was applied to pool the results. No statistical significant difference was found in the correction of angle after
surgery between group A and group B (MD ¼ 0.71, 95% CI 0.43 to 1.94; P ¼ 0.26). Loss of Correction at the Final Follow-Up. All of the studies (24-27), consisting of 253 patients (group A, 129; group B, 124), were included to assess the overall effects of the loss of correction at the final follow-up. The random-effects model was used to determine the overall effects between the 2 groups because of heterogeneity among the literature (c2 ¼ 20.12, I2 ¼ 80%, P< 0.01) (Figure 5). The pooled MD is 0.16 (95% CI 0.38 to 0.70; P ¼ 0.57) for patients in group A compared with group B. The result suggested that there was no significant difference in the loss of correction between these two treatment groups at the final follow-up. Hospital Stay. Three studies (24-26), consisting of 190 patients (group A, 99; group B, 91), were included in this meta-analysis. No heterogeneity was observed among studies (c2 ¼ 2.45, I2 ¼ 18%, P ¼ 0.29), therefore the fix-effects model was applied
to pool the results. Significance difference was found in the hospital stay between group A and group B (MD ¼ 4.49, 95% CI 5.43 to 3.54; P< 0.01) (Figure 6). It indicated that the posterior approach group spent less time in the hospital than the combined posterior and anterior approach group.
Fusion Time and Fusion Rate of the Grafting Bone After Surgery. All of the studies reported the data on fusion time and fusion rate of the grafting bone after surgery (24-27). A total of 253 patients (group A, 129; group B, 124) were included to assess the overall effects of fusion time. Testing of heterogeneity was significant (c2 ¼ 9.97, I2 ¼ 60%, P ¼ 0.04), therefore the random-effects model was valid to conduct the meta-analysis. There was no significant difference in the fusion time of the grafting bone after surgery between group A and group B (MD ¼ 0.65, 95% CI 0.14 to 1.45; P ¼ 0.11) (Figure 7). The fusion rate of the grafting bone was 100% in both of groups in the studies, except for
Figure 6. Forest plot of hospital stay in group A versus group B.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
www.WORLDNEUROSURGERY.org
1161
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 7. Forest plot of the fusion time of the grafting bone in group A versus group B.
the Wang et al. (24) study (95% in group A and 100% in group B). Neurological Improvement After Surgery. The meta-analysis for neurological improvement after surgery is shown in Figure 8. Five studies (24-27), consisting of 187 patients (group A, 96; group B, 91), were included in this analysis. The fixedeffects model was used (c2 ¼ 0.96, I2 ¼ 0%, P ¼ 0.92) and neurological improvement was not found to be significantly different between groups A and B (OR ¼ 0.93, 95% CI 0.43 e 1.97; P ¼ 0.84). Complications After Surgery. Five studies (24-27), consisting of 253 patients (group A, 129; group B, 124), were included in this meta-analysis. No heterogeneity was observed among studies (c2 ¼ 3.96, I2 ¼ 24%, P ¼ 0.27), therefore the fixed-effects model was applied to pool the results. Significant different was found in
complications after the surgery between groups A and B (OR ¼ 0.19, 95% CI 0.08 e 0.45; P< 0.01). The result revealed that less complication occurred with the posterior approach than with the combined posterior and anterior approach. The meta-analysis is shown in Figure 9. Test of Publication Bias The funnel plot of the studies involved in this meta-analysis is shown in Figure 10. According to the funnel plot, the points representing the studies are nearly symmetrical. It is suggested that there was no significant publication bias among the studies involved in this meta-analysis. DISCUSSION Spinal TB can be treated by different approaches: anterior, combined anterior and posterior, or single posterior approaches (12, 16, 22). During the past 3 years, many
studies (24-27) have reported the clinical outcomes of the posterior approach versus the combined anterior and posterior approach for the treatment of spinal TB. However, these studies have shown contradictory results due to small sample sizes or low statistical power. In this metaanalysis, we combined 5 studies that compared the clinical outcomes of the posterior approach with the combined anterior and posterior approach in treating for 253 patients with spinal TB. The results indicated that there were significant differences (P< 0.01) in operation time, blood loss, hospital stay, and complications after the surgery between the 2 groups. However, no significant differences (P> 0.05) were observed in correction of angle, loss of correction at the final follow-up, fusion time of the grafting bone, and neurological improvement after the surgery between groups A and B. These results demonstrated that the
Figure 8. Forest plot of neurological improvement after surgery in group A versus group B.
1162
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
META ANALYSIS OF APPROACH FOR TB
Figure 9. Forest plot of complications after the surgery in group A versus group B.
posterior approach appeared to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complications compared with the combined posterior and anterior approach in the treatment of spinal TB. Since Hodgson et al. (5) first reported their “Hong Kong operation” to treat spinal TB in 1960, various methods of surgical management in patients with spinal TB spondylitis have been reported (12, 16, 22). The aims of such procedures were debridement, spinal cord decompression, stability reconstruction, deformity correction, and late onset deformity prevention (12). Although the anterior approach has some advantages in allowing adequate debridement of the
infected focus, thorough decompression, and direct reconstruction of the vertebrae (1, 8), the disadvantages of increasing difficulty in performing internal instrumentation and the complicated anatomy anterior to the vertebrae present a significant challenge for surgeons (21). Some surgeons recommended the combined anterior and posterior approach in the treatment of spinal TB because of the advantages of a wider surgical field, the ability to thoroughly debride, the high rate of bone fusion, and the effective deformity correction (6, 28). However, longer operation time, greater blood loss, and double the surgical trauma for patients compared with the anterior approach were reported in this approach.
Figure 10. The funnel plot of the studies involved in the meta-analysis. The points that represented the studies included in the meta-analysis are nearly symmetrical according to the plot.
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
With the development in treating spinal TB, the posterior approach has been proposed and has become popular. A posterior approach in combination with internal fixation and posterior or posterolateral fusion may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with spinal TB spondylitis (18). Pang et al. (14) and and Sahoo et al. (19) reported considerable success using one-stage posterior approach in the treatment of spinal TB. Guven et al. (2) also reported satisfactory function of stabilization and kyphosis prevention after posterior transpedicular debridement and instrumented fusion without anterior debridement. In a meta-analysis, Yang et al. (25) suggested that posterior instrumentation may have the same clinical outcome compared with anterior instrumentation in the treatment of spinal TB. However, controversy remains on whether the single posterior or the combined anterior and posterior approach is superior to be applied in the treatment of spinal TB. Huang et al. (6) reported that the onestage surgical management for children with spinal TB by anterior decompression, bone grafting, posterior instrumentation, and fusion was feasible and effective. Soares do Brito et al. (20) believed that the combined anterior and posterior or only the posterior surgical approach is similar in deformity correction and bone fusion for treating spinal TB. Zeng et al. (26) found that posterior surgery is feasible and effective, resulting in better clinical outcomes than combined posterior-anterior
www.WORLDNEUROSURGERY.org
1163
PEER-REVIEW REPORTS JIAMING LIU ET AL.
surgeries, especially in surgical time, blood loss, hospital stay, and complications. However, because of the small sample sizes and low statistical power, the evidence level of these studies was low. Therefore, we reviewed the literatures and combined 5 studies to compare the clinical outcomes of the posterior approach with the combined anterior and posterior approach in treating spinal TB. The results of our meta-analysis showed that the posterior approach appeared to have the same clinical efficacy than the combined posterior and anterior approach in the treatment of spinal TB. Although only published studies were included in the present meta-analysis, the funnel plot showed that the points were nearly symmetrical, suggesting that there was no significant publication bias among the involved studies. However, more studies are needed to decrease the publication bias. All the included studies compared group A to group B for the baseline clinical data. No significant differences were found between the 2 groups on the baseline data. Therefore, we believed that the selection bias in the included studies was low and the metaanalysis can be conducted. Some limitations of this study should be discussed. First, the recruited studies were not randomized controlled trials. The number of the included studies and the sample size of the patients were small, therefore there are still need more and high-quality randomized controlled trials to test and verify the results of this metaanalysis. Second, significant heterogeneities among studies were detected in the current meta-analysis, which may distort the pooled results. Third, the location of the TB lesion were different among the 5 studies. This may affect the surgical strategies and the outcomes. Four of the studies are published from China. We should interpret these results with caution because the population from each country was not uniform. Fourth, the use of variable outcome measures and different bone graft substitute may affect the outcomes and undermine informed decisionmaking.
META ANALYSIS OF APPROACH FOR TB
TB, the posterior approach appears to have the same clinical efficacy, but with less operation time, blood loss, hospital stay, and complication rates compared with the combined posterior and anterior approach. However, the quality of the studies included was not satisfactory. More high-quality, randomized controlled trials are required to guide the selection of the surgical approach in patients with spinal TB. REFERENCES 1. Benli IT, Kaya A, Acaroglu E: Anterior instrumentation in tuberculous spondylitis: is it effective and safe? Clin Orthop Relat Res 460:108-116, 2007. 2. Guven O, Kumano K, Talcin S, Karahan M, Tsuji S: A single stage posterior approach and rigid fixation for preventing kyphosis in the treatment of spinal tuberculosis. Spine 19: 1039-1043, 1994. 3. Handoll HH, Gillespie WJ, Gillespie LD, Madhok R: The Cochrane Collaboration: a leading role in producing reliable evidence to inform healthcare decisions in musculoskeletal trauma and disorders. Indian J Orthop 42:247-251, 2008. 4. Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ 327:557-560, 2003. 5. Hodgson AR, Stock FE, Fang HS, Ong GB: Anterior spinal fusion. The operative approach and pathological findings in 412 patients with Pott’s disease of the spine. Br J Surg 48:172-178, 1960. 6. Huang QS, Zheng C, Hu Y, Yin X, Xu H, Zhang G, Wang Q: One-stage surgical management for children with spinal tuberculosis by anterior decompression and posterior instrumentation. Int Orthop 33:1385-1390, 2009. 7. Jain AK, Dhammi IK, Jain S, Kumar J: Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions. Indian J Orthop 44:409-416, 2010. 8. Jain AK, Dhammi IK, Prashad B, Sinha S, Mishra P: Simultaneous anterior decompression and posterior instrumentation of the tuberculous spine using an anterolateral extrapleural approach. J Bone Joint Surg Br 90:1477-1481, 2008. 9. Jin D, Qu Dongbin, Chen J, Zhang H: One-stage anterior interbody autografting and instrumentation in primary surgical management of thoracolumbar spinal tuberculosis. Eur Spine J 13: 114-121, 2004.
manifestations in 63 patients. Acta Radiol 37: 506-511, 1996. 12. Mak KC, Cheung KM: Surgical treatment of acute TB spondylitis: indications and outcomes. Eur Spine J 22 (Suppl 4):603-611, 2013. 13. Masuda T, Miyamoto K, Hosoe H, Shimizu K: Comparative study on the efficacy of two-staged (posterior followed by anterior) surgical treatment using spinal instrumentation on pyogenic and tuberculotic spondylitis. Arch Orthop Trauma Surg 131:765-772, 2011. 14. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X: Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765-772, 2013. 15. Pang X, Wu P, Shen X, Li D, Luo C, Wang X: One-stage posterior transforaminal lumbar debridement, 360 interbody fusion, and posteriorinstrumentation in treating lumbosacral spinal tuberculosis. Arch Orthop Trauma Surg 133: 1033-1039, 2013. 16. Pola E, Rossi B, Nasto LA, Colangelo D, Logroscino CA: Surgical treatment of tuberculous spondylodiscitis. Eur Rev Med Pharmacol Sci 16 (Suppl 2):79-85, 2012. 17. Rajasekaran S, Prasad Shetty A, Dheenadhayalan J, Shashidhar Reddy J, Naresh-Babu J, Kishen T: Morphological changes during growth in healed childhood spinal tuberculosis. J Pediatr Orthop 26: 716-724, 2006. 18. Rawall S, Mohan K, Nene A: Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases. Musculoskelet Surg 97:67-75, 2013. 19. Sahoo MM, Mahapatra SK, Sethi GC, Dash SK: Posterior-only approach surgery for fixation and decompression of thoracolumbar spinal tuberculosis: a retrospective study. J Spinal Disord Tech 25:E217-223, 2012. 20. Soares do Brito J, Batista N, Tirado A, Fernandes P: Surgical treatment of spinal tuberculosis: an orthopedic service experience. Acta Med Port 26:349-356, 2013. 21. Sansalone CV, Soldano S, Poli C, Tripepi M, D’Aliberti GA, Rossetti O: Anterior approach to the spine. Role of the general surgeon, techniques and surgicalcomplications. The 10-year experience of the Niguarda Hospitals. J Neurosurg Sci 55: 357-363, 2011. 22. Varatharajah S, Charles YP, Buy X, Walter A, Steib JP: Update on the surgical management of Pott’s disease. Orthop Traumatol Surg Res 100: 229-235, 2014.
CONCLUSIONS
10. Lau J, Ioannidis JP, Schmid CH: Quantitative synthesis in systematic reviews. Ann Intern Med 127:820-826, 1997.
23. Wang Z, Yuan H, Geng G, Shi J, Jin W: Posterior mono-segmental fixation, combined with anterior debridement and strut graft, for treatment of the mono-segmental lumbar spine tuberculosis. Int Orthop 36:325-329, 2012.
The results of this meta-analysis showed that in the surgical management of spinal
11. Lindahl S, Nyman RS, Brismar J, Hugosson C, Lundstedt C: Imaging of tuberculosis. IV. Spinal
24. Wang X, Pang X, Wu P, Luo C, Shen X: One-stage anterior debridement, bone grafting and posterior
1164
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.01.041
PEER-REVIEW REPORTS JIAMING LIU ET AL.
instrumentation vs. single posterior debridement, bone grafting, and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis. Eur Spine J 23:830-837, 2014. 25. Yang P, He X, Li H, Zang Q, Yang B: Clinical efficacy of posterior versus anterior instrumentation for the treatment of spinal tuberculosis in adults: a meta-analysis. J Orthop Surg Res 9:10, 2014. 26. Zeng H, Wang X, Pang X, Luo C, Zhang P, Peng W, Wu P, Xu Z: Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults. Eur J Trauma Emerg Surg 40:607-616, 2014.
META ANALYSIS OF APPROACH FOR TB
27. Zhang HQ, Li JS, Zhao SS, Shao YX, Liu SH, Gao Q, Lin MZ, Liu JY, Wu JH, Chen J: Surgical management for thoracic spinal tuberculosis in the elderly: posterior only versus combined posteriorand anterior approaches. Arch Orthop Trauma Surg 132:1717-1723, 2012. 28. Zhang HQ, Lin MZ, Li JS, Tang MX, Guo CF, Wu JH, Liu JY: One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series. Arch Orthop Trauma Surg 133:333-341, 2013.
commercial or financial relationships that could be construed as a potential conflict of interest. This work is supported by Department of Science and Technology Program Funds of Jiangxi Province, P.R.China (No. 20122BBG70121-2) and the Youth Science Fund of Jiangxi Provincial Education Development, P.R. China (No. GJJ13028). Received 28 August 2014; accepted 19 January 2015; published online 16 February 2015 Citation: World Neurosurg. (2015) 83, 6:1157-1165. http://dx.doi.org/10.1016/j.wneu.2015.01.041 Journal homepage: www.WORLDNEUROSURGERY.org
Jiaming Liu and Linyue Wan are joint first authors. Conflict of interest statement: The authors declare that the article content was composed in the absence of any
WORLD NEUROSURGERY 83 [6]: 1157-1165, JUNE 2015
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
1165
