Surg Endosc DOI 10.1007/s00464-014-3913-z
and Other Interventional Techniques
TECHNIQUE
Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis X. Zhang • Z. Zhang • Y. Zhang • J. Wang M. Lu • W. Hu • Y. Wang • X. Ma • Y. Wang
•
Received: 7 April 2014 / Accepted: 8 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Background and study aims Minimally invasive retroperitoneoscopic surgery (MIS) for psoas abscess (PA) in patients with thoracolumbar tuberculosis is not well-illustrated and has not reached the status of being fully clinically assessed when we review the English literatures. The aim of this study is to introduce and investigate on efficacy and feasibility of MIS (retroperitoneoscopic technique) for PA in patients with thoracolumbar tuberculosis. Patients and methods From January 2008 to 2013, 39 consecutive patients of the diagnosis of PA with thoracolumbar tuberculosis received the debridement of abscesses and cavity walls of abscesses by the retroperitoneoscopic technique (MIS) in combination with anti-tuberculosis chemotherapy. Medical records and follow-up data were retrospectively studied. CRP and ESR of every patient preoperatively and postoperatively were analyzed Results Immediate relief in clinical symptoms and signs, and amelioration in imaging and laboratory examinations were obviously observed in all the patients. The follow-up had proceeded for 12–48 (mean 23) months. No complication was observed during the follow-up postoperatively. Conclusions The retroperitoneoscopic technique for PA gain advantages in terms of shorter hospital stay, minimal Xuesong Zhang and Zhifa Zhang contributed equally to this work. X. Zhang Z. Zhang Y. Zhang J. Wang M. Lu W. Hu Y. Wang Y. Wang (&) Department of Orthopedics, PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100000, China e-mail: [email protected]
invasiveness, absence of radiation, quicker recovery to daily life compared with percutaneous drainage, and anterior or posterior debridement surgery. Despite the technique not been fully clinically proved, it seems to be a recommended option as an effective diagnostic and therapeutic technique for PA, especially with massive or complicated PA. Keywords Psoas abscess Spinal tuberculosis Minimally invasive Retroperitoneoscopy Therapeutic Surgical Psoas abscess (PA), which was first described by Mynter in 1881 [1], was often associated with spinal infection of Mycobacterium tuberculosis (TB) in the early 20th century [2, 3]. However, with resurgence of newly emerging multidrugresistant TB in undeveloped countries and increasing infections of HIV (human immunodeficiency virus) in industrialized countries [4, 5], tuberculous spondylitis-induced PA is not a rare entity. The spine is involved in half of cases of extrapulmonary TB, with a predilection for the thoracic and lumbar region [6]. The treatment for PA with thoracolumbar TB, first and most, is the complete evacuation of abscess on the basis of regular anti-tuberculosis chemotherapy [7]. We retrospectively analyzed 39 consecutive cases of PA with thoracolumbar TB from January 2008 to 2013. All these patients underwent minimally invasive retroperitoneoscopic surgery (MIS). MIS is the operation of abscess evacuation through an extraperitoneal approach into the psoas space anatomically by retroperitoneoscopic technique.
Patients X. Ma (&) Department of Urology, PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100000, China e-mail: [email protected]
Approved by the institutional review board, we reviewed medical record database which is prospectively maintained
123
Surg Endosc
Fig. 1 A MIS was performed in the lateral decubitus position under general anesthesia. The anatomical signs were marked on the skin preoperatively. B Two 5 mm-Trocars were, respectively, inserted at
anterior axillary line under the costal margin and iliac crest. A 10 mm Trocar was placed at posterior axillary line under the costal margin
and computerized to get the access to general conditions, surgery data, and pathological results of all the patients. The follow-up data were collected from patients by telephone interview or visits at regular intervals. Thirty-nine patients of the diagnosis of PA with or without active pulmonary TB were enrolled in the study.
Surgical technique
Inclusion criteria and exclusion criteria The general selection criteria for MIS were PA with spinal TB involving the T9-L5 vertebrae, without severe neural deficit and high loss of vertebrae after the total evaluation of X-ray and physical examination. Patients who needed open surgery because of the instability of involved vertebra and/or severe neural deficits were excluded. Patients who underwent MIS before open surgery taking into consideration high fever or acute infectious conditions preoperatively were excluded.
Diagnosis For all the suspected patients preoperatively, the diagnoses of PA associated with tuberculous thoracolumbar spondylitis were made on the evidences of clinical symptoms such as mild fever, night-sweats, weight loss, and fatigue and laboratory examinations such as CRP (C-reactive protein), ESR (erythrocyte sedimentation rate), PPD (purified protein derivative), or IGRA (interferon gamma release assay), as well as examinations such as X-ray, computed tomography (CT), and magnetic resonance imaging (MRI). All the patients took a 2–4 weeks experimental anti-tuberculosis therapy preoperatively. The diagnoses of tuberculosisinduced PA were confirmed by pathological examination, acid-fast stain or/and culture of mycobacterium TB.
123
The patients were in the lateral decubitus position following administration of general anesthesia. Through a subcostal open incision under the extremity of the 12th rib and muscle and tissue dissection under the finger guidance, the approach to the retroperitoneal operation space was obtained by balloon expansion. After the establishment of retroperitoneal CO2 pneumoperitoneum, two 5 mm-Trocars were, respectively, inserted at anterior axillary line under the costal margin and iliac crest. A 10 mm Trocar was placed at posterior axillary line under the costal margin (Fig. 1). Under direct visualization using the optics, the exploration of the retroperitoneum was done and the working space was completed. The psoas muscle is a retroperitoneal and retrofascial structure. Based on the localization and morphology of abscess in the MRI preoperative and comprehension of anatomical location of psoas, blunt and sharp dissection was made in the fascia overlying the muscle. The fascial covering of the muscle usually prevents spread of abscess to the retroperitoneum and free peritoneal cavity. The abscesses were evacuated by suction. The suction procedures needed to be done as soon as the abscess cavity was cut open in case the tissues outside the abscess cavity were polluted. It is a key procedure to prevent the recurrence and plantation of abscess and decrease the dissemination of infection. The lavage and drainage should also be limited in the abscess cavity when the debridement of cavity wall is done. The thick walls of abscess cavity were debrided until the bleeding margin and normal muscle fibers appeared. The pus in the thick wall of abscess cavity was sent for pathological examinations. Then the irrigation with saline solution, dilute betadine solution, and dilute isoniazid
Surg Endosc
Fig. 2 A The appropriate approach of the psoas muscle was split open when the location of abscess (AB) and the extent of its spread were evaluated by MRI. B The suction of abscess was performed as soon as the abscess appeared in case of the dissemination of tuberculous abscess. C The empty cavity and thick wall of abscess
became visible after the evacuation of liquid abscess. D The complete debridement of thick wall of abscess was done when the bleeding margin and muscle tissue appeared. The vein (V) was protected from injury during the debridement under direct vision
solution were performed consecutively. Exploration into the extent of the abscess spread under the direct view was done to ensure that no loculi and cavities were neglected and all the abscesses were eradicated. A silastic drain was placed into the abscess cavity and removed on the second or third day postoperatively. The core technique of MIS includes precise anatomical location of abscesses, procedures limited in the abscess cavity, and complete debridement of cavity wall (Fig. 2).
interview and follow-up were performed with a radiological examination semiannually or when any clinical symptoms appeared.
Postoperative After operation, the anti-tuberculosis chemotherapy of SHRZ (S: streptomycin, H: isoniazid, R: rifampicin, and Z: pyrazinamide) scheme was continued postoperatively. Indirect observation of chemotherapy by telephone
Results A total of 39 MIS were successfully performed and no mortality and complications were associated with the retroperitoneoscopic procedure. Characteristics of patient and abscess were summarized in Table 1. Surgery and followup data are analyzed in Table 2. Treatment success was defined as patient symptomatic, laboratory and imaging improvement. All the patients got immediate remission in symptoms such as fever and back pain. Statistical analysis demonstrated that there was significant difference between pre- and postoperative ESR (P \ 0.05) and CRP
123
Surg Endosc Table 1 Characteristics of patients and abscesses Characteristics
No. (%)
Gender Male
23 (59.0)
Female
16 (41.0)
Symptom Fever
27 (69.2)
Back pain
36 (92.3)
Asymptomatic
3 (7.7)
Location Right
20 (51.3)
Left
16 (41.0)
Bilateral Complication
3 (7.7)
With active pulmonary tuberculosis
14 (35.9)
Without pulmonary tuberculosis
25 (64.1)
Involved vertebra Thoracic vertebrae
6 (15.4)
Thoracolumbar vertebrae
20 (51.3)
Lumbar vertebrae
13 (33.3)
Table 2 Surgery and follow-up data Characteristics of MIS
No.
Age (year)
41.1 ± 16.9
Surgery duration time (min)
56.5 ± 29.2
Blood loss (ml)
54.4 ± 22.7
Drainage of time preoperative (day)
4.7 ± 1.8
Hospital stay preoperative (day)
4.3 ± 1.6
ESR (mm/H)a Preoperative Postoperative
66.0 ± 24.5 b
35.7 ± 17.1
CRP (g/L)c Preoperative Postoperativeb Follow-up time (month)
37.5 ± 24.3 20.0 ± 10.0 26.0 ± 9.8
ESR (erythrocyte sedimentation rate), CRP(C-reactive protein) a
Analyzed by paired t test, compare postoperative to preoperative in ESR, P \ 0.05
b
Postoperative means postoperative 5–7 days
c
Analyzed by paired t test, compare postoperative to preoperative in CRP, P \ 0.05
(P \ 0.05). The first patient of MIS in our group had a recurrent abscess in the follow-up of 9 months postoperative due to dissemination of tuberculous abscess. Inexperience of debridement procedure and irregular anti-tuberculosis medication may be the key factors of recurrence. Two patients had psoas and iliac fossa abscess.
123
A patient who had gone percutaneous abscess drainage under the CT-guided (PD) as initial treatment in another hospital had recurrent abscess 3 months postoperatively, when on admission. The thick wall of the abscess cavity in this patient was completely debrided through MIS. Due to elimination of the dead space and promotion of the recovery of the psoas muscle, successful result was achieved in the follow-up of 24 months (Fig. 3). Two patients with considerable abscesses involving the iliac fossa got a full and quick recovery after complete debridement by retroperitoneoscopic technique. Due to the increase of kyphosis angle, two patients had posterior fixation operations at postoperative 18 and 30 month, respectively.
Discussion Since the first description of PA associated with spinal TB in 1881, various therapeutic methods have been proposed, including anterior or posterior open operation [8, 9] and percutaneous drainage. With the mature application of retroperitoneoscopic technique, MIS is recommended in some literatures and welcomed by patients because of less trauma and quicker recovery to daily life compared with open surgery. Anatomically, the psoas muscle and its fascia have direct communication with the mediastinum and thigh [10]. In the patients with thoracolumbar spinal TB, PA may be formed when paraspinal abscess penetrates the periosteum. PA may extend through the psoas sheath, following the muscle space to iliac fossa and as far as the groin and thigh. The evacuation of abscess, the maintenance of spinal stability, and the debridement of focal vertebrae and disks are key problems of research. Severe tuberculous destruction of vertebra and instability of spine can increase kyphosis angle and deterioration of neurological deficits [3, 11, 12]. Despite the instability of spine and neurological deficits, MIS was recommended as an appropriate initial approach for massive or complicated PA. The data of MIS showed better than percutaneous drainage (PD) or anterior and posterior open surgery when we review the literatures [13–16] in terms of the surgery duration time, blood loss, shorter hospital stay, and recurrence rate of abscesses. It is because MIS achieved more complete debridement of abscess compared with PD, including the thick wall of abscess. Complete debridement of thick wall of abscesses cavity is one of the key factors of reducing the recurrence rate of local abscesses [8]. MIS is characterized by complete debridement under direct vision and is proved to be safe, effective, and technically efficient for other etiologies of PA. Additionally, few articles illustrated in detail the complete debridement of PA cavity under direct view and its significance of reduction of
Surg Endosc
Fig. 3 A MRI showed that right side of psoas abscess existed in a 38-year-old female patient with tuberculous spondylitis of T12-L1. B A 28-year-old male demonstrated spinal tuberculosis of L2-L3 with
a massive iliac fossa abscess. C Psoas abscesses of multi-cavities were detected by MRI in a 49-year-old male patient
recurrent rate of PA. We evaluated and analyzed our institutional series to identify the effectiveness and feasibility of MIS and our patients have a favorable prognosis in the follow-up. Sometimes two-stage operations are necessary to eradicate focal tissue and restore spine stability.
4. Raviglione M, Marais B, Floyd K, Lonnroth K, Getahun H, Migliori GB, Harries AD, Nunn P, Lienhardt C, Graham S, Chakaya J, Weyer K, Cole S, Kaufmann SH, Zumla A (2012) Scaling up interventions to achieve global tuberculosis control: progress and new developments. Lancet 379:1902–1913 5. Chiang CY, Van Weezenbeek C, Mori T, Enarson DA (2013) Challenges to the global control of tuberculosis. Respirology 18:596–604 6. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X (2013) Thoracolumbar spinal tuberculosis with psoas abscesses treated by onestage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765–772 7. Wu TL, Huang CH, Hwang DY, Lai JH, Su RY (1998) Primary pyogenic abscess of the psoas muscle. Int Orthop 22:41–43 8. Jin W, Wang Q, Wang Z, Geng G (2014) Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation. The spine journal: official journal of the North American Spine Society 14:964–970 9. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X (2013) Thoracolumbar spinal tuberculosis with psoas abscesses treated by onestage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765–772 10. Bresee JS, Edwards MS (1990) Psoas abscess in children. Pediatr Infect Dis J 9:201–206 11. Procaccino JA, Lavery IC, Fazio VW, Oakley JR (1991) Psoas abscess: difficulties encountered. Dis Colon Rectum 34:784–789 12. Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL (1995) Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg 83:243–247 13. Atkin G, Qurashi K, Isla A (2005) Laparoscopic drainage of bilateral tuberculous psoas abscesses. Surg laparosc endosc percutan tech 15:380–382 14. Baier PK, Arampatzis G, Imdahl A, Hopt UT (2006) The iliopsoas abscess: aetiology, therapy, and outcome. Langenbeck’s arch surg/Deutsche Gesellschaft fur Chirurgie 391:411–417 15. Buyukbebeci O, Seckiner I, Karsli B, Karakurum G, Baskonus I, Bilge O, Kacira BK (2012) Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis. Eur Spine J 21:470–473 16. Katara AN, Shah RS, Bhandarkar DS, Unadkat RJ (2004) Retroperitoneoscopic drainage of a psoas abscess. J Pediatr Surg 39:e4–e5
Limitations In terms of dealing with the problems of spinal instability and neural deficits, we confess that the shortage of MIS can be well figured out by posterior fixation and transforaminal lumbar debridement [9].
Conclusions MIS is a safe, effective, and efficient treatment for PA with thoracolumbar TB in terms of minimal invasiveness, complete debridement of abscesses, immediate relief of infection source, and quick recovery to daily life. Acknowledgments This publication was founded in part by the Beijing science and technique star foundation (2010B80). Disclosures Xuesong Zhang, Zhifa Zhang, Yan Wang, Yonggang Zhang, Xin Ma, Jiaqi Wang, Ming Lu, Wenhao Hu, and Yao Wang have no conflicts of interest or financial ties to disclose.
References 1. Mynter H (1881) Acute psoitis. Buffalo Med Surg J 21:202–210 2. Santaella RO, Fishman EK, Lipsett PA (1995) Primary vs secondary iliopsoas abscess. Presentation, microbiology, and treatment. Arch Surg 130:1309–1313 3. Franco-Paredes C, Blumberg HM (2001) Psoas muscle abscess caused by Mycobacterium tuberculosis and Staphylococcus aureus: case report and review. Am J med sci 321:415–417
123
and Other Interventional Techniques
TECHNIQUE
Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis X. Zhang • Z. Zhang • Y. Zhang • J. Wang M. Lu • W. Hu • Y. Wang • X. Ma • Y. Wang
•
Received: 7 April 2014 / Accepted: 8 September 2014 Ó Springer Science+Business Media New York 2014
Abstract Background and study aims Minimally invasive retroperitoneoscopic surgery (MIS) for psoas abscess (PA) in patients with thoracolumbar tuberculosis is not well-illustrated and has not reached the status of being fully clinically assessed when we review the English literatures. The aim of this study is to introduce and investigate on efficacy and feasibility of MIS (retroperitoneoscopic technique) for PA in patients with thoracolumbar tuberculosis. Patients and methods From January 2008 to 2013, 39 consecutive patients of the diagnosis of PA with thoracolumbar tuberculosis received the debridement of abscesses and cavity walls of abscesses by the retroperitoneoscopic technique (MIS) in combination with anti-tuberculosis chemotherapy. Medical records and follow-up data were retrospectively studied. CRP and ESR of every patient preoperatively and postoperatively were analyzed Results Immediate relief in clinical symptoms and signs, and amelioration in imaging and laboratory examinations were obviously observed in all the patients. The follow-up had proceeded for 12–48 (mean 23) months. No complication was observed during the follow-up postoperatively. Conclusions The retroperitoneoscopic technique for PA gain advantages in terms of shorter hospital stay, minimal Xuesong Zhang and Zhifa Zhang contributed equally to this work. X. Zhang Z. Zhang Y. Zhang J. Wang M. Lu W. Hu Y. Wang Y. Wang (&) Department of Orthopedics, PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100000, China e-mail: [email protected]
invasiveness, absence of radiation, quicker recovery to daily life compared with percutaneous drainage, and anterior or posterior debridement surgery. Despite the technique not been fully clinically proved, it seems to be a recommended option as an effective diagnostic and therapeutic technique for PA, especially with massive or complicated PA. Keywords Psoas abscess Spinal tuberculosis Minimally invasive Retroperitoneoscopy Therapeutic Surgical Psoas abscess (PA), which was first described by Mynter in 1881 [1], was often associated with spinal infection of Mycobacterium tuberculosis (TB) in the early 20th century [2, 3]. However, with resurgence of newly emerging multidrugresistant TB in undeveloped countries and increasing infections of HIV (human immunodeficiency virus) in industrialized countries [4, 5], tuberculous spondylitis-induced PA is not a rare entity. The spine is involved in half of cases of extrapulmonary TB, with a predilection for the thoracic and lumbar region [6]. The treatment for PA with thoracolumbar TB, first and most, is the complete evacuation of abscess on the basis of regular anti-tuberculosis chemotherapy [7]. We retrospectively analyzed 39 consecutive cases of PA with thoracolumbar TB from January 2008 to 2013. All these patients underwent minimally invasive retroperitoneoscopic surgery (MIS). MIS is the operation of abscess evacuation through an extraperitoneal approach into the psoas space anatomically by retroperitoneoscopic technique.
Patients X. Ma (&) Department of Urology, PLA General Hospital, Fuxing Road 28, Haidian District, Beijing 100000, China e-mail: [email protected]
Approved by the institutional review board, we reviewed medical record database which is prospectively maintained
123
Surg Endosc
Fig. 1 A MIS was performed in the lateral decubitus position under general anesthesia. The anatomical signs were marked on the skin preoperatively. B Two 5 mm-Trocars were, respectively, inserted at
anterior axillary line under the costal margin and iliac crest. A 10 mm Trocar was placed at posterior axillary line under the costal margin
and computerized to get the access to general conditions, surgery data, and pathological results of all the patients. The follow-up data were collected from patients by telephone interview or visits at regular intervals. Thirty-nine patients of the diagnosis of PA with or without active pulmonary TB were enrolled in the study.
Surgical technique
Inclusion criteria and exclusion criteria The general selection criteria for MIS were PA with spinal TB involving the T9-L5 vertebrae, without severe neural deficit and high loss of vertebrae after the total evaluation of X-ray and physical examination. Patients who needed open surgery because of the instability of involved vertebra and/or severe neural deficits were excluded. Patients who underwent MIS before open surgery taking into consideration high fever or acute infectious conditions preoperatively were excluded.
Diagnosis For all the suspected patients preoperatively, the diagnoses of PA associated with tuberculous thoracolumbar spondylitis were made on the evidences of clinical symptoms such as mild fever, night-sweats, weight loss, and fatigue and laboratory examinations such as CRP (C-reactive protein), ESR (erythrocyte sedimentation rate), PPD (purified protein derivative), or IGRA (interferon gamma release assay), as well as examinations such as X-ray, computed tomography (CT), and magnetic resonance imaging (MRI). All the patients took a 2–4 weeks experimental anti-tuberculosis therapy preoperatively. The diagnoses of tuberculosisinduced PA were confirmed by pathological examination, acid-fast stain or/and culture of mycobacterium TB.
123
The patients were in the lateral decubitus position following administration of general anesthesia. Through a subcostal open incision under the extremity of the 12th rib and muscle and tissue dissection under the finger guidance, the approach to the retroperitoneal operation space was obtained by balloon expansion. After the establishment of retroperitoneal CO2 pneumoperitoneum, two 5 mm-Trocars were, respectively, inserted at anterior axillary line under the costal margin and iliac crest. A 10 mm Trocar was placed at posterior axillary line under the costal margin (Fig. 1). Under direct visualization using the optics, the exploration of the retroperitoneum was done and the working space was completed. The psoas muscle is a retroperitoneal and retrofascial structure. Based on the localization and morphology of abscess in the MRI preoperative and comprehension of anatomical location of psoas, blunt and sharp dissection was made in the fascia overlying the muscle. The fascial covering of the muscle usually prevents spread of abscess to the retroperitoneum and free peritoneal cavity. The abscesses were evacuated by suction. The suction procedures needed to be done as soon as the abscess cavity was cut open in case the tissues outside the abscess cavity were polluted. It is a key procedure to prevent the recurrence and plantation of abscess and decrease the dissemination of infection. The lavage and drainage should also be limited in the abscess cavity when the debridement of cavity wall is done. The thick walls of abscess cavity were debrided until the bleeding margin and normal muscle fibers appeared. The pus in the thick wall of abscess cavity was sent for pathological examinations. Then the irrigation with saline solution, dilute betadine solution, and dilute isoniazid
Surg Endosc
Fig. 2 A The appropriate approach of the psoas muscle was split open when the location of abscess (AB) and the extent of its spread were evaluated by MRI. B The suction of abscess was performed as soon as the abscess appeared in case of the dissemination of tuberculous abscess. C The empty cavity and thick wall of abscess
became visible after the evacuation of liquid abscess. D The complete debridement of thick wall of abscess was done when the bleeding margin and muscle tissue appeared. The vein (V) was protected from injury during the debridement under direct vision
solution were performed consecutively. Exploration into the extent of the abscess spread under the direct view was done to ensure that no loculi and cavities were neglected and all the abscesses were eradicated. A silastic drain was placed into the abscess cavity and removed on the second or third day postoperatively. The core technique of MIS includes precise anatomical location of abscesses, procedures limited in the abscess cavity, and complete debridement of cavity wall (Fig. 2).
interview and follow-up were performed with a radiological examination semiannually or when any clinical symptoms appeared.
Postoperative After operation, the anti-tuberculosis chemotherapy of SHRZ (S: streptomycin, H: isoniazid, R: rifampicin, and Z: pyrazinamide) scheme was continued postoperatively. Indirect observation of chemotherapy by telephone
Results A total of 39 MIS were successfully performed and no mortality and complications were associated with the retroperitoneoscopic procedure. Characteristics of patient and abscess were summarized in Table 1. Surgery and followup data are analyzed in Table 2. Treatment success was defined as patient symptomatic, laboratory and imaging improvement. All the patients got immediate remission in symptoms such as fever and back pain. Statistical analysis demonstrated that there was significant difference between pre- and postoperative ESR (P \ 0.05) and CRP
123
Surg Endosc Table 1 Characteristics of patients and abscesses Characteristics
No. (%)
Gender Male
23 (59.0)
Female
16 (41.0)
Symptom Fever
27 (69.2)
Back pain
36 (92.3)
Asymptomatic
3 (7.7)
Location Right
20 (51.3)
Left
16 (41.0)
Bilateral Complication
3 (7.7)
With active pulmonary tuberculosis
14 (35.9)
Without pulmonary tuberculosis
25 (64.1)
Involved vertebra Thoracic vertebrae
6 (15.4)
Thoracolumbar vertebrae
20 (51.3)
Lumbar vertebrae
13 (33.3)
Table 2 Surgery and follow-up data Characteristics of MIS
No.
Age (year)
41.1 ± 16.9
Surgery duration time (min)
56.5 ± 29.2
Blood loss (ml)
54.4 ± 22.7
Drainage of time preoperative (day)
4.7 ± 1.8
Hospital stay preoperative (day)
4.3 ± 1.6
ESR (mm/H)a Preoperative Postoperative
66.0 ± 24.5 b
35.7 ± 17.1
CRP (g/L)c Preoperative Postoperativeb Follow-up time (month)
37.5 ± 24.3 20.0 ± 10.0 26.0 ± 9.8
ESR (erythrocyte sedimentation rate), CRP(C-reactive protein) a
Analyzed by paired t test, compare postoperative to preoperative in ESR, P \ 0.05
b
Postoperative means postoperative 5–7 days
c
Analyzed by paired t test, compare postoperative to preoperative in CRP, P \ 0.05
(P \ 0.05). The first patient of MIS in our group had a recurrent abscess in the follow-up of 9 months postoperative due to dissemination of tuberculous abscess. Inexperience of debridement procedure and irregular anti-tuberculosis medication may be the key factors of recurrence. Two patients had psoas and iliac fossa abscess.
123
A patient who had gone percutaneous abscess drainage under the CT-guided (PD) as initial treatment in another hospital had recurrent abscess 3 months postoperatively, when on admission. The thick wall of the abscess cavity in this patient was completely debrided through MIS. Due to elimination of the dead space and promotion of the recovery of the psoas muscle, successful result was achieved in the follow-up of 24 months (Fig. 3). Two patients with considerable abscesses involving the iliac fossa got a full and quick recovery after complete debridement by retroperitoneoscopic technique. Due to the increase of kyphosis angle, two patients had posterior fixation operations at postoperative 18 and 30 month, respectively.
Discussion Since the first description of PA associated with spinal TB in 1881, various therapeutic methods have been proposed, including anterior or posterior open operation [8, 9] and percutaneous drainage. With the mature application of retroperitoneoscopic technique, MIS is recommended in some literatures and welcomed by patients because of less trauma and quicker recovery to daily life compared with open surgery. Anatomically, the psoas muscle and its fascia have direct communication with the mediastinum and thigh [10]. In the patients with thoracolumbar spinal TB, PA may be formed when paraspinal abscess penetrates the periosteum. PA may extend through the psoas sheath, following the muscle space to iliac fossa and as far as the groin and thigh. The evacuation of abscess, the maintenance of spinal stability, and the debridement of focal vertebrae and disks are key problems of research. Severe tuberculous destruction of vertebra and instability of spine can increase kyphosis angle and deterioration of neurological deficits [3, 11, 12]. Despite the instability of spine and neurological deficits, MIS was recommended as an appropriate initial approach for massive or complicated PA. The data of MIS showed better than percutaneous drainage (PD) or anterior and posterior open surgery when we review the literatures [13–16] in terms of the surgery duration time, blood loss, shorter hospital stay, and recurrence rate of abscesses. It is because MIS achieved more complete debridement of abscess compared with PD, including the thick wall of abscess. Complete debridement of thick wall of abscesses cavity is one of the key factors of reducing the recurrence rate of local abscesses [8]. MIS is characterized by complete debridement under direct vision and is proved to be safe, effective, and technically efficient for other etiologies of PA. Additionally, few articles illustrated in detail the complete debridement of PA cavity under direct view and its significance of reduction of
Surg Endosc
Fig. 3 A MRI showed that right side of psoas abscess existed in a 38-year-old female patient with tuberculous spondylitis of T12-L1. B A 28-year-old male demonstrated spinal tuberculosis of L2-L3 with
a massive iliac fossa abscess. C Psoas abscesses of multi-cavities were detected by MRI in a 49-year-old male patient
recurrent rate of PA. We evaluated and analyzed our institutional series to identify the effectiveness and feasibility of MIS and our patients have a favorable prognosis in the follow-up. Sometimes two-stage operations are necessary to eradicate focal tissue and restore spine stability.
4. Raviglione M, Marais B, Floyd K, Lonnroth K, Getahun H, Migliori GB, Harries AD, Nunn P, Lienhardt C, Graham S, Chakaya J, Weyer K, Cole S, Kaufmann SH, Zumla A (2012) Scaling up interventions to achieve global tuberculosis control: progress and new developments. Lancet 379:1902–1913 5. Chiang CY, Van Weezenbeek C, Mori T, Enarson DA (2013) Challenges to the global control of tuberculosis. Respirology 18:596–604 6. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X (2013) Thoracolumbar spinal tuberculosis with psoas abscesses treated by onestage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765–772 7. Wu TL, Huang CH, Hwang DY, Lai JH, Su RY (1998) Primary pyogenic abscess of the psoas muscle. Int Orthop 22:41–43 8. Jin W, Wang Q, Wang Z, Geng G (2014) Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation. The spine journal: official journal of the North American Spine Society 14:964–970 9. Pang X, Shen X, Wu P, Luo C, Xu Z, Wang X (2013) Thoracolumbar spinal tuberculosis with psoas abscesses treated by onestage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. Arch Orthop Trauma Surg 133:765–772 10. Bresee JS, Edwards MS (1990) Psoas abscess in children. Pediatr Infect Dis J 9:201–206 11. Procaccino JA, Lavery IC, Fazio VW, Oakley JR (1991) Psoas abscess: difficulties encountered. Dis Colon Rectum 34:784–789 12. Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL (1995) Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg 83:243–247 13. Atkin G, Qurashi K, Isla A (2005) Laparoscopic drainage of bilateral tuberculous psoas abscesses. Surg laparosc endosc percutan tech 15:380–382 14. Baier PK, Arampatzis G, Imdahl A, Hopt UT (2006) The iliopsoas abscess: aetiology, therapy, and outcome. Langenbeck’s arch surg/Deutsche Gesellschaft fur Chirurgie 391:411–417 15. Buyukbebeci O, Seckiner I, Karsli B, Karakurum G, Baskonus I, Bilge O, Kacira BK (2012) Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis. Eur Spine J 21:470–473 16. Katara AN, Shah RS, Bhandarkar DS, Unadkat RJ (2004) Retroperitoneoscopic drainage of a psoas abscess. J Pediatr Surg 39:e4–e5
Limitations In terms of dealing with the problems of spinal instability and neural deficits, we confess that the shortage of MIS can be well figured out by posterior fixation and transforaminal lumbar debridement [9].
Conclusions MIS is a safe, effective, and efficient treatment for PA with thoracolumbar TB in terms of minimal invasiveness, complete debridement of abscesses, immediate relief of infection source, and quick recovery to daily life. Acknowledgments This publication was founded in part by the Beijing science and technique star foundation (2010B80). Disclosures Xuesong Zhang, Zhifa Zhang, Yan Wang, Yonggang Zhang, Xin Ma, Jiaqi Wang, Ming Lu, Wenhao Hu, and Yao Wang have no conflicts of interest or financial ties to disclose.
References 1. Mynter H (1881) Acute psoitis. Buffalo Med Surg J 21:202–210 2. Santaella RO, Fishman EK, Lipsett PA (1995) Primary vs secondary iliopsoas abscess. Presentation, microbiology, and treatment. Arch Surg 130:1309–1313 3. Franco-Paredes C, Blumberg HM (2001) Psoas muscle abscess caused by Mycobacterium tuberculosis and Staphylococcus aureus: case report and review. Am J med sci 321:415–417
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