Does timely surgery or not affect surgical outcomes in patients with severe spinal tuberculous kyphosis? An observational cohort study

Does timely surgery or not affect surgical outcomes in patients with severe spinal tuberculous kyphosis? 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An observational cohort study Yuan Gao, Jianquan Zhao, Bowen Lai, Zhanrong Zhang, Heng Jiang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4875943/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Spinal tuberculous kyphosis can cause paralysis, severely affecting patient's life. However, timing of the surgery has become a controversial issue. The aim of this study was to explore whether timely surgery would have an impact on surgical outcomes. Methods In this single-center, retrospective, observational cohort study, we collected clinical data of patients with severe spinal tuberculous kyphosis who underwent surgery from July 1st, 2015 to February 28th, 2019 at Shanghai Changzheng Hospital. We obtained patients' consultation, treatment, and follow-up data from the patient database of Shanghai Changzheng Hospital, and divided them into two groups according to whether they received surgery timely. We compared the data of the two groups using neurological function recovery as the primary outcome indicator and complication rates and deformity correction rates as the secondary outcome indicators. Results A total of 43 patients were included. 48.8% patients underwent surgery within 2 years and all patients underwent surgery within 7 years after the neurological symptoms onset. We grouped the patients who were treated surgically after 2 years as non-timely surgery group (Group A, Number of cases: 22) and the patients who were treated within 2 years as timely surgery group (Group B, Number of cases: 21). There was no statistically significant difference in correction rates between the two groups. There was a statistical difference in pulmonary complication rates (P = 0.037) and follow-up neurological function recovery rates (P = 0.021). Conclusion Considering neurological function recovery, deformity correction and complications, we support that patients with severe spinal tuberculous kyphosis should receive surgical treatment as soon as possible after the neurological symptoms onset and preferably within 2 years. This contributes to postoperative neurological recovery in patients as well as reducing the incidence of pulmonary complications. Spinal tuberculous kyphosis Surgical treatment Neurological function recovery Deformity correction Complication Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Spinal tuberculosis is one of the most common cause of kyphosis in patients 1 . Since Mycobacterium tuberculosis can survive for long periods of time in vertebra and disrupt bony structure, the kyphotic deformity may be progressive and unstable 2 . Clinical data suggested that 15% of patients with spinal tuberculosis treated with conservative treatment have a progression of posterior kyphotic angle > 15° and 3–5% may eventually develop > 60° posterior kyphotic angle, followed by paraplegia, which severely affected the patient's quality of life 3 . Whether to correct the deformity or to protect neurological function, surgical treatment with posterior internal fixation is necessary for patients with severe progressive tuberculous kyphotic deformity 4, 5 . However, reconstruction of tuberculous kyphosis is a difficult and risky procedure, with a high complication rate and even patient death 6 . Based on the above studies, some scholars believed that the benefit of surgical treatment for the purpose to correct the deformity was not balanced with the risks 7 . On the other hand, most patients with progressive tuberculous kyphosis will eventually develop neurological symptoms after a prolonged asymptomatic period. At this point, continued conservative treatment will be ineffective 8 . Therefore, some scholars believed that the benefits of timely surgical treatment after the neurological symptoms onset outweighed the risks for these patients 7, 9 . In this single-center, retrospective, observational cohort study, we propose to analyze the differences in three aspects of neurological function recovery rates, deformity correction rates and complication rates between patients undergoing timely surgery and those not undergoing timely surgery. Aiming to investigate the impact of timely surgery on surgical outcomes. Methods and Materials Patient inclusion and grouping A single-center, retrospective, observational cohort study of patients who underwent surgical treatment after a definitive diagnosis of spinal tuberculous kyphosis was performed from July 1st, 2015 to February 28, 2019 at Shanghai Changzheng Hospital. Inclusion criteria: ( 1 ) the patient was diagnosed with tuberculosis in their adolescence and received standardized anti-tuberculous treatment; and ( 2 ) the patient had signs and symptoms consistent with spinal tuberculosis; and ( 3 ) the patient had kyphotic deformity and a Cobb angle greater than 80°; and ( 4 ) the patient had neurological symptoms and underwent surgical treatment. Exclusion criteria: ( 1 ) irregular treatment with anti-tuberculosis drugs; or ( 2 ) non-tuberculous spinal cord lesions; or ( 3 ) incomplete or missing patient data on clinical information. In conclusion, all patients included in this study were diagnosed with tuberculosis once during their adolescence, developed spinal tuberculous kyphosis, and eventually underwent surgical treatment due to neurological symptoms. Patients with spinal tuberculosis typically experience a prolonged period of spinal destruction, also known as an asymptomatic period, after which they will develop neurological symptoms. We grouped patients according to the time from the onset of neurological symptoms to surgery. Those who underwent surgery after 2 years were grouped into the non-timely surgery group (group A) whereas those within 2 years were into the timely surgery group (group B). Clinical data collection and follow-up strategies In the preoperative and immediate postoperative time, we took the full-length spinal X-rays and collected the Frankle scores of the patients. We used the full-length X-rays to calculate the kyphotic angle and correction rates (preoperative - postoperative / preoperative angle). Within one week after surgery, we need to collect the patients’ lung CT to determine the patient's pulmonary complication rates and neurological physical examination to determine the patient's neurological complication rates.The Frankel score is a simple method for assessing neurological function and consists of five levels. Grade A represents complete sensory-motor loss. Grade B represents partial residual sensation with complete loss of movement. Grade C represents retained sensation with loss of voluntary movement. Grade D represents retained sensation with slight impairment of motor function. Grade E represents basically normal. About follow-up, there are two points: ( 1 ) two years after surgery, we use full-length spinal X-rays to determine the patient's deformity correction rates; ( 2 ) three years after surgery, we use Frankle scores to determine the patient's neurological recovery rates. Preoperative, postoperative and follow-up data collection was performed by two different doctors. The doctors were not aware of the specific grouping of the patients. The final result obtained was the average of the measurements taken by the two doctors. Assessment of surgical outcomes Since most scholars believed that the purpose of the surgery was to relieve nerve compression and protect neurological function 9 , we took the neurological function recovery rates as the primary outcome. According to patients’ follow-up Frankle score, We categorized patients with Frankle scores D and E as ability of self-care patients and scores A, B and C as inability of self-care patients. The patients who have the ability of self-care were considered to have a good neurological function recovery. On the other hand, this surgery had a high complication rates including pulmonary complications and neurological complications and it was difficult to get a great correction rate since the patient's spine is always very rigid, therefore we selected pulmonary and neurological complication rates and deformity correction rates as secondary outcomes 10 . Overall, by comparing the neurological function recovery, complication rates and deformity correction rates between the two groups of patients, we were able to determine which group had a better surgical outcome. The sample size of this study was calculated based on the primary outcome. According to the pre-test data, we used tests for two proportions as the main statistical method in this study under the requirement of α = 0.05 and 90% certainty, and the required sample size was calculated by PASS software. The results showed that to compare the neurological recovery rates between patients with timely surgery and patients without timely surgery, 21 patients were required in both groups. Therefore, we finally included 43 patients (22 non-timely surgery patients and 21 timely surgery patients). Statistical Analysis We used IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA) for statistical analysis. After grouping the patients depending on whether they received surgical treatment within two years after the neurological symptoms onset, we compared the baseline characteristics, deformity correction rates, complication rates, and neurological function recovery rates between the two groups. Data were tested by independent samples t-test. For data that did not meet the criteria of t test, the Wilcoxon rank-sum test was applied. Categorical variables including sex, complication rates and ability/inability of self-care rate was tested by Fisher's exact test. P < 0.05 considered as statistically significant difference. Results Baseline characteristics and grouping of patients According to the inclusion and exclusion criteria, a total of 43 patients were finally included. The inclusion process was detailed in Fig. 1 . There were 18 males and 25 females. The most common vertebral region affected was the thoracolumbar spine (T10-L2). The average number of vertebrae involved was 4.34. The average time from their first diagnosis of tuberculosis in their adolescence to neurological symptoms onset was 47.05 years. The average time from neurological symptoms onset to surgery was 3.21 years. After analyzing the clinical course of the patients, we found that no patient had neurological symptoms onset until 38 years after diagnosis, 50% patients had symptoms onset until 46 years, and after 58 years, all patients had symptoms onset. After the onset of neurological symptoms, 48.8% of patients received surgical treatment within 2 years, 88.4% of patients received treatment within 5 years and all patients received treatment within 7 years. Depending on whether the patient received surgical treatment within two years after the neurological symptoms onset, we got the non-timely surgical group (Group A, 22 cases) and the timely surgical group (Group B, 21 cases). We also compared the baseline characteristics between the two groups of patients (Table 1 ). Table 1 Comparison of baseline characteristics between two groups of patients Group A (> 2 years, N = 22) Group B (≤ 2 years, N = 21) P value Age of diagnosis 11.337 ± 3.568 10.836 ± 3.302 0.636 Height 1.492 ± 0.079 1.459 ± 0.073 0.150 Weight 48.199 ± 5.499 46.340 ± 6.236 0.305 Sex (male/female) 10/12 8/13 0.748 The time from diagnosis to neurological symptoms onset 46.409 ± 4.317 47.952 ± 5.757 0.324 Comparison of baseline characteristics and deformity correction rates Between group A and group B, There were no statistically significant difference in age of diagnosis (P = 0.636), height (P = 0.150), weight (P = 0.305), sex (P = 0.748) and the time from neurological symptoms onset to surgery (P = 0.324). See Table 1 for details. In comparison of spinal deformity correction between two groups of patients, preoperative kyphotic angle (P = 0.811), postoperative kyphotic angle (P = 0.302) and correction rate (P = 0.269) were no statistically significant difference. See Table 2 and Fig. 2 for details. Overall, there was no significant difference in baseline characteristics and deformity correction rates between the non-timely surgical group and the timely surgical group. Table 2 Comparison of spinal deformity correction between two groups of patients Group A (> 2 years, N = 22) Group B (≤ 2 years, N = 21) P value Preoperative kyphotic angle (°) 91.716 ± 7.893 91.147 ± 7.624 0.811 Postoperative kyphotic angle(°) 30.468 ± 7.277 28.336 ± 6.012 0.302 Correction rate (%) 66.666 ± 7.768 68.985 ± 5.563 0.269 Comparison of complication rates The pulmonary complication counted in this study was postoperative crural pneumonia while the neurological complication was postoperative sensory or motor dysfunction. In group A, the percentage of pulmonary complication rate was 36.4% while the neurological complication rate was 36.4%. In group B, the percentage of pulmonary complication rate was 9.5% while the neurological complications was 28.6%. There was statistically significant difference in pulmonary complication rate (P = 0.037) but no difference in neurological complication rate (P = 0.586). See Table 3 and Fig. 3 for details. Table 3 Comparison of complication rates between two groups of patients Group A (> 2 years, N = 22) Group B (≤ 2 years, N = 21) Total Pulmonary complication(+) 8 2 10 Pulmonary complication(-) 14 19 33 P value ———— ———— 0.037 Neurological complication(+) 8 6 14 Neurological complication(-) 14 15 29 P value ———— ———— 0.586 Comparison of neurological function recovery rates In group A, the number of patients who have the ability of self-care was 16 preoperatively, 14 postoperatively, and only 8 at follow-up. In group B, the number of patients who have the ability of self-care was 14 preoperatively, 15 postoperatively, and 15 at follow-up. The rate of patients capable of self-care was not statistically different between preoperative (P = 0.665) and postoperative (P = 0.586) in both groups, but was statistically different at follow-up (P = 0.021). See Table 4 and Fig. 4 for details. Table 4 Comparison of neurological function between two groups of patients Group A (> 2 years, N = 22) Group B (≤ 2 years, N = 21) Total Preoperative Ability of self-care 16 14 30 Inability of self-care 6 7 13 P value ———— ———— 0.665 Postoperative Ability of self-care 14 15 29 Inability of self-care 8 6 14 P value ———— ———— 0.586 Follow-up Ability of self-care 8 15 23 Inability of self-care 14 6 20 P value ———— ———— 0.021 Discussion Epidemiological data indicate that about 150 million patients die from tuberculosis worldwide, which places a great burden on personal health and socio-economics 11 . When Mycobacterium tuberculosis infects the spine, due to the depth of the lesion and the lack of obvious symptoms, patients are often unable to discover it in the early stages of the infection. When symptoms appear, Mycobacterium tuberculosis has often already spread through the paravertebral arterial and venous system, which makes it difficult to completely clear the lesion with internal medicine treatment. As a result, the spinal structure is destroyed, and eventually neurological symptoms onset and even paralysis occur 12, 13 . An epidemiological study showed that the spinal tuberculosis was usually secondary to the tuberculosis lesions in early childhood or adolescence and accounts for approximately 2–4% of patients with tuberculosis 14 . According to clinical studies, spinal tuberculosis usually undergoes 4 stages 15, 16 : ( 1 ) implantation stage also called initial stage: within 3 months of primary tuberculosis, Mycobacterium tuberculosis invades the vertebra through bloodstream infection, with no spinal or neurological related clinical symptoms, and slight destruction at the back of the vertebrae can be seen on the imaging 15 ; ( 2 ) early destruction stage: at this stage, Mycobacterium tuberculosis and the immune system reach a state of balance, the paravertebral muscles and the nearby connective tissues form caseous granulomas, and the patient may have low back pain and mild kyphosis of the spine, which lasts for about 9 months 17 ; ( 3 ) late destructive stage: Mycobacterium tuberculosis forms an infected cavity in the vertebra, the intervertebral space narrows, the vertebral body destroyed, the imaging showing worm-eaten-like changes of the vertebral plate, the vertebral body and the intervertebral space blurred 18 . At this stage, the patients' kyphotic angle gradually aggravates and finally even reaches more than 60°, but there are no neurological symptoms. This stage generally lasts for more than 30 years; ( 4 ) nerve damage or paraplegia stage: this stage usually occurs more than 30 years after the primary tuberculosis, and patients usually have unexplained chronic back pain 19 . At the same time, with the aggravation of posterior kyphosis, connective tissue proliferation behind the vertebral body, and long-term accumulation of intervertebral structural disorders, nerve compression or even paraplegia occurs. In our study, we analyzed the clinical course of the patients with severe spinal tuberculosis: 100% of the patients were diagnosed with tuberculosis in their adolescence; they underwent an asymptomatic period of more than 30 years, during which spinal tuberculosis was detected by imaging tests, usually with atypical symptoms such as low back pain, but no patients developed neurological symptoms during this period; after more than 30 years, the patients gradually developed neurological symptoms and underwent surgical treatment within 7 years. This is consistent with the results of previous studies. Standardized treatment and management of patients with spinal tuberculosis based on the clinical stage can maximize patient benefit 12 . Since in the early stages of spinal tuberculosis, the symptoms of the motor system are mild and the spinal kyphotic deformity is also mild, patients often ignore the disease and does not take any therapeutic measures 15 . Therefore, pathological testing for tuberculosis and regular anti-tuberculosis treatment are essential during this period. During the destructive stage of spinal tuberculosis, patients often present with posterior kyphotic deformity or unexplained low back pain. Posterior lesion removal alone may improve patient prognosis 20 . Since there is no nerve damage, spinal internal fixation or neural root canal dilatation is usually not required 21 . In the stage of nerve damage or paraplegia, the patient has a severe spinal kyphotic deformity. Symptoms such as limb weakness and numbness occur due to the compression of the spinal cord as a result of the destruction of the structures in the posterior part of the spine 22 . Symptoms of nerve compression progress with the severe destruction of bone, at which point at which point surgical treatment is essential. However, in patients with severe spinal kyphotic deformity, spinal kyphosis orthopedic surgery is risky and difficult 23, 24 . The destruction of vertebral bone around the tuberculosis lesion, loss of the vertebral space, fusion of the vertebral bodies, and peripheral connective tissue proliferation result in a very rigid tuberculosis kyphotic deformity, making it difficult to ensure a good correction rate. At the same time, prolonged tuberculosis causes the patient to be in a state of chronic disease depletion and malnutrition. Severe kyphotic deformity leads to decreased lung function, prolonged hypothermic state due to long orthopedic time and intraoperative blood loss make patients unable to tolerate anesthesia 10, 25, 26 . Overall, this surgery is a great challenge for the patient as well as the spine surgeon. Currently, there are no high-quality, large samples, multi-center randomized controlled trials clearly defined the surgical indications for spinal tuberculosis. However, some retrospective studies and even a small number of randomized controlled trials 27–29 have shown that nerve injury is a clear indication for surgery, and it remains controversial whether severe spinal deformity is an indication for surgery 7 . The severity of a patient's spinal deformity is evaluated primarily by whether the patient's kyphotic angle is greater than 80°. If the angle is greater than 80°, the patient always has sagittal imbalance alignments and pulmonary function can be significantly impaired 10 . The surgery should be offered to those patients if they are symptomatic (intolerable back pain or neurological function impaired) and are physically fit to undergo surgery 9 . In our study, we grouped our patients depending on whether the surgery was timely or not, and evaluated the surgical outcomes in terms of deformity correction, occurrence of complications, and neurological function recovery. We found that the neurological function recovery of patients in the timely surgical group was significantly better than that of the non-timely surgical group. This is consistent with previous studies 4, 9, 19 . At the same time, the risks of performing the surgery during the asymptomatic period are not significantly reduced, and the surgery during the asymptomatic period does not provide the patient with benefits beyond correction of the deformity. Therefore, we recommend surgery only after the onset of neurological symptoms, and we believe that the timeliness of surgery is an important factor in the surgical outcomes. Since the symptoms are mild at the time of neurological symptoms onset, usually soreness and numbness of the lower limbs, and obvious sensory-motor disorders often appear a few years later, the patients' willingness to undergo surgery is not strong at the time of neurological symptoms onset, and some of the patients miss the optimal time for surgery. Figure 5 is an example of an untimely surgery while Fig. 6 is an example of a timely surgery. While both patients achieved good correction rates, the neurological function recovery in case 2 was significantly better than that in case 1. Our study also has some limitations that need to be considered. Firstly, our study is a single-center retrospective study, and a multi-center study with a larger sample size could be considered in the future. Second, because our study is a retrospective study, we used the Frankle score to assess the primary surgical outcome, which was not detailed enough to assess the neurological function of the patients. In the future, if a prospective study is conducted, we would consider using more detailed scores such as the DASH or JOA score to assess the neurological function. Conclusion Based on previously reported findings, the following three points were considered: ( 1 ) patients with spinal tuberculosis always have more than 30 years from the diagnosis to the neurological symptoms onset; ( 2 ) the risk of surgery during the asymptomatic period is not significantly reduced; ( 3 ) surgery during the the asymptomatic period does not provide the patient with benefits beyond correction of the deformity. We do not recommend surgery for spinal tuberculosis patients during the asymptomatic period. In addition, our study showed that patients who underwent surgery within 2 years from the neurological symptoms onset retained better neurological function recovery as well as experienced fewer pulmonary complications. Therefore, we suggest that the time from neurological symptoms onset (less than 2 years) be used as a criterion for determining the timing of surgery. Declarations Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics approval This study was approved by the Ethics Committee of Medicine, Naval Medical University, PLA. Informed consent Informed consent was obtained from all individual participants included in the study. Author contributions Yuan Gao and Jianquan Zhao contributed to the data analysis and manuscript writing; Bowen lai and Zhanrong Zhang contributed to the data collection; Xuhui Zhou and Heng Jiang contributed to the design of the study and the final review of the manuscript. Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Funding This study was supported by Voyage Talent Program No. SL07 and People's Liberation Army (PLA) Army Program No.BHJ22J031. 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Eur Rev Med Pharmacol Sci Jul. 2016;20(15):3161–7. Jin W, Wang Z. Clinical evaluation of the stability of single-segment short pedicle screw fixation for the reconstruction of lumbar and sacral tuberculosis lesions. Arch Orthop Trauma Surg Oct. 2012;132(10):1429–35. Qian J, Rijiepu A, Zhu B, Tian D, Chen L, Jing J. Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis. Int Orthop Oct. 2016;40(10):2081–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4875943","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":337733778,"identity":"0c46ad06-bc25-40cf-9829-b60a361f1736","order_by":0,"name":"Yuan Gao","email":"","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Gao","suffix":""},{"id":337733780,"identity":"da1f72d0-803b-43dc-bf67-7ff1748b7cbf","order_by":1,"name":"Jianquan Zhao","email":"","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jianquan","middleName":"","lastName":"Zhao","suffix":""},{"id":337733781,"identity":"c4d8d66f-25d4-4bea-9ead-ff325ec2b9f9","order_by":2,"name":"Bowen Lai","email":"","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bowen","middleName":"","lastName":"Lai","suffix":""},{"id":337733783,"identity":"a2f23d00-212a-4eab-8a25-22d3749e8eed","order_by":3,"name":"Zhanrong Zhang","email":"","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhanrong","middleName":"","lastName":"Zhang","suffix":""},{"id":337733784,"identity":"50b947f7-3ab7-4b49-8e6c-b1c4a78e9c09","order_by":4,"name":"Heng Jiang","email":"","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Heng","middleName":"","lastName":"Jiang","suffix":""},{"id":337733785,"identity":"e238094a-cc16-47f9-9a12-67fec33f529d","order_by":5,"name":"Xuhui Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCQY2MA0kGR8kVNiQpoXZ4MGZNBK0gHRJPmw7RFiHwe32Zw8+ttXl8Uk3H6tIYDvAwN/enYBXi+ScA+mGM9sOF7PJHEu7kcBzh0HizNkNeLXwSyQck+ZtO5DYJpFjdiNB4hmDgUQufi1sEoltQC11QC353woSDA4T1sIvkcwG1MIMsoWNISGBCC2SM9LYJGecA/pFIs1YIuFAGg9BvxjcSH8m8aGsLk9+RvLDjz//2cjxt/fi1wIDCTAGD1HKUbSMglEwCkbBKMAAAHaBReOdD8RMAAAAAElFTkSuQmCC","orcid":"","institution":"Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xuhui","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2024-08-07 15:48:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4875943/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4875943/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64623131,"identity":"16f9297c-dec8-4e47-a759-d79d7c52ffdc","added_by":"auto","created_at":"2024-09-16 16:56:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47457,"visible":true,"origin":"","legend":"\u003cp\u003eThe inclusion process used in this study.\u003c/p\u003e","description":"","filename":"OnlineFigure17.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/a72d4d1c29e8411a6cfc8ef7.png"},{"id":64622084,"identity":"29647332-0e0e-4a84-9d5f-117ed4df3c35","added_by":"auto","created_at":"2024-09-16 16:48:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18713,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of spinal kyphotic angles between two groups of patients. (A) Comparison of preoperative and postoperative spinal kyphotic angles; (B) Comparison of correction rate\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/e46be839b9defdca22f40acc.png"},{"id":64623132,"identity":"4f9c71cb-c7d3-43db-9eef-a0ec3f37380a","added_by":"auto","created_at":"2024-09-16 16:56:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51013,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of complication rates between two groups of patients. (A) Comparison of pulmonary complication rates; (B) Comparison of neurological complication rates.\u003c/p\u003e","description":"","filename":"OnlineFigure36.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/8ccd461b34f77ae463114442.png"},{"id":64622083,"identity":"a04cf621-3076-4980-a39d-b3fe502e579c","added_by":"auto","created_at":"2024-09-16 16:48:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42410,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of neurological function between two groups of patients. (A) Comparison of preoperative neurological function; (B) Comparison of postoperative neurological function; (C) Comparison of follow-up neurological function.\u003c/p\u003e","description":"","filename":"OnlineFigure42.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/40fc8db7ce2212dbcc56be13.png"},{"id":64622085,"identity":"c65634fa-b239-4029-9e1e-576e56476d43","added_by":"auto","created_at":"2024-09-16 16:48:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":446348,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1：This is a 53-year-old male patient with spinal tuberculosis for 42 years and lower limb neurological symptoms for 4 years. The cobb angle of kyphosis was 142 °. (A) Preoperative full body photos; (B) Anterior and lateral radiographs of spine; (C) Preoperative spinal MRI; (D) Preoperative marking on MRI; (E) 3D printing model of thoracolumbar spine; (F) Anterior and lateral radiographs of spine 3 days after operation; (G) MRI of spine 3 days after operation; (H) Full-body photos at 3 months after operation.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/b6177489e4fd8ecdb3a185fd.png"},{"id":64622087,"identity":"971b89e7-b88d-438a-a5a7-ed9c4252067e","added_by":"auto","created_at":"2024-09-16 16:48:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":455148,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2：This is a 44-year-old female patient with spinal tuberculosis for 39 years and Frenkel grade E before operation. The cobb angle of kyphosis was 113 °. (A) Preoperative full body photos; (B) Anterior and lateral radiographs of spine; (C) Preoperative spinal MRI; (D) MRI cross section of the posterior convex pyramidal region; (E) 3D printing model of thoracolumbar spine; (F) Anterior and lateral radiographs of spine 3 days after operation; (G) MRI of spine 3 days after operation; (H) Full-body photos at 3 months after operation.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/7b84efced211de5d000d69d0.png"},{"id":99686907,"identity":"0df78c25-96cd-4b98-a9d7-3432642918d5","added_by":"auto","created_at":"2026-01-07 09:40:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2245582,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4875943/v1/56784c96-ffe7-433d-866a-a6f0225a4def.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does timely surgery or not affect surgical outcomes in patients with severe spinal tuberculous kyphosis? An observational cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpinal tuberculosis is one of the most common cause of kyphosis in patients\u003csup\u003e1\u003c/sup\u003e. Since \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e can survive for long periods of time in vertebra and disrupt bony structure, the kyphotic deformity may be progressive and unstable\u003csup\u003e2\u003c/sup\u003e. Clinical data suggested that 15% of patients with spinal tuberculosis treated with conservative treatment have a progression of posterior kyphotic angle\u0026thinsp;\u0026gt;\u0026thinsp;15\u0026deg; and 3\u0026ndash;5% may eventually develop\u0026thinsp;\u0026gt;\u0026thinsp;60\u0026deg; posterior kyphotic angle, followed by paraplegia, which severely affected the patient's quality of life\u003csup\u003e3\u003c/sup\u003e. Whether to correct the deformity or to protect neurological function, surgical treatment with posterior internal fixation is necessary for patients with severe progressive tuberculous kyphotic deformity\u003csup\u003e4, 5\u003c/sup\u003e. However, reconstruction of tuberculous kyphosis is a difficult and risky procedure, with a high complication rate and even patient death\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBased on the above studies, some scholars believed that the benefit of surgical treatment for the purpose to correct the deformity was not balanced with the risks\u003csup\u003e7\u003c/sup\u003e. On the other hand, most patients with progressive tuberculous kyphosis will eventually develop neurological symptoms after a prolonged asymptomatic period. At this point, continued conservative treatment will be ineffective\u003csup\u003e8\u003c/sup\u003e. Therefore, some scholars believed that the benefits of timely surgical treatment after the neurological symptoms onset outweighed the risks for these patients\u003csup\u003e7, 9\u003c/sup\u003e. In this single-center, retrospective, observational cohort study, we propose to analyze the differences in three aspects of neurological function recovery rates, deformity correction rates and complication rates between patients undergoing timely surgery and those not undergoing timely surgery. Aiming to investigate the impact of timely surgery on surgical outcomes.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient inclusion and grouping\u003c/h2\u003e \u003cp\u003eA single-center, retrospective, observational cohort study of patients who underwent surgical treatment after a definitive diagnosis of spinal tuberculous kyphosis was performed from July 1st, 2015 to February 28, 2019 at Shanghai Changzheng Hospital. Inclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the patient was diagnosed with tuberculosis in their adolescence and received standardized anti-tuberculous treatment; and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the patient had signs and symptoms consistent with spinal tuberculosis; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) the patient had kyphotic deformity and a Cobb angle greater than 80\u0026deg;; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) the patient had neurological symptoms and underwent surgical treatment. Exclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) irregular treatment with anti-tuberculosis drugs; or (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non-tuberculous spinal cord lesions; or (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) incomplete or missing patient data on clinical information. In conclusion, all patients included in this study were diagnosed with tuberculosis once during their adolescence, developed spinal tuberculous kyphosis, and eventually underwent surgical treatment due to neurological symptoms.\u003c/p\u003e \u003cp\u003ePatients with spinal tuberculosis typically experience a prolonged period of spinal destruction, also known as an asymptomatic period, after which they will develop neurological symptoms. We grouped patients according to the time from the onset of neurological symptoms to surgery. Those who underwent surgery after 2 years were grouped into the non-timely surgery group (group A) whereas those within 2 years were into the timely surgery group (group B).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eClinical data collection and follow-up strategies\u003c/h2\u003e \u003cp\u003eIn the preoperative and immediate postoperative time, we took the full-length spinal X-rays and collected the Frankle scores of the patients. We used the full-length X-rays to calculate the kyphotic angle and correction rates (preoperative - postoperative / preoperative angle). Within one week after surgery, we need to collect the patients\u0026rsquo; lung CT to determine the patient's pulmonary complication rates and neurological physical examination to determine the patient's neurological complication rates.The Frankel score is a simple method for assessing neurological function and consists of five levels. Grade A represents complete sensory-motor loss. Grade B represents partial residual sensation with complete loss of movement. Grade C represents retained sensation with loss of voluntary movement. Grade D represents retained sensation with slight impairment of motor function. Grade E represents basically normal.\u003c/p\u003e \u003cp\u003eAbout follow-up, there are two points: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) two years after surgery, we use full-length spinal X-rays to determine the patient's deformity correction rates; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) three years after surgery, we use Frankle scores to determine the patient's neurological recovery rates. Preoperative, postoperative and follow-up data collection was performed by two different doctors. The doctors were not aware of the specific grouping of the patients. The final result obtained was the average of the measurements taken by the two doctors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of surgical outcomes\u003c/h2\u003e \u003cp\u003eSince most scholars believed that the purpose of the surgery was to relieve nerve compression and protect neurological function\u003csup\u003e9\u003c/sup\u003e, we took the neurological function recovery rates as the primary outcome. According to patients\u0026rsquo; follow-up Frankle score, We categorized patients with Frankle scores D and E as ability of self-care patients and scores A, B and C as inability of self-care patients. The patients who have the ability of self-care were considered to have a good neurological function recovery. On the other hand, this surgery had a high complication rates including pulmonary complications and neurological complications and it was difficult to get a great correction rate since the patient's spine is always very rigid, therefore we selected pulmonary and neurological complication rates and deformity correction rates as secondary outcomes\u003csup\u003e10\u003c/sup\u003e. Overall, by comparing the neurological function recovery, complication rates and deformity correction rates between the two groups of patients, we were able to determine which group had a better surgical outcome.\u003c/p\u003e \u003cp\u003eThe sample size of this study was calculated based on the primary outcome. According to the pre-test data, we used tests for two proportions as the main statistical method in this study under the requirement of α\u0026thinsp;=\u0026thinsp;0.05 and 90% certainty, and the required sample size was calculated by PASS software. The results showed that to compare the neurological recovery rates between patients with timely surgery and patients without timely surgery, 21 patients were required in both groups. Therefore, we finally included 43 patients (22 non-timely surgery patients and 21 timely surgery patients).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eWe used IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA) for statistical analysis. After grouping the patients depending on whether they received surgical treatment within two years after the neurological symptoms onset, we compared the baseline characteristics, deformity correction rates, complication rates, and neurological function recovery rates between the two groups. Data were tested by independent samples t-test. For data that did not meet the criteria of t test, the Wilcoxon rank-sum test was applied. Categorical variables including sex, complication rates and ability/inability of self-care rate was tested by Fisher's exact test. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered as statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics and grouping of patients\u003c/h2\u003e \u003cp\u003eAccording to the inclusion and exclusion criteria, a total of 43 patients were finally included. The inclusion process was detailed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were 18 males and 25 females. The most common vertebral region affected was the thoracolumbar spine (T10-L2). The average number of vertebrae involved was 4.34. The average time from their first diagnosis of tuberculosis in their adolescence to neurological symptoms onset was 47.05 years. The average time from neurological symptoms onset to surgery was 3.21 years. After analyzing the clinical course of the patients, we found that no patient had neurological symptoms onset until 38 years after diagnosis, 50% patients had symptoms onset until 46 years, and after 58 years, all patients had symptoms onset. After the onset of neurological symptoms, 48.8% of patients received surgical treatment within 2 years, 88.4% of patients received treatment within 5 years and all patients received treatment within 7 years. Depending on whether the patient received surgical treatment within two years after the neurological symptoms onset, we got the non-timely surgical group (Group A, 22 cases) and the timely surgical group (Group B, 21 cases). We also compared the baseline characteristics between the two groups of patients (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline characteristics between two groups of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (\u0026gt;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (\u0026le;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.337\u0026thinsp;\u0026plusmn;\u0026thinsp;3.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.836\u0026thinsp;\u0026plusmn;\u0026thinsp;3.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.492\u0026thinsp;\u0026plusmn;\u0026thinsp;0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.459\u0026thinsp;\u0026plusmn;\u0026thinsp;0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.199\u0026thinsp;\u0026plusmn;\u0026thinsp;5.499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.340\u0026thinsp;\u0026plusmn;\u0026thinsp;6.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (male/female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe time from diagnosis to neurological symptoms onset\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.409\u0026thinsp;\u0026plusmn;\u0026thinsp;4.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.952\u0026thinsp;\u0026plusmn;\u0026thinsp;5.757\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComparison of baseline characteristics and deformity correction rates\u003c/h2\u003e \u003cp\u003eBetween group A and group B, There were no statistically significant difference in age of diagnosis (P\u0026thinsp;=\u0026thinsp;0.636), height (P\u0026thinsp;=\u0026thinsp;0.150), weight (P\u0026thinsp;=\u0026thinsp;0.305), sex (P\u0026thinsp;=\u0026thinsp;0.748) and the time from neurological symptoms onset to surgery (P\u0026thinsp;=\u0026thinsp;0.324). See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details. In comparison of spinal deformity correction between two groups of patients, preoperative kyphotic angle (P\u0026thinsp;=\u0026thinsp;0.811), postoperative kyphotic angle (P\u0026thinsp;=\u0026thinsp;0.302) and correction rate (P\u0026thinsp;=\u0026thinsp;0.269) were no statistically significant difference. See Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for details. Overall, there was no significant difference in baseline characteristics and deformity correction rates between the non-timely surgical group and the timely surgical group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of spinal deformity correction between two groups of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (\u0026gt;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (\u0026le;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative kyphotic angle (\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e91.716\u0026thinsp;\u0026plusmn;\u0026thinsp;7.893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e91.147\u0026thinsp;\u0026plusmn;\u0026thinsp;7.624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative kyphotic angle(\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.468\u0026thinsp;\u0026plusmn;\u0026thinsp;7.277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.336\u0026thinsp;\u0026plusmn;\u0026thinsp;6.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorrection rate (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e66.666\u0026thinsp;\u0026plusmn;\u0026thinsp;7.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e68.985\u0026thinsp;\u0026plusmn;\u0026thinsp;5.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparison of complication rates\u003c/h2\u003e \u003cp\u003eThe pulmonary complication counted in this study was postoperative crural pneumonia while the neurological complication was postoperative sensory or motor dysfunction. In group A, the percentage of pulmonary complication rate was 36.4% while the neurological complication rate was 36.4%. In group B, the percentage of pulmonary complication rate was 9.5% while the neurological complications was 28.6%. There was statistically significant difference in pulmonary complication rate (P\u0026thinsp;=\u0026thinsp;0.037) but no difference in neurological complication rate (P\u0026thinsp;=\u0026thinsp;0.586). See Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e for details.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of complication rates between two groups of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (\u0026gt;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (\u0026le;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary complication(+)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary complication(-)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeurological complication(+)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeurological complication(-)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison of neurological function recovery rates\u003c/h2\u003e \u003cp\u003eIn group A, the number of patients who have the ability of self-care was 16 preoperatively, 14 postoperatively, and only 8 at follow-up. In group B, the number of patients who have the ability of self-care was 14 preoperatively, 15 postoperatively, and 15 at follow-up. The rate of patients capable of self-care was not statistically different between preoperative (P\u0026thinsp;=\u0026thinsp;0.665) and postoperative (P\u0026thinsp;=\u0026thinsp;0.586) in both groups, but was statistically different at follow-up (P\u0026thinsp;=\u0026thinsp;0.021). See Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for details.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of neurological function between two groups of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A (\u0026gt;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup B (\u0026le;\u0026thinsp;2 years, N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePreoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAbility of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInability of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePostoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAbility of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInability of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eFollow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAbility of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInability of self-care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u0026mdash;\u0026mdash;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEpidemiological data indicate that about 150\u0026nbsp;million patients die from tuberculosis worldwide, which places a great burden on personal health and socio-economics\u003csup\u003e11\u003c/sup\u003e. When \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e infects the spine, due to the depth of the lesion and the lack of obvious symptoms, patients are often unable to discover it in the early stages of the infection. When symptoms appear, \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e has often already spread through the paravertebral arterial and venous system, which makes it difficult to completely clear the lesion with internal medicine treatment. As a result, the spinal structure is destroyed, and eventually neurological symptoms onset and even paralysis occur\u003csup\u003e12, 13\u003c/sup\u003e. An epidemiological study showed that the spinal tuberculosis was usually secondary to the tuberculosis lesions in early childhood or adolescence and accounts for approximately 2\u0026ndash;4% of patients with tuberculosis\u003csup\u003e14\u003c/sup\u003e. According to clinical studies, spinal tuberculosis usually undergoes 4 stages\u003csup\u003e15, 16\u003c/sup\u003e: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) implantation stage also called initial stage: within 3 months of primary tuberculosis, \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e invades the vertebra through bloodstream infection, with no spinal or neurological related clinical symptoms, and slight destruction at the back of the vertebrae can be seen on the imaging\u003csup\u003e15\u003c/sup\u003e; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) early destruction stage: at this stage, \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e and the immune system reach a state of balance, the paravertebral muscles and the nearby connective tissues form caseous granulomas, and the patient may have low back pain and mild kyphosis of the spine, which lasts for about 9 months\u003csup\u003e17\u003c/sup\u003e; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) late destructive stage: \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e forms an infected cavity in the vertebra, the intervertebral space narrows, the vertebral body destroyed, the imaging showing worm-eaten-like changes of the vertebral plate, the vertebral body and the intervertebral space blurred\u003csup\u003e18\u003c/sup\u003e. At this stage, the patients' kyphotic angle gradually aggravates and finally even reaches more than 60\u0026deg;, but there are no neurological symptoms. This stage generally lasts for more than 30 years; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) nerve damage or paraplegia stage: this stage usually occurs more than 30 years after the primary tuberculosis, and patients usually have unexplained chronic back pain\u003csup\u003e19\u003c/sup\u003e. At the same time, with the aggravation of posterior kyphosis, connective tissue proliferation behind the vertebral body, and long-term accumulation of intervertebral structural disorders, nerve compression or even paraplegia occurs. In our study, we analyzed the clinical course of the patients with severe spinal tuberculosis: 100% of the patients were diagnosed with tuberculosis in their adolescence; they underwent an asymptomatic period of more than 30 years, during which spinal tuberculosis was detected by imaging tests, usually with atypical symptoms such as low back pain, but no patients developed neurological symptoms during this period; after more than 30 years, the patients gradually developed neurological symptoms and underwent surgical treatment within 7 years. This is consistent with the results of previous studies.\u003c/p\u003e \u003cp\u003eStandardized treatment and management of patients with spinal tuberculosis based on the clinical stage can maximize patient benefit\u003csup\u003e12\u003c/sup\u003e. Since in the early stages of spinal tuberculosis, the symptoms of the motor system are mild and the spinal kyphotic deformity is also mild, patients often ignore the disease and does not take any therapeutic measures\u003csup\u003e15\u003c/sup\u003e. Therefore, pathological testing for tuberculosis and regular anti-tuberculosis treatment are essential during this period. During the destructive stage of spinal tuberculosis, patients often present with posterior kyphotic deformity or unexplained low back pain. Posterior lesion removal alone may improve patient prognosis\u003csup\u003e20\u003c/sup\u003e. Since there is no nerve damage, spinal internal fixation or neural root canal dilatation is usually not required\u003csup\u003e21\u003c/sup\u003e. In the stage of nerve damage or paraplegia, the patient has a severe spinal kyphotic deformity. Symptoms such as limb weakness and numbness occur due to the compression of the spinal cord as a result of the destruction of the structures in the posterior part of the spine\u003csup\u003e22\u003c/sup\u003e. Symptoms of nerve compression progress with the severe destruction of bone, at which point at which point surgical treatment is essential. However, in patients with severe spinal kyphotic deformity, spinal kyphosis orthopedic surgery is risky and difficult\u003csup\u003e23, 24\u003c/sup\u003e. The destruction of vertebral bone around the tuberculosis lesion, loss of the vertebral space, fusion of the vertebral bodies, and peripheral connective tissue proliferation result in a very rigid tuberculosis kyphotic deformity, making it difficult to ensure a good correction rate. At the same time, prolonged tuberculosis causes the patient to be in a state of chronic disease depletion and malnutrition. Severe kyphotic deformity leads to decreased lung function, prolonged hypothermic state due to long orthopedic time and intraoperative blood loss make patients unable to tolerate anesthesia\u003csup\u003e10, 25, 26\u003c/sup\u003e. Overall, this surgery is a great challenge for the patient as well as the spine surgeon.\u003c/p\u003e \u003cp\u003eCurrently, there are no high-quality, large samples, multi-center randomized controlled trials clearly defined the surgical indications for spinal tuberculosis. However, some retrospective studies and even a small number of randomized controlled trials\u003csup\u003e27\u0026ndash;29\u003c/sup\u003e have shown that nerve injury is a clear indication for surgery, and it remains controversial whether severe spinal deformity is an indication for surgery\u003csup\u003e7\u003c/sup\u003e. The severity of a patient's spinal deformity is evaluated primarily by whether the patient's kyphotic angle is greater than 80\u0026deg;. If the angle is greater than 80\u0026deg;, the patient always has sagittal imbalance alignments and pulmonary function can be significantly impaired\u003csup\u003e10\u003c/sup\u003e. The surgery should be offered to those patients if they are symptomatic (intolerable back pain or neurological function impaired) and are physically fit to undergo surgery\u003csup\u003e9\u003c/sup\u003e. In our study, we grouped our patients depending on whether the surgery was timely or not, and evaluated the surgical outcomes in terms of deformity correction, occurrence of complications, and neurological function recovery. We found that the neurological function recovery of patients in the timely surgical group was significantly better than that of the non-timely surgical group. This is consistent with previous studies\u003csup\u003e4, 9, 19\u003c/sup\u003e. At the same time, the risks of performing the surgery during the asymptomatic period are not significantly reduced, and the surgery during the asymptomatic period does not provide the patient with benefits beyond correction of the deformity. Therefore, we recommend surgery only after the onset of neurological symptoms, and we believe that the timeliness of surgery is an important factor in the surgical outcomes. Since the symptoms are mild at the time of neurological symptoms onset, usually soreness and numbness of the lower limbs, and obvious sensory-motor disorders often appear a few years later, the patients' willingness to undergo surgery is not strong at the time of neurological symptoms onset, and some of the patients miss the optimal time for surgery. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e is an example of an untimely surgery while Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e is an example of a timely surgery. While both patients achieved good correction rates, the neurological function recovery in case 2 was significantly better than that in case 1.\u003c/p\u003e \u003cp\u003eOur study also has some limitations that need to be considered. Firstly, our study is a single-center retrospective study, and a multi-center study with a larger sample size could be considered in the future. Second, because our study is a retrospective study, we used the Frankle score to assess the primary surgical outcome, which was not detailed enough to assess the neurological function of the patients. In the future, if a prospective study is conducted, we would consider using more detailed scores such as the DASH or JOA score to assess the neurological function.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on previously reported findings, the following three points were considered: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) patients with spinal tuberculosis always have more than 30 years from the diagnosis to the neurological symptoms onset; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the risk of surgery during the asymptomatic period is not significantly reduced; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) surgery during the the asymptomatic period does not provide the patient with benefits beyond correction of the deformity. We do not recommend surgery for spinal tuberculosis patients during the asymptomatic period. In addition, our study showed that patients who underwent surgery within 2 years from the neurological symptoms onset retained better neurological function recovery as well as experienced fewer pulmonary complications. Therefore, we suggest that the time from neurological symptoms onset (less than 2 years) be used as a criterion for determining the timing of surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of\u0026nbsp;Medicine, Naval Medical University, PLA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYuan Gao and Jianquan Zhao contributed to the data analysis and manuscript writing; Bowen lai and Zhanrong Zhang contributed to the data collection; Xuhui Zhou and Heng Jiang contributed to the design of the study and the final review of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by Voyage Talent Program No. SL07 and People\u0026apos;s Liberation Army (PLA) Army Program No.BHJ22J031.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the patients who participated in this stud\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJain AK, Rajasekaran S, Jaggi KR, Myneedu VP. Tuberculosis of the Spine. J Bone Joint Surg Am Apr. 2020;1(7):617\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur K, Sharma S, Abhishek S, et al. Metabolic switching and cell wall remodelling of Mycobacterium tuberculosis during bone tuberculosis. J Infect Feb. 2023;86(2):134\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajasekaran S. The problem of deformity in spinal tuberculosis. Clin Orthop Relat Res May 2002(398):85\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuparel S, Tanaka M, Mehta R et al. Surgical Management of Spinal Tuberculosis-The Past, Present, and Future. Diagnostics (Basel) May 24 2022;12(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang L, Fu CG, Zhou ZY, et al. Clinical Features and Outcomes of Spinal Tuberculosis in Central China. Infect Drug Resist. 2022;15:6641\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajasekaran S. Buckling collapse of the spine in childhood spinal tuberculosis. Clin Orthop Relat Res Jul. 2007;460:86\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisahn C, Alonso F, Hasan GA, et al. Trends in Spinal Surgery for Pott's Disease (2000\u0026ndash;2016): An Overview and Bibliometric Study. Global Spine J Dec. 2017;7(8):821\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg B, Mehta N, Mukherjee RN, Swamy AM, Siamwala BS, Malik G. Epidemiological Insights from 1,652 Patients with Spinal Tuberculosis Managed at a Single Center: A Retrospective Review of 5-Year Data. Asian Spine J Apr. 2022;16(2):162\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenugopal Menon K, Basu S, Oka G, Gohil K. Delphi-Based Survey for Surgical Indications in Biopsy Proven Active Adult Spinal Tuberculosis. Global Spine J Sep. 2023;30:21925682231204157.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahi P, Chadha M, Sehgal A, et al. Sagittal Balance, Pulmonary Function, and Spinopelvic Parameters in Severe Post-Tubercular Thoracic Kyphosis. Asian Spine J Jun. 2022;16(3):394\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIgbokwe V, Ruby LC, Sultanli A, B\u0026eacute;lard S. Post-tuberculosis sequelae in children and adolescents: a systematic review. Lancet Infect Dis Apr. 2023;23(4):e138\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg Aug. 1995;83(2):243\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn RN, Ben Husien M. Spinal tuberculosis: review of current management. Bone Joint J Apr. 2018;1(100\u0026ndash;b4):425\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebster AS, Shandera WX. The extrapulmonary dissemination of tuberculosis: A meta-analysis. Int J Mycobacteriol Mar. 2014;3(1):9\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar K. Spinal tuberculosis, natural history of disease, classifications and principles of management with historical perspective. Eur J Orthop Surg Traumatol Aug. 2016;26(6):551\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu SH, Tsai WC, Lin CY, et al. Clinical features and outcomes of spinal tuberculosis in southern Taiwan. J Microbiol Immunol Infect Aug. 2010;43(4):291\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders BM, Britton WJ. Life and death in the granuloma: immunopathology of tuberculosis. Immunol Cell Biol Feb-Mar. 2007;85(2):103\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain AK, Sreenivasan R, Saini NS, Kumar S, Jain S, Dhammi IK. Magnetic resonance evaluation of tubercular lesion in spine. Int Orthop Feb. 2012;36(2):261\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao SS, Saxena A, Herwadkar A, Chinoy H. Diagnosis of spinal tuberculosis in an Asian patient with unexplained chronic back pain. \u003cem\u003eRheumatology (Oxford).\u003c/em\u003e Aug 3. 2022;61(8):e244-e245.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin W, Wang Q, Wang Z, Geng G. Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation. Spine J Jun. 2014;1(6):964\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao Z, Wang M, Zhu W, Zheng G, Meng Y. 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Eur Rev Med Pharmacol Sci Jul. 2016;20(15):3161\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin W, Wang Z. Clinical evaluation of the stability of single-segment short pedicle screw fixation for the reconstruction of lumbar and sacral tuberculosis lesions. Arch Orthop Trauma Surg Oct. 2012;132(10):1429\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQian J, Rijiepu A, Zhu B, Tian D, Chen L, Jing J. Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis. Int Orthop Oct. 2016;40(10):2081\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spinal tuberculous kyphosis, Surgical treatment, Neurological function recovery, Deformity correction, Complication","lastPublishedDoi":"10.21203/rs.3.rs-4875943/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4875943/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e Spinal tuberculous kyphosis can cause paralysis, severely affecting patient's life. However, timing of the surgery has become a controversial issue. The aim of this study was to explore whether timely surgery would have an impact on surgical outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e In this single-center, retrospective, observational cohort study, we collected clinical data of patients with severe spinal tuberculous kyphosis who underwent surgery from July 1st, 2015 to February 28th, 2019 at Shanghai Changzheng Hospital. We obtained patients' consultation, treatment, and follow-up data from the patient database of Shanghai Changzheng Hospital, and divided them into two groups according to whether they received surgery timely. We compared the data of the two groups using neurological function recovery as the primary outcome indicator and complication rates and deformity correction rates as the secondary outcome indicators.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e A total of 43 patients were included. 48.8% patients underwent surgery within 2 years and all patients underwent surgery within 7 years after the neurological symptoms onset. We grouped the patients who were treated surgically after 2 years as non-timely surgery group (Group A, Number of cases: 22) and the patients who were treated within 2 years as timely surgery group (Group B, Number of cases: 21). There was no statistically significant difference in correction rates between the two groups. There was a statistical difference in pulmonary complication rates (P\u0026thinsp;=\u0026thinsp;0.037) and follow-up neurological function recovery rates (P\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e Considering neurological function recovery, deformity correction and complications, we support that patients with severe spinal tuberculous kyphosis should receive surgical treatment as soon as possible after the neurological symptoms onset and preferably within 2 years. This contributes to postoperative neurological recovery in patients as well as reducing the incidence of pulmonary complications.\u003c/p\u003e","manuscriptTitle":"Does timely surgery or not affect surgical outcomes in patients with severe spinal tuberculous kyphosis? 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