Evolution of surgery for active spinal tuberculosis in adults: A narrative review

Background Surgical management of Tuberculosis (Tb) spine has evolved from debridement and laminectomy to navigation assisted procedures; from high morbidity and mortality to excellent clinical outcomes. Objective The objective of this narrative review was to trace the evolution of surgical procedures for the treatment of active spinal tuberculosis in adults. Methods PubMed, MEDLINE, EMBASE, Springer, Elsevier Science Direct, Cochrane Library, and Google scholar were searched for relevant studies published up to May 2023. The keywords of ‘spinal tuberculosis’, ‘surgery and spinal tuberculosis’, ‘surgery and Pott's paraplegia’ ‘decompression and spinal tuberculosis’ ‘instrumentation and spinal tuberculosis’, ‘bone graft and spinal tuberculosis’, ‘surgical approach and spinal tuberculosis’ were used. Results Initial search resulted in 5673 articles. 298 were listed for full text review. Six studies were meta-analyses, two systematic reviews and one a randomized control trial. One hundred five studies described anterior approach and debridement with or without instrumentation; 153 described posterior approach and instrumentation with or without debridement; 74 described combined anterior and posterior approach while 6 studies described a direct lateral approach to the lesion. One hundred seventy five studies advocated use of autologous bone graft while 27 studies used interbody cages. Fourteen studies described minimally invasive techniques. Conclusion Spine surgery for Tb has evolved through the pre-chemotherapy, biological, mechanical and technological eras over the last 7 decades. Current strategy includes posterior instrumentation with anterior column debridement and reconstruction preferably by less invasive technologies.