Mid- to short-term efficacy of Uniportal Video-Assisted Thoracoscopic Surgery in the treatment of thoracic spinal tuberculosis

Abstract

Background

Surgical treatment of thoracic spine tuberculosis using traditional procedures is often challenged by high trauma and slow recovery. This study aimed to investigate the short- and medium-term efficacy and safety of Uniportal Video-Assisted Thoracoscopic Surgery, a minimally invasive single-port thoracoscopy combined with posterior internal fixation for the treatment of thoracic spinal tuberculosis.

Methods

Nineteen patients with thoracic spinal tuberculosis (15 men and four women, mean age of 52 years) were retrospectively included. All patients underwent single-port thoracoscopic lesion removal and intervertebral implant fusion combined with posterior internal fixation. Surgical time, intraoperative bleeding volume, hospitalization time, and complications were recorded, and the rate of bone fusion and correction of the kyphosis angle were assessed using imaging, with a follow-up period of 6–12 months.

Results

All patients achieved postoperative bone fusion without serious complications. The average operative time was 149.58 min (75–212 min), the average intraoperative bleeding volume was 210.53 mL (50–600 mL), and the average hospital stay was 15.58 d (2–29 d). The mean thoracic kyphosis angle improved from 23.33° preoperatively to 19.00° at the final follow-up.

Conclusions

Single-port thoracoscopic technique combined with posterior internal fixation can effectively remove thoracic tuberculosis foci and correct kyphosis deformity. Moreover, it has the advantages of less trauma, quicker recovery, and significant short- and medium-term efficacy, making it a feasible, minimally invasive surgical procedure for treating thoracic spinal tuberculosis. However, further optimizing the instrumentation design and expanding the sample size in the future is necessary to validate its long-term effects.

Background

Thoracic spinal tuberculosis (TSTB) is a severe form of extrapulmonary tuberculosis and the leading cause of spinal deformities and neurological deficits in endemic areas [1, 2]. Despite advances in antituberculosis treatment (ATT), surgical intervention is still necessary in patients with progressive kyphosis, spinal instability, or neurological damage [3] to completely remove the lesion, improve spinal stability, correct kyphotic deformity, and relieve symptoms caused by compression of the spinal cord or nerve roots [2, 4]. However, traditional surgical approaches (anterior, posterior, or combined), although widely used, have many pitfalls, including but not limited to prolonged recovery time and risk of vascular or lung injury [5–7]. Thus, minimizing traumatic irritation to the body while allowing for adequate exposure of the lesion is crucial for choosing the appropriate surgical approach [2].

With the development of minimally invasive spine surgery, video-assisted thoracoscopic surgery (VATS) has emerged as a viable alternative for direct visualization of anterior spinal lesions with reduced tissue damage [8–11] However, conventional multiport VATS involves multiple incisions and the potential for intercostal nerve injury. Single-port thoracoscopy (Uniportal Video-Assisted Thoracoscopic Surgery [UVATS]) utilizes a single small incision, further reducing surgical trauma while maintaining surgical efficacy for thoracic lesions [10, 12]. Preliminary studies have shown that UVATS achieves lesion clearance and fusion rates comparable to those of open surgery; however, strong evidence for TSTB treatment are lacking, especially in terms of short- and medium-term outcomes [11].

This study aimed to evaluate the feasibility and efficacy of UVATS combined with posterior internal fixation for TSTB treatment; to address the limitations of the traditional technique; to guide the clinic by focusing on key data such as surgical parameters, imaging results, and complications; and to use UVATS as a safer and less invasive treatment option for TSTB.

Methods

Study design and patient selection

This single-center retrospective study enrolled 19 consecutive patients diagnosed with TSTB between 2022 and 2024. Inclusion criteria were as follows: (1) TSTB confirmed by histopathologic or clinicoradiologic evidence (vertebral destruction, paravertebral abscesses, and positive tuberculosis-specific tests), (2) Consistent use antituberculosis drugs during the entire treatment process—including the combined application of isoniazid, rifampicin, pyrazinamide, and ethambutol—despite conservative treatment failure (persistent pain, progressive kyphosis, or neurological deficits), and (3) lesions confined to 1–2 consecutive thoracic vertebrae. Exclusion criteria were (1) multisegmental involvement (> 2 vertebrae), (2) severe cardiopulmonary dysfunction with contraindications to one-lung ventilation, and (3) active systemic tuberculosis or malignancy. The requirement for written informed consent was waived due to the retrospective nature of the study.

Preoperative management

All patients received standardized preoperative 4-week ATT consisting of rifampicin (10 mg/kg/d), isoniazid (5 mg/kg/d), ethambutol (15 mg/kg/d), and pyrazinamide (25 mg/kg/d). Surgical intervention was prioritized in patients with acute neurological deterioration (e.g., paraplegia). Preoperatively, patients underwent routine blood tests and erythrocyte sedimentation rate and C-reactive protein evaluation. Vertebral body destruction was quantified by computed tomography (CT), thoracic kyphosis angle was calculated (Cobb's angle was measured for T5–T12), spinal cord compression was assessed by magnetic resonance imaging, and surgery was performed when the patient was in a stable phase.

Surgical procedure

The procedure was performed under general anesthesia with the patient in the lateral position and the upper extremities abducted and secured with an arm brace. The trachea was intubated, and all hemodynamic and respiratory parameters were closely monitored. Under fluoroscopic guidance, a 4–7 cm incision was made parallel to the target intercostal space and perpendicular to the posterior margin of the involved vertebra. After completing the pathway incision, the soft tissues were further processed to create the pathway. The chest cavity was opened for examination and a blunt dissection was performed to successfully free the lung tissue that was mildly adhered to the thoracic cavity. The pleural cavity was accessed through the intercostal space, and an ultrasound scalpel was used to access the lesion through the pathway, severing segmental vessels that obstructed the view or pathway establishment. The vertebral fascia at the location of the affected vertebral abscess was incised using an ultrasonic scalpel, and the pus was aspirated. The dead bone, damaged discs, and granulation tissue were removed using a curette, nucleus pulposus forceps, and bone-biting forceps to create the graft bed. After flushing the lesion, the allograft bone was plasticized according to the size of the vertebral defect, implanted into the intervertebral space, and tapped to ensure a secure fit while preserving the anterior intervertebral space. Subsequently, the thoracic cavity was thoroughly flushed to achieve hemostasis. A drain was placed adjacent to the involved vertebrae to ensure complete drainage, followed by wound suturing (Fig. 1).

Fig. 1.

The Key to the surgery. (I) The required standard lateral position before the operation.(II) The vertebral fascia was incised with an ultrasonic scalpel, and the pus was aspirated.(III) The pus cavity and necrotic tissue after aspiration of pus. (IV) Clear necrotic bone, damaged intervertebral discs, and necrotic granulation tissue. (V) Preparation for high-pressure rinsing after removing the necrotic tissue.(VI) High-pressure irrigation of the lesion using a rinse gun. I (VII)mplantation of allogeneic bone into the intervertebral space.(VIII) The placement of the postoperative drainage tube and suturing of the incision

Results

Surgical and clinical outcomes

All 19 patients achieved complete osseointegration after a mean follow-up period of 9 months (6–12 months). The mean operative time was 149.58 ± 38.21 min (range: 75–212 min), and intraoperative bleeding volume was 210.53 ± 142.67 mL (range: 50–600 mL). The mean length of hospitalization was 15.58 ± 7.34 d (2–29 days)( Table 1). Superficial infection at the surgical site occurred in one patient (5.3%), which resolved after debridement and targeted antibiotic therapy. No fusion displacement, implanted allograft bone failure, or neurological function deterioration were observed.

Table 1.

Patient Information

Cage	Age	Sex	Segment(s)	Cobb° (preoperation)	Cobb° (postoperative)	Cobb° (first postoperative follow-up)	Cobb° (second postoperative follow-up)
1	62	M	T6-7	26.12	24.09	18.65	17.32
2	20	M	T8-9	21.23	16.04	17.22	15.5
3	40	M	T7-8	18.86	21.33	26	20.82
4	70	M	T9-10	41.92	46.21	37.28	29.47
5	42	F	T9-10	31.08	25.52	17.35	19.24
6	77	M	T9-10	8.35	15.48	15.65	16.44
7	68	M	T11-12	33.07	28.05	27.69	27.21
8	70	F	T6-7	24.92	24.27	23.57	22.35
9	59	M	T8-9	25.96	20.44	16.25	15.49
10	28	M	T9-10	22.13	21.2	18.43	24.58
11	40	F	T9-10	19.48	8.3	8.69	9.95
12	40	M	T7-8	18.62	16.35	16.64	20.15
13	64	M	T11-12	19.35	16.27	13.71	13.52
14	38	F	T7-8	25.52	17.62	21.7	16.17
15	64	M	T10-11	14.21	13.65	12.49	12.67
16	55	M	T7-8	25.72	23.76	23.23	22.81
17	71	M	T8	24.94	22.71	20.57	19.58
18	36	M	T9-10	17.59	18.27	19.77	16.99
19	50	M	T6-7	24.15	21.13	22.54	20.89

Imaging results

The preoperative thoracic lordosis angle (Cobb angle) averaged 23.33° ± 8.91° (range: 8.35°–41.92°) and significantly improved to 19.00° ± 5.67° (range: 9.95°–29.47°) at the final follow-up (Fig. 2). Progressive correction was evident over time: immediate postoperative retroconvexity, which measured 21.09° ± 9.45° (range: 8.3°–46.21°), was decreased to 19.86° ± 7.12° (range: 8.69°–37.28°) at 3 months and stabilized at 19.00° at 12 months( Table 1).

Fig. 2.

CT scans of a 28-year-old man with TSTB. (I) Preoperative CT. (II) Postoperative CT. (III) First postoperative follow-up CT. (IV) Second postoperative follow-up CT

Discussion

This study demonstrated that single-port thoracoscopy (UVATS) combined with posterior internal fixation for the treatment of TSTB yields favorable short- and medium-term outcomes. All patients achieved osseointegration and significant posterior convexity correction (preoperative Cobb angle: 23.33°, final follow-up: 19.00°) while exhibiting low bleeding volume (210.53 ± 142.67 mL) and complication rates (5.3% superficial infections). These results suggested that UVATS can serve as a less invasive alternative to the traditional open procedure for posterior stabilization through the combination of direct anterior debridement with posterior stabilization. This strategy effectively balanced lesion eradication and spinal stabilization, thereby addressing the dual challenges associated with TSTB surgery.

Compared with anterior or combined approaches, UVATS can further minimize damage to the intercostal muscles, blood vessels, and nerves through its single-hole design, reduce the rate of wound infection at the surgical site, and enhance the healing effect, thus reducing postoperative pain and allowing patients to resume their daily routine faster [6, 7] The operative time (149.58 min) and bleeding volume (210.53 mL) were significantly lower than those of open thoracic surgery (mean time, 220 min; blood loss volume, 450 mL) [5], whereas the resulting fusion rates were similar to those of open thoracic surgery. In addition, the absence of major complications (e.g., fusion displacement and implanted allograft bone failure) reinforced its safety, further demonstrating the feasibility of UVATS in the treatment of thoracic spinal tuberculosis infection.

Despite its clear advantages, UVATS has technical limitations. A restricted workspace increases the risk of instrument collision, potentially prolonging complex cases. To mitigate this situation, we emphasize the requirement for preoperative personalized planning of surgical approaches, selecting the optimal incision position (the right-sided approach is ideal for targeting upper and middle thoracic vertebrae, whereas the left-sided approach is better for treating the lower thoracic vertebrae), and advocating the modularization of instruments. This can be achieved by selecting instruments that can be flexed or adjusted in angle to increase flexibility during the operation, smaller-sized instruments to reduce instrument interference, or instruments with integrating functions such as cutting, hemostasis, and suction to reduce the frequency of changing instruments, and combining it with intelligent control systems to achieve precise instrument control. However, to improve operability, ensuring the durability and stability of instruments is necessary to avoid intraoperative breakage or malfunctioning. In addition, spinal tuberculosis lesions may involve multiple segments, which may be difficult to fully expose with single-port thoracoscopy, thus, combination with intraoperative imaging navigation techniques may be required. Intraoperative discussions based on intraoperative reference imaging enable the surgeon to continually reconfirm the actual anatomical structures, thereby avoiding the misidentification of blood vessels, pinpointing lesions, and reducing unnecessary tissue damage. In addition, two patients showed severe pleural adhesions, which made hemostasis difficult under single-hole manipulation during treatment. Therefore, the operator was required to fully assess the vascular condition of the patient before surgery, use blunt separation techniques to reduce the pull and damage to the surrounding tissues, and employ the timely use of equipment such as electrocoagulation or ultrasonic knives according to the condition to achieve precise hemostasis. Because UVATS requires high proficiency and a long learning cycle for the operator, we felt that we could develop a virtual surgical simulation system with a standardized training program to help the operator become familiar with the single-hole procedure and shorten the learning curve to improve the efficiency and safety of the procedure while reducing intraoperative complications, so that it can be applied to more complex spinal tuberculosis cases. The above analysis demonstrated the value of single-port thoracoscopy in the treatment of spinal tuberculosis while identifying its limitations and providing directions for future research. However, this study had several limitations as it was a single-center retrospective study with a relatively small patient sample size and lack of high-quality randomized controls, which may affect the generalizability of the results. Therefore, we will continue to perform this type of procedure with rigorous long-term follow-up to comprehensively assess the long-term prognosis of patients in a multidimensional manner.

Conclusion

Single-port thoracoscopy (UVATS) combined with posterior internal fixation has favorable short- and medium-term outcomes for the treatment of TSTB. Our study showed complete osseointegration in all patients, significant correction of posterior convexity (mean Cobb angle improvement: 23.33°–19.00°), and a low incidence of complications (5.3% of minor complications), supporting its use as a minimally invasive alternative to the traditional open approach. The advantages of this technique included a shorter operative time (mean: 149.58 min), reduced bleeding volume (mean, 210.53 mL), and rapid postoperative recovery, which are highly consistent with the principles of modern spine surgery, especially in resource-constrained environments, where minimizing surgical trauma is critical.

However, the retrospective design, small cohort (n = 19), and limited follow-up did not provide sufficient evidence that UVATS can fully replace conventional procedures. Therefore, future multicenter prospective studies are needed to validate the long-term results of this approach. In addition, technological improvements are expected to advance single-port thoracoscopy, further improving its precision and fusion success. Despite these limitations, UVATS remains a viable and less invasive option for the treatment of TSTB that balances radical debridement and spinal stabilization while prioritizing patient safety and functional recovery.

Abbreviations

TSTB

Thoracic spinal tuberculosis

ATT

Antituberculosis treatment

VATS

Video-assisted thoracoscopic surgery

UVATS

Uniportal Video-Assisted Thoracoscopic Surgery

CT

Computed tomography

Authors’ contributions

WH wrote the main manuscript text. QZ and DC provided the main ideas for the manuscript and provided documentary support for the manuscript. XB，YC and CX organized the images and patient data. RF and XL were responsible for the data analysis.All authors read and approved the final manuscript.

Funding

This research was supported by the Natural Science Foundation of Shandong Province under grant number ZR2024MH251,and the Jinan Health Commission Science and Technology Plan under grant numbers No. 2023–2-3.

Data availability

No datasets were generated or analysed during the current study.

the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.