Simple anterior approach and anterior combined with posterior approach for upper cervical tuberculosis

English Keywords:Upper cervical tuberculosis  Anterior surgery  Combined anterior and posterior surgery  Effective

English Abstract:

  【Abstract】 Objectives: To evaluate the clinical efficacy of single anterior approach and combined anterior and posterior approach for the treatment of tuberculosis involved upper cervical spine. Methods: A total of 31 patients with upper cervical tuberculosis who underwent surgery in our hospital from January 2014 to January 2018 was reviewed, including 12 males and 19 females aged from 3.5 to 70 years. All 31 patients had different degrees of neck and shoulder pain; 19 cases had limited neck activity, decreased strength and sensation of upper limb muscle, with symptoms from 1 to 12 months. Twenty-three patients had varying degrees of tuberculosis symptoms. In them, 14 cases involved single vertebral body, 16 cases involved 2 adjacent vertebral bodies, and 1 case involved multiple segments. Four-drug anti-tuberculosis regimen was given before surgery for 2 to 4 weeks. 17 patients with mild vertebral destruction were treated with simple anterior debridement, bone graft fusion and internal fixation(group A), 14 patients with severe vertebral destruction were treated with anterior debridement and bone graft fusion combined posterior internal fixation(group AP). All the patients received postoperative anti-tuberculosis drug treatment for 12-18 months. The clinical data before and after surgery in the two groups were recorded: the American Spinal Injury Association(ASIA), the Japanese Orthopaedic Association(JOA), the cervical spine dysfunction index(NDI), and visual analog score(VAS) of neck and shoulder pain, bone graft fusion and complications. Results: All the 31 patients were operated successfully. The operation time and intraoperative blood loss in group A were 80-200min(128.8±40.8min) and 50-120ml(73.5±23.2ml), and the operation time and intraoperative blood loss in group AP were 120-300min (212.9±56.2min) and 200-450ml(295.7±74.3ml). There was no injury of spinal cord, nerve root, vertebral artery or other tissue, except 1 case of C2 nerve injury in group AP. The postoperative pathological result was all tuberculosis. All the 31 patients were followed up for 18.1±8.2 months. The JOA scores in group A were 9.9±1.6, 14.1±1.2 and 15.1±0.9 before operation, after operation, and at the last follow-up respectively. The VAS scores of neck and shoulder pain were 6.8±1.5, 2.9±1.4 and 1.9±1.1 respectively. The NDI scores were 31.8±4.3, 14.2±2.7 and 10.2±2.1. The JOA scores in group AP was 9.4±1.2, 14.0±1.2 and 15.3±1.1 before operation, after operation, and at the last follow-up respectively. The VAS scores of neck and shoulder pain were 6.9±1.4, 2.9±1.4 and 3.1±0.9 respectively. The NDI scores were 33.3±3.8, 15.6±2.8 and 10.4±2.0. There were significant differences of the scores between before operation and after operation immediately, before operation and at the last follow-up in the two groups(P<0.05). There was significant difference between after operation immediately and at the last follow-up in the two groups(P>0.05). In group AP, 1 patient had sinus in the operation area and was cured after debridement and adjustment of anti-tuberculosis drugs. In the other patients, there was no complication such as internal fixation failure, and all the incision healed well. The cervical stability was all reconstructed, and there was no recurrence of tuberculosis. 8 patients in group A had neurological dysfunction(ASIA grade C in 3 cases, grade D in 5 cases) before surgery and recovered to grade E at the last follow-up; 11 patients in group AP had neurological dysfunction(ASIA grade B in 1 case, grade C in 7 cases, grade D in 7 cases) before surgery, 1 case improved from grade B to C, 1 case recovered from grade C to D, and the rest recovered to grade E. Conclusions: In upper cervical tuberculosis, surgical choice is made according to the tuberculosis characteristics, the extent of vertebral damage, the rang of involvement, and the degree of spinal cord and nerve compression damage. Simple anterior and anterior combined with posterior approach can safely and effectively achieve nerve decompression, lesion clearance, bone graft fusion and cervical stability reconstruction.