Selection of surgical treatment approaches for cervicothoracic spinal tuberculosis: A 10-year case review

<div><p>Background</p><p>Cervicothoracic spinal tuberculosis is a rare disease. Due to its difficult and challenging surgical exposure, its surgical treatment approach remains inconclusive. Long-term follow-up studies to address this puzzling issue are rarely seen in the literature. The purpose of this study was to explore the selection of surgical treatment approaches for cervicothoracic spinal tuberculosis through a 10-year case review.</p><p>Methods</p><p>From January 2003 to January 2013, 45 patients suffering from cervicothoracic spinal tuberculosis were treated surgically. According to the relation between the tuberculosis lesion segments and the suprasternal notch on sagittal MRI, 19 patients were treated with a single-stage anterior debridement, fusion and instrumentation approach, and the other 26 patients were treated with a single-stage anterior debridement and fusion, posterior fusion and instrumentation approach. The clinical efficacy was evaluated using statistical analysis based on the Cobb angle of kyphosis, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scoring system. The neurofunctional recovery was assessed by the American Spinal Injury Association (ASIA) system.</p><p>Results</p><p>All patients were followed up for 6.6 years on average (range 3–13 years). No instrumentation loosening, migration or breakage was observed during the follow-up. The kyphosis angle and NDI and JOA scores were significantly changed from preoperative values of 34.7±6.8°, 39.6±4.6 and 10.7±2.8 to postoperative values of 10.2±2.4°, 11.4±3.6 and 17.6±2.4, respectively (p<0.05). Aside from one recurrent patient, bone fusion was achieved in the other 44 patients within 6 to 9 months (mean 7.2 months). No severe postoperative complications occurred, and patients’ neurologic function was improved in various degrees.</p><p>Conclusions</p><p>In the surgical treatment of cervicothoracic spinal tuberculosis, single-stage cervical anterior approach with or without partial manubriotomy is capable of complete debridement for tuberculosis lesions. The manner of fixation should be selected based on the anatomical relation of the suprasternal notch and the diseased segments as revealed on sagittal MRI images.</p></div

A typical case for group B and C.

<p>A 27-year-old patient’s preoperative CT scanning shows destructive segments located at the T2/3 segments (a-b). Preoperative MRI shows a huge paravertebral abscess located in front of the vertebral bodies and the compression of the spinal cord, while the tuberculosis focus lies exactly on the suprasternal notch level (c-d). Two-week postoperative antero-posterior and lateral plain radiograph shows the internal instruments in a satisfactory position (e-f). Four-year postoperative CT scanning demonstrates that the cervicothoracic fusion is consolidated completely (g). Six-year postoperative lateral plain radiograph shows no instrumentation loosening, migration or breakage (h).</p

Another typical case for group A.

<p>A 45-years-old patient’s preoperative CT scanning shows destructive segments located at C7/T1 segments with collapse of T1 vertebra (a-b). Preoperative sagittal MRI shows the tuberculosis focus is located higher than the suprasternal notch level (c). One-week postoperative X-ray image shows internal fixation in good position (d). Three years postoperative CT scanning reveals cervicothoracic anterior graft fusion (e-f).</p

Classification of patients.

<p>Group A: the tuberculosis focus was located higher than the suprasternal notch level. Group B: the tuberculosis focus lay exactly on the suprasternal notch level. Group C: the tuberculosis focus was located lower than the suprasternal notch level. D: diseased segments. M: manubrium. Arrow: the suprasternal notch level.</p

Statistical results in the kyphosis Cobb angle, NDI score and JOA score.

<p>Statistical results in the kyphosis Cobb angle, NDI score and JOA score.</p

Another typical case for group B and C.

<p>A 38-year-old patient’s preoperative CT scanning shows destructive segments located at the T2/3 segments (a-c). Preoperative MRI shows the tuberculosis focus lies lower than the suprasternal notch level (d). Two-week postoperative antero-posterior and lateral plain radiograph shows the internal instruments in a satisfactory position (e-f). Six-month postoperative CT scanning shows the anterior bone grafting is in a good position but without fusion (g). Five-year postoperative CT scanning demonstrates that the cervicothoracic fusion is consolidated completely (h).</p

Demographic and clinical characteristics of the patients.

<p>Demographic and clinical characteristics of the patients.</p

A typical case for group A.

<p>A 56-year-old patient’s preoperative CT scanning shows destructive segments located at the T1 segments with corrasion of the T1 vertebra (a-b). Preoperative sagittal MRI shows that the tuberculosis focus is located higher than the suprasternal notch level (c). One-week postoperative X-ray image shows internal fixation in good position (d). Six-month postoperative CT scanning reveals no cervicothoracic anterior graft fusion yet (e). Three-year postoperative CT scanning reveals cervicothoracic anterior graft fusion (f).</p

Neurological functional recovery according to the ASIA system.

<p>Neurological functional recovery according to the ASIA system.</p