Preoperative Skull Traction, Anterior Debridement, Bone Grafting, and Internal Fixation for Cervical Tuberculosis with Severe Kyphosis

Abstract

Objective: Cervical tuberculosis (CTB) readily causes local kyphosis, and its surgical strategy remains controversial. Although some previous studies suggested that the anterior approach could effectively treat CTB, patients in these studies only suffered mild to moderate kyphosis. Therefore, little is known about whether the anterior approach can achieve satisfactory outcomes in CTB patients with severe kyphosis. This study was performed to evaluate the safety and efficacy of preoperative skull traction combined with anterior surgery for the treatment of CTB patients with a severe kyphosis angle of more than 35°.

Methods: In this retrospective study, we enrolled 31 CTB patients with severe kyphosis who underwent preoperative skull traction combined with anterior surgery from April 2015 to January 2021. Patients were followed up for at least 2 years. Clinical data, such as operative time, blood loss, and postoperative hospital stay, were collected. The clinical outcomes included American Spinal Injury Association (ASIA) spinal cord injury grade, Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, and related complications. The radiological outcomes included the Cobb angle of cervical kyphosis at each time point and the bony fusion state. Clinical efficacy was evaluated by paired Student's t-test, Mann-Whitney U-test, and others.

Results: Six patients had involvement of one vertebra, 21 had involvement of two vertebrae, and four had involvement of three vertebrae. The most common level of vertebral involvement was C4-5, whereas the most common apical vertebra of kyphosis was C4. The mean kyphosis angle was 46.1° ± 7.7° preoperatively, and the flexibility on dynamic extension-flexion X-rays and cervical MRI was 17.5% ± 7.8% and 43.6% ± 11.0%, respectively (p = 0.000). The kyphosis angle significantly decreased to 13.2° ± 3.2° after skull traction, and it further corrected to -6.1° ± 4.3° after surgery, which was well maintained at the final follow-up with a mean Cobb angle of -5.4° ± 3.9°. The VAS and JOA scores showed significant improvement after surgery. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels normalized at 3 months after surgery. All patients achieved solid bone fusion, and no complications related to the instrumentation or recurrence were observed.

Conclusion: Preoperative skull traction combined with anterior debridement, autologous iliac bone grafting, and internal plate fixation can be an effective and safe surgical method for the treatment of cervical tuberculosis with severe kyphosis. Skull traction can improve the safety and success rate of subsequent anterior corrective surgery.

Keywords: Anterior Surgery; Cervical Tuberculosis; Severe Kyphosis; Skull Traction.

FIGURE 1

A 41‐year‐old male with cervical tuberculosis suffered from neck pain, spastic quadriparesis, and dysphagia due to a retropharyngeal abscess. Neutral lateral cervical spine radiograph (A) indicates cervical kyphosis of 51° at C3‐6, and C4 is the apical vertebra. The kyphosis Cobb angle was 54° and 49° on flexion and extension, respectively (B, C), which indicated that the flexibility was only 3.9%. MRI showed the formation of a retropharyngeal abscess and ventral compression of the spinal cord. The Cobb angle was 21° on MRI, which indicated that the flexibility was 58.8% (D). The kyphosis angle was relieved to 14° after skull traction (E), and it was corrected to −3° after surgery (F–H). The x‐ray and CT scans at the final follow‐up showed that the correction was well maintained without significant loss, and solid bone fusion was finally achieved.

FIGURE 2

A 22‐year‐old female with cervical tuberculosis presented with worsening cervical pain, dysphagia, stridor, and weakness of extremities. The lateral cervical X‐ray (A, B) showed severe kyphosis of 41° at C2‐4, and C3 is the apical vertebra which was destroyed by the lesion. The MRI indicated clearly bony destruction located in the C3 vertebrae body, and a large retropharyngeal abscess anterior to C2‐4 vertebra which also connected with the spinal canal and the lesion caused significant compression of the spinal cord (C). The lateral radiograph showed a recovering cervical alignment after skull traction, the kyphosis was relieved to 19° (D), and it was further corrected to 5° after surgery (E). The X‐ray and three‐dimensional CT at the final follow‐up indicated the cervical sagittal alignment maintained well, and the solid bone fusion was achieved without internal fixation related complications (F–H).