Fusion Surgeries of Lower Cervical Spine
Among tuberculosis cases outside of the lungs, spinal tuberculosis is the most frequently occurring. Tuberculosis tends to affect the cervical spine less frequently when compared to the thoracic and lumbar regions.
Although cervical spine tuberculosis is rare and comprises only 3% to 5% of spinal TB cases, it can be highly dangerous due to the potential for severe complications. The weight transmission line in the cervical spine primarily runs through the posterior half of the vertebral bodies.
However, since tuberculosis typically damages the anterior and middle sections of the spine, it can lead to neurological deficits and kyphosis, which can ultimately result in paraplegia.
Furthermore, cervical spine tuberculosis may cause compression of the trachea due to a buildup of pus in the retropharyngeal area, which can result in respiratory insufficiency.
In addition, cervical spine tuberculosis can lead to invasion of the vertebral artery. Nonetheless, conservative treatment may not be appropriate in every case, particularly when there is a risk of kyphosis, worsening neurological deficits, or if conservative treatment has already proven ineffective. Patients who develop kyphosis or neurological deficits typically require surgical interventions for treatment.
Developing countries are currently seeing a significant increase in the incidence of tuberculosis. Spinal tuberculosis primarily affects the musculoskeletal system and can result in severe complications if not adequately treated.
Tuberculosis of the lower cervical spine is a relatively uncommon occurrence in comparison to tuberculosis affecting the lumbar and thoracic regions. Diagnosing cervical tuberculosis is often delayed due to the non-specific and indistinct clinical presentation of the disease.
The primary symptoms of cervical tuberculosis include neck pain and limited range of motion in the neck. The management strategies for cervical spine tuberculosis have varied over time, alternating between conservative treatment and surgical interventions.
Neurological deficits resulting from cervical spinal cord lesions are typically severe due to the relatively small size of the cervical spinal canal in relation to the diameter of the spinal cord in that region.
One possible paraphrased statement: “For patients with spinal tuberculosis-related deformities and significant neurological deficits, surgical decompression and correction are often necessary for effective treatment. In cases where the spinal cord is compressed by a large prevertebral abscess and kyphosis, surgical intervention is always necessary.
Tuberculosis primarily affects the anterior column of the spine, and the most frequently used surgical approach for debridement, spinal cord and nerve decompression, bone fusion, and internal fixation involves accessing the spine from the anterior. The anterior approach is advantageous in that it allows direct exposure of the affected spinal segments and effective relief of spinal cord compression.
In patients with lower cervical spine tuberculosis, normal ESR and CRP levels were observed during the final follow-up, and there were no indications of TB recurrence or spread. The successful outcome of the treatment may be attributed to the increased operative space that allowed for direct visualization of the affected areas.
In contrast to spinal tuberculosis affecting the thoracic and lumbar regions, anterior debridement can lead to destruction of the anterior growth and impede the spine’s ability to undergo remodeling.
Due to the fact that the line of weight transmission in the cervical spine is located in the posterior half of the vertebral bodies, the anterior approach may be more appropriate for surgical treatment. In patients with kyphosis, anterior instrumentation can effectively correct the deformity and sustain the correction over time.
Literature has documented the results of 25 patients who had lower cervical spine tuberculosis and were treated with anterior debridement, decompression, bone grafting, and instrumentation. Towards the end of the follow-up period, all patients exhibited successful bone fusion and no exacerbation in neurological deficits.
Patients showed bone fusion at the end of the follow-up period, and significant neurological improvement was observed after the surgery. At the end of the last follow-up assessment, full neurological restoration was observed in 9 out of 17 patients.
If more than three vertebrae undergo anterior fusion, both proximal and distal screws will experience higher stress levels and are more prone to loosening, which is a well-known fact.
A different study in the literature describes the results of treating 16 patients with lower cervical spine tuberculosis and neurological complications using a one-stage anterior approach that included debridement, decompression, fusion with iliac bone graft, and H-plate fixation. All patients involved a maximum of three vertebrae and none experienced failure of the internal fixation.
When comparing the use of a titanium mesh cage or iliac crest grafting for patients with cervical TB, it was found that the cage-using group had better sagittal profile and kyphosis correction than the iliac bone grafting group.
A commonly preferred method to restore vertebral sequence in patients with cervical TB is the use of a titanium mesh or cage filled with allograft bone instead of autologous iliac crest. This method avoids issues such as pain and infection at the harvest site.
Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy are frequently reported as complications related to the anterior surgical approach for the cervical spine.
A feasible and effective surgical method for treating lower cervical spine tuberculosis is anterior debridement, decompression, fusion, and instrumentation, particularly for patients with the disease affecting fewer than three vertebrae.
The surgical approach of anterior debridement, decompression, correction of kyphosis, and reconstruction of cervical spinal stability can effectively clear the tuberculosis focus, fully decompress the spine, correct the kyphosis, and restore spinal stability.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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