Table of Contents  

Amin, Ahmed, Imran, Bashir, Zaman, Javed, and Aziz: Efficacy of anterior column reconstruction in tuberculosis of the cervical spine with stand-alone titanium cage without anterior plating

Introduction

Tuberculosis (TB) of the spine is a common disease, especially in underdeveloped countries. According to a study published by the World Health Organization, TB affects approximately 181 people per 100,000 population per year.1 Almost 30% of cases of TB of the spine result in severe kyphotic deformity. The patients most at risk are those who develop the disease before the age of 10 years, who have involvement of three or more vertebral bodies and who have lesions between C7 and L1.2 This may result in serious adverse consequences, especially in the cervical spine, as a result of its peculiar anatomy and inherent instability.3 Most tuberculous spondylitis (TBS) patients are of low socioeconomic status, and cannot afford costly treatment or to be out of work for a long period of time.4 The mainstay of treatment for TBS is usually anti-TB chemotherapy, but the consequences of late treatment and misdiagnosis may be dangerous. The time between diagnosis and treatment is usually about 16–19 months,5 and about 10–47% of patients develop paraplegia.6 Surgical treatment of vertebral osteomyelitis is indicated in cases of sepsis, neurological impairment, vertebral instability, spinal deformity and intractable pain and selected cases of infections that do not respond to antibiotics; surgery may provide the only opportunity to drain the abscess, obtain a culture for assay or administer local intracavitary antibiotic therapy.7,8 There is controversy about whether the anterior or posterior approach is better: Muller performed anterior spinal fusion in 1906;9 Hibbs and Albee performed posterior fusion in 1911;10,11 Girdlestone, in 1923,12 stated that the posterior approach can prevent flexion only if the lateral columns are intact; and Hodgson and Stock described anterior debridement and fusion as a classical surgical treatment for this disease.11,13 Anterior cervical carpectomy offers the most direct approach for adequate decompression under direct visualization of the cervical spine.14 Titanium cages have proven their efficacy in reconstruction and restoration of spinal column stability in trauma and tumour surgery.15,16 D’Aliberti et al.7 proved that radical debridement followed by anterior reconstruction with titanium cages is the best way to control infection and provide stability.

The aim of this study is to evaluate the effectiveness of a stand-alone titanium cage and bone graft without anterior plating in TBS of the cervical spine in terms of immediate correction of the kyphotic deformity, loss of correction at last follow-up and improvement in neural symptoms and pain, and to report the incidence of complications.

Methodology

This study was approved by the Institutional Review Board and the Ethics Committee of Ghurki Trust Teaching Hospital, Pakistan, and 47 patients with TBS of the cervical spine gave their informed consent to be included in the research between 1 June 2015 and 31 December 2016. The diagnosis of TBS was based on clinical observations, including night fever, loss of weight, fatigue and neck pain, and laboratory investigations including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and tuberculin. All patients underwent single-stage anterior radical debridement, decompression, correction, anterior column reconstruction and instrumentation. Patients were placed in the supine position under general anaesthesia and their cervical spine was exposed through an anterolateral approach. Careful dissection was performed by an experienced surgeon, and debridement of all necrotic and dead material was performed until the normal bleeding margins of the bone were reached. Paravertebral and epidural abscesses were drained and the dura was exposed anteriorly by gentle use of curettes and rongeurs. The local kyphotic deformity was corrected using an intervertebral body spreader; the cage was packed with an autogenous iliac crest cancellous bone graft obtained through a small stab incision using a hollow trephine.

Standard radiographs were obtained postoperatively and a broad-spectrum cephalosporin was administered for 4 days with anti-tubercular therapy (ATT) for an average of 18 months. A Philadelphia collar was supplied to be used for 8 weeks post surgery. All patients were followed up at 6, 12, 18, 24 and 36 weeks and 1 year post operation. After this they were followed up on a yearly basis for 3 years. Clinical examination and laboratory investigations were planned on each visit depending on the individual patient.

Material obtained during debridement was sent for analysis and the diagnosis of TB was confirmed by histopathology. ESR and CRP were also measured at subsequent visits. We observed that these parameters decreased gradually and by the end of the 18-month course of ATT had returned to baseline levels. The collected data were entered in SPSS version 17.0 (IBM Corporation, Armonk, NY, USA) for analysis. The variables analysed included age, sex and improvement in neurological outcome by the Frankel Impairment Scale. For quantitative variables, such as age, mean and standard deviations (SDs) were calculated. Frequency and percentage were calculated for qualitative data such as sex and improvement in neurological outcome.

Results

Of the 47 patients, 26 (55.32%) were men and 21 (44.68%) were women (Table 1). A total of 61.6% of patients were aged 3–35 years and 28.4% of patients were aged 36–70 years (Table 2).

TABLE 1

Frequency and percentage of sex

Sex Frequency Percentage
Male 26 55.3
Female 21 44.7
Male-to-female ratio 1.2 : 1
TABLE 2

Frequency and percentage of age

Age (years) Frequency Percentage
3–35 29 61.6
36–70 18 28.4
Mean (SD) 35.83 (17.55)

Cervical spine involvement in tuberculosis varied according to sex. One-level involvement was less common (i.e. 38.30%) than two-level involvement (i.e. 51.06%). One-level involvement was more common in males and two-level involvement was more common in females (Table 3).

TABLE 3

Frequency of levels involvement according to sex

Level Frequency Percentage
Single level 18 38.30
 Men 12 25.53
 Women 6 12.77
Two level 24 51.06
 Men 11 23.40
 Women 13 27.66
More than two levels 5 10.64
 Men 3 6.38
 Women 2 4.26
Total 47 100

The mean preoperative Cobb angle was 39.06° (SD 10.92°), which improved to –5.51° (SD 4.77°) postoperatively (Table 4) and showed no significant loss of correction at last follow-up. The change in visual analogue score from before to after surgery was statistically significant (Table 5).

TABLE 4

Comparison of pre- and postoperative Cobb angle

Cobb angle Mean (SD)
Before surgery (°) 39.06 (10.92)
After surgery (°) –5.51 (4.77)
P-value < 0.05
TABLE 5

Comparison of pre- and postoperative visual analogue scale scores

Visual analogue scale score Mean (SD)
Before surgery 7.89 (0.60)
After surgery 1.23 (0.43)
P-value < 0.05

Preoperative spinal function was categorized as Frankel grade E in 26 patients (55.32%), Frankel grade D in four patients (8.51%), Frankel grade C in 10 patients (21.28%), Frankel grade B in two patients (4.25%) and Frankel grade A in five patients (10.64%). Following surgery, one patient categorized as Frankel grade A remained the same while the remaining four improved to grade C at follow-up. The rest of the patients improved from their preoperative grade to grade E at the 2-year follow-up (P < 0.05).

Four patients had superficial surgical site infection; in three cases this improved with antibiotics and one patient underwent a wound wash.

Discussion

Tuberculous spondylitis results in the destruction of the anterior and middle vertebral column, and results in kyphotic deformity, which can damage nearby neural elements.17 Hodgson et al.11 reported the efficacy of anterior debridement and graft in 1960 while Kemp et al.18 reported a 32% incidence of rib graft fracture using the same technique. Poor results with this technique are mainly attributable to graft fracture, so it is necessary to stabilize the spine with some form of instrumentation; however, surgeons can have reservations about using internal implants in the presence of infection.19 Very few authors have reported surgical management of cervical spine infections. Hassan20 reported the results of 16 patients with cervical spine TB who underwent anterior debridement, autogenous iliac bone grafting and instrumentation. Koptan et al.3 reported a multicentre study of 30 patients with TBS, in which they used a titanium cage in 16 patients and bone graft in 14 patients. They concluded that the use of titanium cages in TB of the cervical spine gives adequate stability and correction of kyphotic deformity; they used anterior plates along with the cage in the cervical spine. We found that the use of the cage is sufficient to correct and maintain sagittal profile, and use of the cage allows only 1–2 mm settling, helping it to become fixed in more compression mode.

The placement of a cage in the setting of infection is controversial. Lee et al.21 found in their study that titanium cages are acceptable in the reconstruction of the anterior column of the cervical spine, performed even in the presence of infection. In biofilm formation, when comparing the adherence between Staphylococcus epidermidis and Mycobacterium tuberculosis, the latter had less adhesive capability. Therefore, a titanium cage may be reliably used in the treatment of patients with TB.21

The procedure ensured the immediate restoration of kyphotic deformity with no need for supplementary anterior plates or posterior instrumentation. Depending on the size of the resulting defect, variable sizes of titanium cages are available. This did not result in dislodgement or expulsion of the cage in any patient; mild settling was found in six patients.

Limitations

There has been very little research into TB of the cervical spine. We studied a small number of patients using a retrograde design and our follow-up time is short. Further studies with a higher number of patients and a longer follow-up are recommended for better results, and additional variables are strongly encouraged.

Conclusion

The use of titanium cages provides sufficient stability without anterior plating and posterior instrumentation. These cages are filled with an autogenous, iliac, cancellous bone graft taken through a small stab incision, and these cages may be used satisfactorily in the presence of infection.

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