Surgical Management of Cervical Spinal Tuberculosis with quadriplegia - A case study
Introduction
Tuberculosis is often confined to the respiratory system, but may affect any organ system, including the musculoskeletal system, via hematogenous spread. Skeletal involvement is seen in 1% to 3% of patients with tuberculosis, yet greater than 50% of this subset does not have concurrent active pulmonary tuberculosis. Spinal tuberculosis, which comprises approximately 50% of skeletal tuberculosis, is most commonly spread to the vertebral body through Batson’s prevertebral venous plexus. Vertebral tuberculosis, also known as Pott disease or tuberculous spondylitis, is most often found in the lower thoracic and upper lumbar regions. The middle thoracic region and the cervical spine are less frequently involved. Paravertebral abscess formation is an early and important feature of Pott disease.
Case
A 22-year-old woman presented to our emergency department with a 9-week history of worsening neck stiffness, inability to grip objects, lift arms up, self-care and lower limb weakness. She reported no recent travel or history of trauma and denied previous TB exposure. Systemically, there had loss of appetite, weight loss and night sweats. On examination, Her neck was held in right lateral flexion with marked kyphosis. Neurological examination revealed upper limb hypertonia and power of 3/5 with lower limb hypotonia and 4/5 weakness. Reflexes were present and symmetrical and sensation to light touch was reduced in dermatomes below C5 with axillary sparing. Paraesthesia was noted in both arms and Lhermitte's sign was positive. No sphincteric dysfunction was noted. All base-line blood investigations were normal except ESR of 131 and a C-reactive protein of 94 IU.
A lateral cervical spine radiograph demonstrated angulated kyphosis with partial destruction of C6 with with soft tissue density in the pre-vertebral and retropharyngeal soft tissues.
An MRI and CT scan of the cervical spine demonstrated altered signal intensity within the C5–C7 vertebral bodies with complete destruction of C6 vertebra with an epidural collection extending from the C3/4 disc space to the bottom of T1(Fig 1-4). There was no evidence of enhancement within the cord, but there was high signal intensity within it on T2 weighted scans; indicative of cord oedema. Collectively, the appearances were consistent with an epidural abscess lying anterior to the cord in the cervical spine with large vertebral abscesses. A diagnosis of tuberculosis was made and the patient was commenced on quadruple anti-tubercular therapy (Rifampicin 450 mg o.d., Isoniazid 300 mg o.d., pyrazinamide 1.5 g o.d. and ethambutol 600 mg o.d.).
Four days later the patient underwent anterior decompression of C5–C7 and corpectomy of C6 with insertion of tricortical illia cest Graft and plating and drainage of the pus collection at C3–C7(fig 5-6). Tissue from the abscess was sent for pathological analysis, which grew Mycobacterium tuberulosis. Histopthology was consistent with Tuberculosis and organism was sensitive to first line ATT. The patient made an uneventful recovery and was mobilised with collar.
Patient was given ATT for 9 months. There was progressive improvement in neurology and blood parameters. MRI done at 9 months showed complete resolution of abscess and fusion of graft (Fig7).
Discussion
Tuberculosis of the vertebral column has been around for over 5000 years; evidence of the disease has been observed in mummies from Ancient Egypt. Sir Perceival Pott was the first to report this extra-pulmonary manifestation of tuberculosis (TB) in association with paraplegia and kyphotic deformity of the spine. The commonest extra-pulmonary skeletal manifestation of TB is within the spine. In 2–3% of cases, the cervical spine may be affected with resultant lesions giving rise to instability and neurological deficits. With the number of cases of TB increasing, clinicians need to have a heightened awareness of its many presentations so that an early diagnosis can prevent long-lasting sequelae.
There exist few reports in the literature describing TB of the cervical spine. The duration between onset of symptoms and presentation is 11–15 months. The patients are typically young with a mean age of 38 years (range 29–52). The delay in presentation is secondary to the low intensity of the initial symptoms and incorrect attribution to musculoskeletal pain. In the largest case series (n = 61), constitutional symptoms such as fever, malaise and weight loss did not contribute to the diagnosis in a single patient.
Neurological deficits are the most serious complication of spinal TB with patients presenting with para- or tetraplegia, hemiplegia or monoplegia. When the cervical spine is involved the commonest presenting symptom is neck pain and can precede the diagnosis by 24 months. Over 50% of patients will have muscular weakness. The development of kyphosis, secondary to spinal TB, is the rule rather than the exception. Our patient presented with severe cervical kyphosis. In severe cases kyphosis can be as great as 60 degrees.
TB of the cervical spine complicated by worsening neurological deficit and or progressive deformity should be treated early. The gold standard treatment, following decompression, is anterior spinal instrumentation to support the collapsed anterior weight-bearing column of the cervical spine. Our patient underwent decompression and stabilization within 4 days of presentation, with significant improvement in kyphotic deformity. In the absence of gross deformity or neurological deficit, TB of the spine is a medical disease and should be treated with antituberculous medication, rest and mobilization with suitable orthosis.
The best treatment for TB of the cervical spine with paraplegia is to prevent the development of paraplegia. This can only be achieved by approaching patients with worsening neck pain with caution and spotting TB early before it represents with concomitant neurological deficits.
Dr Pramod Saini is an Executive Consultant spine surgeon associated with Jaypee hospital, Noida. He is an Orthopaeidic surgeon with a special training in spine surgery. His area of expertise is Minimally Invasive Spine Surgery. He specializes in Management of Slip disc, Sciatica, back pain and all spinal problems.
