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.

Abstract

Preoperatively, 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. It can completely clear the tuberculosis lesion, achieve full decompression, effectively correct kyphosis, avoid loss of correction, and reconstruct the local stability. Since the spinal cord can adapt to slow stretching, preoperative skull traction can not only improve kyphosis but also provide better conditions for surgical treatment. With tolerance to gradual traction, spinal cord injury caused by overcorrection does not easily occur during corrective surgery.