Selection of surgical treatment approaches for cervicothoracic spinal tuberculosis: A 10-year case review
Selection of surgical treatment approaches for cervicothoracic spinal tuberculosis: A 10- year case review
Editor: Helen Howard
Ziqi Zhu 0
0 Xi'an Medical University , Beilin District, Xi'an, Shaanxi , China , 2 Department of Spine Surgery, Honghui Hospital Xi'an Jiaotong University College of Medicine , Xi'an, Shaanxi , China
Cervicothoracic spinal tuberculosis is a rare disease. Due to its difficult and challenging surgical exposure, its surgical treatment approach remains inconclusive. Long-term follow-up studies to address this puzzling issue are rarely seen in the literature. The purpose of this study was to explore the selection of surgical treatment approaches for cervicothoracic spinal tuberculosis through a 10-year case review.
Data Availability Statement: An ethical restriction
by Honghui hospital's ethical committee prohibits
us from making the data set publicly available,
because some patients don't want their information
available to the public. However, readers may
contact the ethical committee of Honghui hospital
to request the data, and the data will be available
upon request to all interested researchers. Readers
can contact the ethical committee at the address of
Funding: The authors received no specific funding
for this work.
From January 2003 to January 2013, 45 patients suffering from cervicothoracic spinal
tuberculosis were treated surgically. According to the relation between the tuberculosis lesion
segments and the suprasternal notch on sagittal MRI, 19 patients were treated with a
singlestage anterior debridement, fusion and instrumentation approach, and the other 26 patients
were treated with a single-stage anterior debridement and fusion, posterior fusion and
instrumentation approach. The clinical efficacy was evaluated using statistical analysis
based on the Cobb angle of kyphosis, the Neck Disability Index (NDI) and the Japanese
Orthopedic Association (JOA) scoring system. The neurofunctional recovery was assessed
by the American Spinal Injury Association (ASIA) system.
All patients were followed up for 6.6 years on average (range 3±13 years). No
instrumentation loosening, migration or breakage was observed during the follow-up. The kyphosis
angle and NDI and JOA scores were significantly changed from preoperative values of 34.7
±6.8Ê, 39.6±4.6 and 10.7±2.8 to postoperative values of 10.2±2.4Ê, 11.4±3.6 and 17.6±2.4,
respectively (p<0.05). Aside from one recurrent patient, bone fusion was achieved in the
other 44 patients within 6 to 9 months (mean 7.2 months). No severe postoperative
complications occurred, and patients' neurologic function was improved in various degrees.
Competing interests: The authors have declared
that no competing interests exist.
In the surgical treatment of cervicothoracic spinal tuberculosis, single-stage cervical anterior
approach with or without partial manubriotomy is capable of complete debridement for
tuberculosis lesions. The manner of fixation should be selected based on the anatomical
relation of the suprasternal notch and the diseased segments as revealed on sagittal MRI
Cervicothoracic spinal tuberculosis is a disease that involves the C7 to T3 levels of the spine,
constituting only 5% of all spinal tuberculosis [1±3]. Anatomically, the cervicothoracic
junction is a transitional zone between the lordotic cervical spine and the kyphotic thoracic spine.
Because the cervicothoracic vertebrae are weight-bearing structures, destruction of these
vertebrae by tuberculosis frequently results in spinal instability, severe kyphosis deformity, large
paravertebral abscesses and progressive neurological deficit, which cause severe suffering for
the patients [
]. Due to the deep location of the cervicothoracic vertebrae, with the sternum,
clavicles and mediastinum in the front, the scapulae in the back, and the complicated
anatomical relationships of the region, exposure is usually less than satisfactory, making surgical
procedures even more challenging . To tackle this issue, a variety of surgical approaches have
been proposed. However, it remains inconclusive which surgical treatment approach is
optimal for this type of difficult spinal disorder, and long-term follow-up studies to discuss this
puzzling issue are rarely seen in the literature. The present study retrospectively reviewed 45
cervicothoracic spinal tuberculosis cases that were surgically treated between January 2003
and January 2013 in our hospital to explore the selection of surgical approaches and clinical
outcomes for cervicothoracic spinal tuberculosis patients.
Materials and methods
45 patients with cervicothoracic spinal tuberculosis were treated surgically between January
2003 and January 2013, among which 29 were males and 16 were females. The average age was
35.4 (range 17 to 62) years. All patients suffered from neck pain, stiffness and limitation of
motion, with low-grade fever, night sweat and weight loss. The average erythrocyte
sedimentation rate (ESR) was 67.8 (range 28 to 115) mm/h. C-reactive protein (CRP) was 18.7 (range
10.6 to 55) mmol/l. Eleven of the patients had a prior history of tuberculosis infection.
Preoperative imaging showed bone destruction and narrowing of intervertebral spaces of the
diseased segments in all patients. In 41 cases, herniation of caseating materials into the spinal
canal resulted in spinal canal stenosis and spinal cord compression. Paravertebral cold abscess
and retropharyngeal abscess were seen in 37 and 4 cases, respectively. The presurgical
cervicothoracic Cobb angle was 34.7±6.8Ê. The pathologic change regions were as follows: C7/T1 in
8 cases, T1 in 11 cases, T1/T2 in 7 cases, T2 in 6 cases, T2/T3 in 8 cases and T3 in 5 cases. The
presurgical neurological and functional classifications were Class A for 2 case, B for 5 cases, C
for 9 cases, D for 22 cases and E for 7 cases according to the American Spinal Injury
Association (ASIA) system (Table 1).
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35.4 (range 17±62)
67.8 (range 28±115)
18.7 (range 10.6±55)
19 (C7/T1 in 8, T1 in 11)
13 (T1/T2 in 7, T2 in 6)
13 (T2/T3 in 8, T3 in 5)
Isoniazid, rifampicin, pyrazinamide and streptomycin were administered to each patient for a
course of over 2 weeks before surgery. Supportive therapies were also given to address anemia
and hypoproteinemia. Surgeries were performed when ESR either significantly decreased or
fell below 60 mm/h.
Patient classification in the present study was based on the location of the tuberculosis lesion
in relation to the suprasternal notch on sagittal Magnetic Resonance Imaging (MRI) images, as
A. The tuberculosis focus was located higher than the suprasternal notch level.
B. The tuberculosis focus lay exactly on the suprasternal notch level.
C. The tuberculosis focus was located lower than the suprasternal notch level.
19, 13 and 13 cases fell into Groups A, B and C in the present study, respectively (Fig 1).
Patients in group A were treated with a single-stage anterior debridement and intervertebral
fusion with instrumentation. Fusion was performed at the levels above, below, and through
the diseased vertebral bodies. The patient was placed supine on the operation table, and
general endotracheal anesthesia was induced. Selection of a right-sided or left-sided approach was
based on the location of paravertebral abscess. In the case that both sides had equivalent
amounts of abscess, a left-sided approach was preferred to avoid the possibility of injuring the
recurrent laryngeal nerve. An oblique incision was made along the anterior border of the
sternocleidomastoid (SCM) to the sternal notch. The omohyoid was transected, and the SCM was
retracted outwards to expose the prevertebral fascia through the interval between the carotid
sheath and the trachea and esophagus. Structures posterior to the sternum were dissected with
a finger following its exposure. Dissection was then carried down between the carotid sheath
and the esophagus and trachea. A retractor was employed to divide the brachiocephalic trunk
and left common carotid artery to expose the prevertebral fascia of the cervicothoracic spine.
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Fig 1. Classification of patients. Group A: the tuberculosis focus was located higher than the suprasternal notch level. Group B: the tuberculosis
focus lay exactly on the suprasternal notch level. Group C: the tuberculosis focus was located lower than the suprasternal notch level. D: diseased
segments. M: manubrium. Arrow: the suprasternal notch level.
The fascia and abscess wall were carefully incised, and the pus was suctioned thoroughly. The
caseous necrotic tissue, dead bone and damaged intervertebral disc were thoroughly removed.
Intraspinal herniated tissue was also removed to relieve spinal cord compression completely.
A curette was used to thin the graft bed until leakage of blood was observed. Under monitoring
of somatosensory evoked potentials (SSEPs), intervertebral retraction was performed to
correct kyphosis. An appropriately sized autogenous bone graft harvested from the iliac crest was
placed into the graft bed. Streptomycin powder was applied locally, followed by anterior
instrumentation of a titanium plate. A typical case is described in Figs 2 and 3.
For patients in groups B and C, anterior debridement and fusion with posterior fusion and
instrumentation was performed. The anterior procedure was identical to that of group A
patients, except that in 6 patients median manubriotomy was adopted for a more favorable
exposure to make distal tuberculosis lesions accessible. In posterior procedures, fixation was
performed at one level above and below the diseased vertebrae. Pedicle screws were applied,
while interlaminar grafting and bilateral facet joint grafting were performed to obtain optimal
stability. A typical case is described in Figs 4 and 5.
After surgery, the patients were routinely administered antibiotics for 48 hours as well as
corticosteroids and dehydrants for 72 hours. Patients were discharged when their conditions were
stable and were asked to wear a cervicothoracic brace for 3 months afterwards. Isoniazid,
rifampin, pyrazinamide and streptomycin quadruple chemotherapy was administered for 3
months, after which streptomycin was replaced with ethambutol and the therapy was
continued for another 9 to 15 months. ESR, CRP, hepatic and renal function tests were ordered upon
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Fig 2. A typical case for group A. A 56-year-old patient's preoperative CT scanning shows destructive segments located at the T1 segments with
corrasion of the T1 vertebra (a-b). Preoperative sagittal MRI shows that the tuberculosis focus is located higher than the suprasternal notch level (c).
One-week postoperative X-ray image shows internal fixation in good position (d). Six-month postoperative CT scanning reveals no cervicothoracic
anterior graft fusion yet (e). Three-year postoperative CT scanning reveals cervicothoracic anterior graft fusion (f).
Therapeutic effect assessment
X-ray and computed tomography (CT) scans were performed at 3, 6, 9, 12, 18, and 24 months
and every 6 months thereafter to evaluate the position of the internal fixation, presence of
loosening, migration, graft bone fusion, recurrence of tuberculosis and change in the
cervicothoracic Cobb angle. Symptomatic and neurofunctional recovery after surgery was evaluated
according to the NDI and JOA scoring systems as well as the ASIA system.
We adopted Student's t-test to examine the NDI scores, JOA scores and Cobb angles before
surgery and at the final follow-up after surgery. To avoid bias in collecting Cobb angles and
scores caused by multiplayer, data were collected by one author who is an attending physician
and specializes in the diagnosis and treatment of spinal disorders. The Statistical Package for
the Social Sciences version 16.0 (SPSS, Chicago, IL, USA) was used for the statistical analysis.
p<0.05 denotes a statistically significant difference, and the descriptive data were presented as
the mean ± standard deviation.
This study was approved by the Xi'an Honghui Hospital Ethics Committee, and all 45
patients provided written informed consent of participating in the study. The consent for
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Fig 3. Another typical case for group A. A 45-years-old patient's preoperative CT scanning shows destructive
segments located at C7/T1 segments with collapse of T1 vertebra (a-b). Preoperative sagittal MRI shows the
tuberculosis focus is located higher than the suprasternal notch level (c). One-week postoperative X-ray image shows
internal fixation in good position (d). Three years postoperative CT scanning reveals cervicothoracic anterior graft
The mean surgical duration was 178 minutes (range 65 to 270 minutes). Intraoperative blood
loss was on average 590 milliliters (range 100 to 1200 milliliters). No injury of the major vessels
or the spinal cord was observed. Esophageal laceration occurred in 1 patient as a result of
excessive retraction during surgery; the damage was repaired immediately and did not result in
esophageal fistula or dysphagia. One patient presented with dysphonia and bucking after
surgery, laryngoscopy revealed glottal insufficiency, indicating an injury of the recurrent laryngeal
nerve and superior laryngeal nerve. However, at the 3-month follow-up, the symptoms were
relieved. No operation-associated complications were observed in any other patients. The mean
follow-up period was 6.6 years (range 3 to 13 years). One patient in group A who received
single-stage anterior debridement, intervertebral fusion and internal fixation presented with a
sinus of the incision, representing recurrent tuberculosis at the 3-month follow-up. This
particular patient then received one-stage anterior instrumentation removal, radical debridement
and intervertebral fusion, second-stage posterior fusion and instrumentation. Fusion of the
cervicothoracic segment was achieved at 6-month follow-up, and after a follow-up period of more
than 5 years, there was no recurrent tuberculosis. Bony fusion was achieved in the other 44
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Fig 4. A typical case for group B and C. A 27-year-old patient's preoperative CT scanning shows destructive segments located at the T2/3 segments
(ab). Preoperative MRI shows a huge paravertebral abscess located in front of the vertebral bodies and the compression of the spinal cord, while the
tuberculosis focus lies exactly on the suprasternal notch level (c-d). Two-week postoperative antero-posterior and lateral plain radiograph shows the
internal instruments in a satisfactory position (e-f). Four-year postoperative CT scanning demonstrates that the cervicothoracic fusion is consolidated
completely (g). Six-year postoperative lateral plain radiograph shows no instrumentation loosening, migration or breakage (h).
patients within 6 to 9 months (mean 7.2 months) postoperatively. During the follow-up, no
instrumentation loosening, migration or breakage was observed. The cervicothoracic Cobb
angle was significantly decreased to 10.2±2.4Ê at final follow-up, and the difference between the
preoperative and postoperative Cobb angles was statistically significant (P<0.05). The mean
NDI score and JOA score were changed from 39.6±4.6 and 10.7±2.8 preoperatively to 11.4±3.6
and 17.6±2.4 at final follow-up, respectively. The differences between preoperative and
postoperative NDI and JOA scores were both statistically significant (P<0.05). The detailed statistical
results are shown in Table 2. Aside from the patient with recurrent tuberculosis, the remaining
44 patients' ESR and CRP returned to normal within three months' follow-up. In 38 cases
complicated with neurological impairment, 29 (76%) showed various degrees of neurological
functional recovery; detailed ASIA scores are shown in Table 3.
Exposure of the cervicothoracic junction continues to be a challenge in spinal surgeries.
Compared to the anterior approach, the posterior approach may appear to be simpler, but it makes
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Fig 5. Another typical case for group B and C. A 38-year-old patient's preoperative CT scanning shows destructive segments located at the T2/3
segments (a-c). Preoperative MRI shows the tuberculosis focus lies lower than the suprasternal notch level (d). Two-week postoperative
anteroposterior and lateral plain radiograph shows the internal instruments in a satisfactory position (e-f). Six-month postoperative CT scanning shows the
anterior bone grafting is in a good position but without fusion (g). Five-year postoperative CT scanning demonstrates that the cervicothoracic fusion is
consolidated completely (h).
no sense because the majority of lesions are situated in the anterior vertebral bodies.
Consequently, the anterior approach is widely accepted. With bony structures including the sternum,
clavicles and ribs in the front and large vessels, the thoracic duct and important nerves nearby,
it is difficult to expose the cervicothoracic junction anteriorly, and the procedure is
accompanied with high risks. Meanwhile, patient suffering from cervicothoracic tuberculosis is usually
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complicated with regional kyphosis caused by bony structure destruction, which presents a
further challenge to the surgeons [7±11]. As a result, for patients with cervicothoracic
tuberculosis, it is essential to individualize specific surgical approaches based on the location of lesions
to obtain optimal exposure and maximize safety for the patients.
Currently, approaches to the cervicothoracic spine include conventional anterior cervical
approach, anterior approach combined with sternotomy or manubriotomy, standard
transclavicular approach, approach by resection of the manubrio-clavicular complex, anterolateral
transthoracic approach, and combined approaches. The conventional anterior cervical
approach is the simplest one, inflicting minimal damage to adjacent structures, and thus yields
early patient recovery. The procedure is capable of exposing down to the T1-T2 segments.
However, in regard to the T3 segment diseases or surgeries that involve stabilization down to
the T3 segment, the approach may not provide sufficient exposure. Other approaches may
obtain optimal T3 segment exposure, but the procedures themselves are complicated and
patients suffer from high morbidity and high risk of mediastinal infections, bone defects and
nonunion, which to a great extent impair the therapeutic effect of the surgery [
Sharan et al [
] revealed that the T1-T2 disc could be visualized in its entirety above the
suprasternal notch in 45.28% of patients but that the T2-T3 disc could be exposed only in
14.15% from a radiographic analysis. To expose the T3 vertebra, anterior approach with
manubriotomy would be necessary in 80% to 85% cases [14±17]. Kaya RA et al [
] reported the
successful utilization of conventional anterior cervical approach in T2 vertebral instrumentation
and T3 vertebral decompression in long-neck patients. They proposed that in a selected group
of patients, conventional anterior cervical approach achieved sufficient exposure for
debridement of cervicothoracic segments. In the present study, anterior approaches were performed
on all 45 patients for debridement; 19 patients had anterior titanium plate fixation, and the
other 26 patients had posterior pedicle screw fixation. Our experience showed that for patients
with cervicothoracic spinal tuberculosis, presurgical MRI scanning should be a routine exam
to determine the anatomical relation between the suprasternal notch and the diseased spinal
segments. For patients with lesions higher than suprasternal notch or planned for internal
fixation at the suprasternal notch level, single-stage anterior debridement, bone grafting, fusion
and instrumentation yielded satisfactory therapeutic effect. For lesions lower than the
suprasternal notch level or planned for internal fixation below the suprasternal notch level,
singlestage anterior debridement and fusion, posterior fusion and instrumentation approach would
be a safe and effective option.
To debride tuberculosis foci located below the suprasternal notch level, an extensive
prevertebral fascia dissection was preferred to achieve complete debridement. In short-neck
patients or those with a long sternum, debridement might be difficult. In this circumstance, a
partial median manubriotomy is preferred to obtain a larger surgical field and achieve
complete debridement of remote lesions. In the present study, 6 patients had a short neck; thus, a
conventional anterior cervical approach was insufficient for clearance of remote lesions in the
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T3 segment. We thus performed a partial median manubriotomy to achieve complete
For lesions involving the T3 vertebral body, it is possible to achieve debridement through
conventional anterior cervical approach with or without partial manubriotomy, but internal
fixation is impractical due to the blockade of nearby bony structures. In such cases, anterior
approach for internal fixation requires full sternotomy, which demands high technical
proficiency, leading to increased morbidity and extending the recovery time of the patient after
surgery. However, approaching by resection of the manubrio-clavicular complex might induce
shoulder girdle dysfunction [7, 17±20]. Given the above considerations, we performed anterior
debridement, bone grafting and fusion, posterior bone grafting and internal fixation on these
patients. In the present study, 8 patients had lesions at the T2/3 segments, and 5 patients had
lesions at the T3 segment, which were below the suprasternal notch levels. We performed
onestage combined anterior and posterior approaches as described above. After a follow-up period
of over 3 years, all 13 patients presented with anteroposterior 360Ê fusion of the spine and
none had recurrent spinal tuberculosis. Our findings demonstrated that anterior cervical
approach with partial manubriotomy was capable of exposing the T3 level and allowing for a
complete debridement. Without the need for full sternotomy or clavicular resection or
entering the pleural cavity, the procedure not only has a lower impact on respiration and circulation
but also takes less time and is less likely to induce morbidity, benefiting the patients' recovery
The anterior approaches are capable of restoring the stability and physiological curvatures
of the spine through complete debridement and autogenous bone grafting, and they prevent
the loss of physiological curvature post-surgically. In the present study, we performed an
intervertebral retraction after debridement to correct kyphosis of the cervicothoracic spine induced
by tuberculosis. Anterior approaches also allowed for complete clearance of abscesses and
dead bone in the spinal canal. Such direct decompression functioned positively in the patients'
neurofunctional recovery after surgery. Of the 38 patients who had presented with
neurological impairment, 29 showed various degrees of neurofunctional improvement after surgery.
To summarize, in the surgical treatment of cervicothoracic spinal tuberculosis, single-stage
cervical anterior approach with or without partial manubriotomy is capable of complete
debridement for tuberculosis lesions. Meanwhile, it is relatively simple and induces less
morbidity. The manner of fixation should be selected based on the anatomical relation of the
suprasternal notch and the diseased segments as revealed on sagittal MRI images.
S1 File. Editorial certificate. The editorial certificate of American Journal Experts.
S2 File. Consent form. A blank copy of the consent form used.
The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for
this indication. No funds were received in support of this work. No benefits in any form have
been or will be received from a commercial party related directly or indirectly to the subject of
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this manuscript. No financial assistance was provided to any of the authors involved in the
production of this paper.
Conceptualization: Dingjun Hao, Biao Wang.
Data curation: Ruize Yang, Yongyi Wang, Lingbo Kong.
Formal analysis: Ruize Yang.
Investigation: Dingjun Hao, Wenjie Gao, Lingbo Kong.
Methodology: Dingjun Hao, Biao Wang.
Project administration: Biao Wang.
Resources: Biao Wang, Hua Guo, Yongyi Wang.
Software: Wenjie Gao, Hua Guo.
Supervision: Biao Wang, Lingbo Kong.
Validation: Lingbo Kong.
Visualization: Wenjie Gao, Hua Guo.
Writing ± original draft: Ziqi Zhu, Biao Wang.
Writing ± review & editing: Biao Wang.
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