| Objectives:To explore the clinical effects of anterior retropharyngeal debridement combined with posterior fusion and fixation to upper cervical Tuberculosis; To summarize the surgical techniques and precautions of anterior retropharyngeal debridement; To comparative analysis the clinical efficacy and merits of atlantoaxial fusion and occipital-cervical fusion on treatment of upper cervical Tuberculosis. Methods:1. General informationBetween February 2002 and May 2014, 21 patients who underwent anterior retropharyngeal debridement combined with posterior fusion and fixation were selected and retrospectively analyzed. 10 males and 11 females, Aged 26 ~ 65(43.4 ± 12.8) years, duration of 9 ~ 34(17.3 ± 8.8) months. According to the cervical spine X-ray, MRI scan of cervical pillow neck CT scan and other imaging studies, 9 cases of atlantoaxial Tuberculosis, 6 cases of atlas Tuberculosis and 6 cases of axial-Tuberculosis. 21 patients presented varying degrees of neck pillow persistent pain and limited mobility symptoms. And 8 patients presented upper limbs numbness, pain, weakness, 6 cases exist lower limb weakness, unsteady gait,9 cases of low-grade fever, night sweats, weight loss and other symptoms. According to imaging data, the damage of atlas lateral mass and pedicle extent and the development of the situation and atlas lateral mass and endurance as well as the degree of difficulty of the pedicle screw screws implanted were evaluated. Preoperative routine 1-3 months of anti-TB treatment, TB symptoms to be reduced, ESR <at 30 mm / h, C-reactive protein of normal, surgical treatment. 2. Surgical methodsAnterior debridement: After patients were put in a supine position with a slight cervical extension, a right anterior cervical curved incision was performed. The subcutaneous tissue and platysma were stripped in layers. Sharp dissection was performed up and down along the deep platysma to reveal the deep fascia. Then the deep fascia was longitudinally incised along the inner edge of the sternocleidomastoid. After that, the supraomohyoid was found and incised. The prevertebral space was entered via the interspace between the internal edge of the vascular sheath and the outer edge of the offal sheath. Prevertebral loose tissue was sharp dissected. A suitable vertebra was located with the C-arm ray machine during the operation and it revealed the atlantoaxial joint. Sequestrum, abscesses and other lesions were removed. The abscess cavity was washed repeatedly and autologous grafting was done if necessary. The surgical cavity was filled with gel foam containing streptomycin. Lastly, a drainage strip was set and the incision was closed accordingly layer by layer.Posterior fusion surgery: The patients were changed to a prone position. A skull traction device was installed. After disinfecting the surgical area, the posterior operation was performed. There was blunt dissection of the subcutaneous tissue layer by layer to reveal the external occipital protuberance and its lower part squama, the posterior arch of the atlas, the lamina and the pedicle of the axis. If the proximal vertebral artery was damaged, it should be exposed to be ready for ligation to avoid hemorrhaging. Lesions and sequestrum were fully removed. Scrape the diseased tissue to the surrounding healthy bone, and the whole wound surface bleeding slightly. Based on preoperative CT and MRI findings, occipital cervical fusion or atlantoaxial fusion were performed. According to the extent of the damage of the pedicle and axial body, laminar screws or pedicle screws were selected for fixation. After the internal fixation was placed well, which was shown by the C-arm ray machine, and the atlantoaxial joint was well reduced. The following irrigation was completed in the operative cavity with providone-iodine solution. After autologous bone grafting, streptomycin gel foam was placed behind the bilateral atlantoaxial joint. The incision was not closed until drainage tube was placed inside. Postoperative treatment48 hours after removal of drainage tube, All patients were treated with regular anti-tuberculosis for 17-21 months after surgery. Drainage tube was not removed after surgery until 48 hours later(drainage volume <50ml). The cervical lateral X-rays and cervical CT scan were reviewed one week after operation. All patients were asked to waer a rigid cervical collar for 6 weeks or more for recovery. The rigid cervical collar was removed when the union of the bone graft or fracture line blurred displayed on the X-ray. JOA score formulated by the Japanese Orthopaedic Association was used to evaluate the neurological function; Visual analog scale(VAS) and neck disability index(NDI) was used to measure the degree of pain of the occipitocervical area. Bony fusion was confirmed with no solid or translucent line around grafting area and no instrument movement in dynamic radiograph. Complete reduction was confirmed with atlanto-dental interval(ADI)<3.5mm. At last follow-up, using Odom’s grade evaluate integrated clinical efficacy. Results: 1 General data21 cases of patients were treated with anterior retropharyngeal debridement, while 12 patients underwent posterior occipital cervical fusion, and 9 patients underwent atlantoaxial fusion, 9 cases underwent unilateral laminar screws combined with unilateral pedicle screw fixation, because of one side pedicle screw path was heavy damaged, 12 cases with bilateral pedicle screws. The operation time 262.9±32.5min, blood loss 518.6±120.5ml. Eight patients C2 nerve root debridement dur to blocking operation. 2 Clinical dataAfter operation,21 cases were followed up an average follow-up of 49.9 ± 15.8(34~78) months. Cervical spine and upper cervical spine X-ray CT showed: Tuberculosis was completely cleared, no residue sequestrum, fixation position was well, the upper cervical spine sequences were well; Routine use of anti-TB drug therapy 18.5 ± 1.5 months(17 to 21 months); After 4 months of follow-up, particles are partially absorbed on seven patients, after systematic treatment, eight months later, all reached the bone fusion.Depending on the operation, 21 cases were divided into two groups: occipital-cervical fusion and atlantoaxial fusion group, the age, sex, duration and other aspects of the groups were balanced and comparabled, the difference was not statistically significant. Among the preoperative, postoperative and final follow-up, the JOA score of two groups were successive increased, the difference was statistically significant(P <0.05). There was no statistically significant difference between groups(P> 0.05); while the NDI and VAS scores were decreasing gradually, and the difference was statistically significant(P <0.05),, The difference was not statistically significant(P> 0.05) between groups. At last follow-up, according to Odom’s criteria, in occipital-cervical fusion group: 8 cases were scaled excellent, 3 good and 1 remained; in atlantoaxial fusion group: 7 cases excellent, 1 casegood, and 1remained, the difference was not statistically significant(P> 0.05).During follow-up, No loosening, fracture displacement and other complications were documented, 4 cases of the presence of stiff neck pillow, give local therapy, muscle relaxant drug use and other measures, significant improvement in symptoms; 8 cases due to cut C2 nerve root, after C2 Nerves sensory loss, no pain and other discomfort; 4 cases C2 nerves of persistent pain symptoms, consider surgery related to repeated stretch, given neurotrophic, inflammatory pain and other symptomatic treatment, symptoms improved after six weeks. Conclusion:The approach of anterior cervical and retropharyngeal debridement combined with posterior fusion has been proved to be an effective treatment of upper cervical tuberculosis, which can remove tuberculosis, available and reliable upper cervical spine stability. On the option of sposterior surgical, whether occipital-cervical fusion or atlantoaxial fusion, you would get a good fixed effect. This operation result partial loss of function of the cervical spine, anterior surgical trauma, the atlantoaxial vertebral and damage should be carefully evaluated before surgery, basedon CT, etc, and strict control of surgical indications.. |
