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Outcome of surgical versus conservative management of cervical spine myelopathy secondary to cervical tuberculosis

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Abstract

Cervical spine tuberculosis is a rare infectious disease that is not yet discussed well regarding the optimal method of its management. This is a prospective study of a total of 29 patients with cervical spine tuberculosis with a mean follow-up of 14 months (range, 10–21); they were classified randomly into two groups: group I, patients who underwent anterior cervical decompression and fixation and followed by the anti-tuberculous medications (16 patients) and group II, patients who had conservative anti-tuberculous medications only without surgical intervention (13 patients). All patients had complete clinical assessments using Nurick scale and the modified Japanese Orthopaedic Association score for myelopathy and the visual analogue scale for assessment of cervical pain. We had also neuro-radiographic assessment (cervical spine X-ray and MRI) at the first presentation and at 3, 6, and 12 months later. At final follow-up, significant neurological improvement was demonstrated in both management approaches, more obvious in the surgical group. Cervical pain showed a statistically significant improvement (P < 0.05) in surgical group rather than in conservatively treated group. In the surgical group, the mean Cobb angle showed a significant change from a preoperative mean of −3.1 ± 1.6° to postoperative mean of 16.6 ± 5.4°, significantly correlated to the improvement of cervical pain (P = 0.004), while it was changed from a mean of −0.8 ± 2.2 to a mean of 9.2 ± 3.8 1 year after starting of medical treatment in group II. In spite of the conservative trend in the management of Pott’s disease, surgical management of cervical spine myelopathy secondary to cervical tuberculosis could be the optimal treatment even in an early stage of the disease.

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Disclosure

The authors have no financial interest in the instrumentation and methodology advanced in this manuscript. The study was done after consent was taken from all the patients and full discussion with them about all the benefits and hazard of both approaches of management. All patients in group II were known about the study. They had a thorough discussion about the many and close follow-up visits and probability of surgical intervention if any clinical deterioration happens.

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Authors and Affiliations

  1. Department of Neurosurgery, Suez Canal University Hospital, Ismailia, Egypt

    Ahmed Elsawaf

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  1. Ahmed Elsawaf
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Correspondence to Ahmed Elsawaf.

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Comments

Atul Goel, Mumbai, India

The study presented by Dr. Elsawaf is interesting. It preaches surgical activism in cervical spine tuberculosis in preference to the entrenched, fairly successful, conservative chemotherapeutic management.

It must be stated at the outset that avoidance of surgery is traceable not so much to the efficacy of medical management, but to the hazards that attend operating on a delicate area. Now that, for example, Base Of Skull Surgery is a fait accompli, the surgery of the cervical spine ceases to be an adventure and falls into the fairly-easily-doable procedure.

Mycobacterium tuberculosis is a dull, toxin-free, almost sullen organism, which per se, does not destroy the host tissues. The patient pays the price for the assault that the immunocytes make on the organism, in the bargain destroying the host tissues. Both in leprosy and TB, it is almost an autoimmune destruction of self by self. Modern medicine is ignorant of the modus operandi of antituberculous regime, as also the rapid emergence of multi-drug-resistant tuberculosis.

The factors that favor surgical ablation of the infective focus comprise a number of factors. The infection is relatively indolent, progression is slow, the vertebra and the disc are relatively avascular, the pus has poor outlet to the exterior, and the continuing inflammation promotes arteriolar thrombosis of not only the column vessels but also of the adjacent arterioles feeding the spinal cord. All these realities justify the surgical option that Dr. Elsawaf suggests.

The inevitable kyphosis that attends the pathological collapse of the disc and vertebrae is taken care of by the metallic fixation done anteriorly to not only stabilize the spine but also to reverse the kyphotic trend. The radical en-masse excision of the tuberculous focus cuts short the natural history of the infection to enable the body and the cord to recover faster and better.

The series is, as must happen with the uncommon cervical spinal tuberculosis, is small. Yet, the logic behind it and the sound follow-up make this paper highly acceptable.

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Elsawaf, A. Outcome of surgical versus conservative management of cervical spine myelopathy secondary to cervical tuberculosis. Neurosurg Rev 36, 621–628 (2013). https://doi.org/10.1007/s10143-013-0475-9

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