Reconstruction of the Odontoid Process by a Tricortical Iliac Crest Graft in a Case of Tuberculosis of C1, C2, and C3 Vertebrae

[Treatment of tuberculosis in craniovertebral junction]

OBJECTIVE

To investigate the method of treating tuberculosis in the craniovertebral junction and its effectiveness.

METHODS

The clinical data of 18 patients with tuberculosis in the craniovertebral junction between July 2010 and January 2019 was analyzed retrospectively. There were 14 males and 4 females, aged 21 months to 75 years (median, 35 years). The disease duration ranged from 2 weeks to 60 months (median, 4 months), and the affected segment was C 0-C 3. Preoperative visual analogue scale (VAS) score was 6.7±1.5 and the Japanese Orthopaedic Association (JOA) score was 16.1±1.8. The American Spinal Cord Injury Association (ASIA) grading system was applied to classify their neurological functions, according to which there were 6 cases of grade D and 12 cases of grade E. Among 18 patients, 4 patients underwent conservative treatment, 1 patient removed tuberculosis via transoral approach, 1 patient removed tuberculosis via posterior cervical approach, and 12 patients removed tuberculosis via transoral approach immediately after posterior cervical (atlantoaxial or occipitalcervical) fusion and internal fixation. The VAS score, ASIA grading, and JOA score were applied to evaluate effectiveness. X-ray film, CT, and MRI were taken after treatment to evaluate the tubercular recurrence, cervical stability, and bone healing.

RESULTS

All the patients were followed up 3 to 42 months (median, 12 months). At 3 months after treatment, the VAS score was 1.7±1.0, showing significant difference when compared with preoperative score ( t=15.000, P=0.000); and the JOA score was 16.7±1.0, showing no significant difference when compared with preoperative score ( t=1.317, P=0.205). According to ASIA grading, 6 patients with grade D before treatment had upgraded to grade E after treatment, while the remaining patients with grade E had no change in grading. The imaging examinations showed the good stability of the cervical spine. All patients had complete tuberculosis resection and no recurrence, and the patients who underwent internal fixation via posterior cervical approach achieved atlantoaxial or occipitalcervical bone fusion.

CONCLUSION

On the premise of regular chemotherapy, if there is no huge abscess causing dysphagia or dyspnea, atlantoaxial instability, and neurological symptoms, patients can undergo conservative treatment. If not, however, the transoral approach can be used to completely remove the tuberculosis lesion in the craniovertebral junction. One-stage debridement via transoral approach combined with posterior cervical fusion and internal fixation can achieve satisfactory effectiveness.