SMJ Current Issue

Treatment of tuberculous spondylitis at the cervicothoracic junction. Clinical impact of surgery by means of a sternotomy
  Stefane M Knoeller,  Ludwige F Brethner
Saudi Medical Journal 2002; Vol.  (11): 1414-1418


Tuberculous spondylitis occupies a special place among the different types of spondylitis. The causative organism is Mycobacterium tuberculosis, but sometimes Mycobacterium bovis or atypical types are found. Tuberculosis affects the skeletal system in 1%1 of patients in Western countries and 10%2 of patients in endemic regions. Up to 50% of these affected people have tuberculosis of the spine.3 It is often found in undeveloped countries with problems of overcrowding and malnutrition.4-6 Adults and children of all age groups are affected there. In Western countries, it primarily affects the old, alcoholics and heroin addicts.7,4 Tuberculosis of the spine remains the most common cause of nontraumatic paraplegia.8 Up to 40% of cases with skeletal tuberculosis will develop a neurologic deficit.9-11 Surgery is indicated in case of neurologic deficit, paraspinous abscess, severe bone destruction or deformity. The procedure includes drainage of the paravertebral abscess, debridement of infected bone and the sequestered disc, decompression of the spinal cord, and stabilization of the spine.12,13 The procedure was first described by Ito et al.14 The literature describes constructs of autogenous bone graft coming from the ileac crest or from the rib and allograft. Using this procedure, the extent of bony fusion is 95%.11,15 Nevertheless, surgery at the cervicothoracal junction is a challenge with respect to the approach and stabilization. P> FONT> FONT>

Case Report.FONT> FONT>Patient One.B>I>FONT> FONT>A 25-year-old African man with destruction of vertebral bodies dorsal (D)1, D2 and D3 combined with incomplete motor and sensory paraplegia was admitted to our clinic (Frankel grade C). Gait disturbance had appeared several days previously. In the blood the cyclic adenosine monophosphate receptor protein (CRP) was found 7.7mg/dl, erythrocyte sedimentation rate (ESR) 68/115 and white blood cell count (WBC) 6600/nl. Mantoux test was positive. The neurological examination showed the following: A sensory level at C7/D1 with unsteady gait, signs of a thoracal myelopathy, and progressive paralysis of the legs with a strength of 3/5. Plain radiographs showed bone rarefaction and destruction of the vertebral bodies D1, D2 and D3 accompanied by kyphosis. The magnetic resonance (MR) imaging not only confirmed bone destruction but also showed ventral compression of the spinal cord. The spinal channel was narrowed to 50% (Figures 1a & b). Because of the paraplegia, we decided to perform a sternotomia immediately to approach the cervicothoracic junction and effect decompression of the spinal cord by corporectomy of D1, D2 and D3. The defect was restored with a titanium cage (DePuy Corp, Warsaw, Indiana (IN), United States of America (USA) described by Harms16 and filled with autogenous bone graft taken from the dorsal iliac crest. Due to a high aortic arch, it was not possible to fix a ventral instrumentation. No intraoperative complications occurred, and the wound healing was inconspicuous. Acid-resistant rods were isolated in the secretion. The neurologic findings disappeared postoperatively. Motor strength returned first, followed 2 weeks later by sensation. The patient was confined to bed for reasons of instability. After complete neurological restitution, we inserted dorsal instrumentation with Moss-Miami titanium (DePuy Corp, Warsaw, IN, USA) from Cervical (C)7 to D6 and continued with dorsal spinal fusion using autogenous bone graft from the dorsal iliac crest. Lamina hooks were used in C7, and pedicle screws were inserted in D5 and D6. The instrumentation was connected using a 5 mm rod. Titanium was used that still allowed for MR imaging. Postoperative x-rays showed a complete correction of the kypho


From the Department of Orthopedic Surgery (Knoeller), Orthopadische Universitatsklinik and the Department of Thoracic Surgery (Brethner), Chirurgische Universitatsklinik, Freiburg Germany.

Received 25th March 2002. Accepted for publication in final form 15th June 2002.

Address correspondence and reprint request to: Dr. Stefan M. Knoeller, Department of Orthopedic Surgery Freiburg, Hugstetter Str. 55, D 79106 Freiburg, Germany. Tel. +49 761 2610. Fax. +49 761 270 2894. E-mail:




1. Davidson PT, Horowitz I. Skeletal tuberculosis. A review with patient presentation and discussion. Am J Med 1970; 48: 77-84.P>

2. Govender S, Charles RW, Naidoo KS, Goga IE. Results of surgical decompression in chronic tuberculous paraplegia. S Afr Med J 1988; 74: 58-59.P>

3. Cauchoix J, Binet JP, Evrard J. Les voies d`abord inhabituelles dans l`abord des corps vertebraux, cervicaux et dorsaux. Ann Chir 1957; 74: 1463-1472.P>

4. Friedman B. Chemotherapy of tuberculosis of the spine. J Bone Joint Surg (Am) 1966; 48: 451-474.P>

5. Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg (Am) 1985; 67: 1405-1413.P>

6. Martin NS. Tuberculosis of the spine: A study of the results of treatment during the last 25 years. J Bone Joint Surg (Br) 1970; 52: 613-628.P>

7. Forlenza SW, Axelrod JL, Grieco MH. Pott`s disease in heroin addicts. JAMA 1979; 241: 379-380.P>

8. Scrimgeour EM, Kaven J, Gajdusek DC. Spinal tuberculosis the commonest cause of non-traumatic paraplegia in Papua New Guinea. Trop Geogr Med 1987; 39: 218-221.P>

9. Bosworth DM, Pietra AD, Rahilly G. Paraplegia resulting from tuberculosis of the spine. J Bone Joint Surg (Am) 1953; 35: 735-739.P>

10. Cleveland M. Tuberculosis of the spine. A clinical study of 203 patients from Sea View and St. Luke`s Hospital. Tuberculosis 1940; 41: 215-218.P>

11. Hodgson AR, Stock FE. Anterior fusion for the treatment of tuberculosis of the spine. The operative findings and results of treatment in the first onehundred cases. J Bone Joint Surg (Am) 1960; 42: 295-298.P>

12. Girdlestone GR. The operative treatment of Pott`s paraplegia Br J Surg 1931; 19: 121-123.P>

13. Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine 1997; 22: 1791-1797.P>

14. Ito H, Tsuchiya J, Asami G. A new radical operation for Pott’s disease: Report of ten cases. J Bone Joint Surg 1934; 16: 499-504.P>

15. Slucky AV, Eismont FJ. Spinal infections. In: Bridwell KH, DeWald RL, editors. The textbook of spinal surgery. 2nd ed. Philadelphia (PA): Lippincott-Raven Publishers; 1997. p. 2160-2165.P>

16. Harms J, Stoltze D, Biedermann L, editors. Wirbelkörperersatz,-platzhalter. Oral Presentation. Proceedings of the Workshop on correction and stabilisation of spinal diseases with the Moss system; 1990 June 29; Nauheim, Germany. P>

17. Upadhyay SS, Saji MJ, Yau AC. Duration of antituberculosis chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis. Spine 1996; 21: 1898- 1903.P>

18. Kirkaldy-Willis WH, Thomas G. Anterior approaches in the diagnosis and treatment of infections of the vertebral bodies. J Bone Joint Surg (Am) 1965; 47: 87-92.P>

19. Kemp HBS, Jackson JW, Jeremiah JD, Cook J. Anterior fusion of the spine for infective lesions in adults. J Bone Joint Surg (Br) 1973; 55: 715-734.P>

20. Bradford DS, Daher YH. Vascular rib grafts for stabilisation of kyphosis. J Bone Joint Surg (Br) 1986; 68: 357-361.P>

21. Mironski E. Arthroplasty using metal cups in tuberculosis of the hip in growing subjects. Chirurgia Narzadow Ruchu i Ortopedia Polska 1894; 33: 637-643.P>

22. Wolkow MW. Alloplastik von Metallgelenken. Acta Orthop Scand 1969; 40: 571-576.P>

23. Iukhno AI, Fedoruk FF. Reconstructive resection of the coxofemoral joint with fixation of the resected ends with a metal screw. Probl Tuberk 1968; 46: 88-89.P>

24. Enneking WF, Burchardt H, Puhl JJ, Pitrowski G. Physical and biological aspects of repair in dog cortical-bone transplants. J Bone Joint Surg (Am) 1975; 57: 237-252. P>

25. Medical Research Council Working Party on Tuberculosis of the Spine. A 10 year assessement of controlled trail comparing debridement and anterior

Saudi Medical Journal is copyright under the Berne Convention and the International Copyright Convention. All rights reserved. Saudi Medical Journal is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. Electronic ISSN 1658-3175. Print ISSN 0379-5284.