Turkish Neiirosiirgery 8: 50 - 52, 1998 Özkal: Transoral Approach lo Cervical Polfs Disease

Transoral Approach to Pott's Disease of Cervical Spine

Servikal Omurganm Pott Hastaligina Transoral Yaklasim

ERTUC; ÖZKAL,M. ERKANÜSTÜN, YAVUZUYAR

Selçuk University Medical SchoolDepartment of Neurosurgery, Department of (EÖ,MEÜ),Otorhinolaryngology (YU)Konya, Turkey

Abstract: A rare case of tuberculosis of the upper cervicalspine managed with transoral surgery is presented.

Key Word s: Cervical spine, Pott's disease, transoralsurgery

INTRODUCTION

Pott's disease or tuberculosis (TB) of the spinefavors the thoradc and lumbar regions. Accordingto the reported case series from the Far East anddeveloping nations, cervical Pott' s disease isrelatively rare and only 4 % to 5 % ofextrapulmonary TB affects the cervical region, whilein developed countries it is reduced to 0.4 % (2,6,9,13).The presentation of the cervical Pott's disease canbe unusual and the diagnosis may not be apparent;therefore, delays in diagnosis are common (2,13).This cas e report describes a patient with cervicalPott's disease and reviews the related literature.

CASE REPORT

A 49-year-old woman was admitted with acomplaint of pain in the neck, right shoulder andright arm. The pain began one year ago withmoderate limitation of neck movements, worseningin the two-month period prior to admission. She hadno cough or chest pain.

On examination, she was holding her neckrigidly. Examination of the neck revealed no palpablelymphadenopathy. Neck movements were limitedin all directions due to pain. Neurological

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Özet: Transonal cerrahiyle tedavi edilen üst servikalomurgaya ait nadir bir tüberküloz olgusu sunuldu.

Anahtar Sözcükler: Pott hastaligi, servikal omurga,transoral cerrahi

examination of the extremities revealed normal

strength, sensation and reflexes.

Chest X-ray and full blood counts were normaL.PPD skin testing was unhelpful. X-rays of thecervical spine showed destruction and osteosclerosisof the body of the second cervical vertebra. A CT seanshowed destruction of the body of the second cervicalvertebra, but no evidence of cana i compression andparavertebral mass was seen (Figure 1).

As the lesion was in the body of the secondcervical vertebra a transoral a pproach wasconsidered. During transoral surgery following theexcision of anterior longitudinal ligament aprotruded mass was seen in the corpus of the axis.After puncturing the mass, a yellow-gray pus wasdrained and the infected bone was curetted. After

the operation there was a considerable relief of thecervical spine pain.

Histopathological examination of the biopsymaterial showed calcification necrosis and

Langhans giant cells, which revealed a tuberculosisinfection. After the diagnosis of tuberculosis wasmade, triple antituberculous drug therapy(Rifampicin, isoniazid, ethambutol) was carried outfor 18 months.

Turkish Neurosurgery· 8: 50 - 52, 1998

Figure 1: The arrow points to the destruction of the bodyofC2.

DISCUSSION

Although Pott' s disease is not uncommon,tuberculosis of the cervical spine remains relativelyrare (13). Theyare thought to arise by hematogenousspread from a lung focus, followed by a period ofquiescence due to a hypersensitivity responsetrapping them in fibrous tissue, followed byreactivation at alater date (1).

The most common prevailing symptoms ofcervical Pott's disease are neck pain and decreasedran ge of motion, but hoarseness, dysphagia,torticoiiis, fever, anorexia, and neurologic deficitsmayaiso be present (9,12,15).

The diagnosis of Pott's disease may be difficultwithout high index of suspicion. The absence ofsystemic manifestation makes the diagnosis moredifficult; the rate of the missed diagnoses comes outto be over 80% in some series (3). Surprisingly, only50% of patients have chest roentgenograms thatshow abnormalities consistent with tuberculosis(lS).

Conventional radiographs of the spine arethe best initial diagnostic test (6,8,12,15). Spinaltuberculosis usually produces osteolysis of theanterior portion of a vertebral body, with gibbusformation and an associated partiaiiy cakified

Özkal: Trausoral Approach to Cervical Pol/'s Disease

paraspinous mass (6,7). Although similar findingsmay be seen with metastatic disease or pyogenicand fungal infections, osteolysis of the posteriorelements is uncommon in tuberculosis, but is commonwith pyogenic infection and is typical of metastases(4,7).Both TBand pyogenic infections typically involvethe disk space whereas metastases andcoccidioidomycosis spare the disk. Calcification of aparaspinous mass is also typical of TB, and is mostsensitively detected by CT scan (7).

In our case only osteolysis of the anterior portionof the second vertebral body was detected by CT scanbut no paraspinous mass was detected. Either CT orMRI can be used to define the extent of cana 1compromise (14).

The results of posterior operations todecompress or stabilize the tuberculous cervicalspine have generaiiy been disappointing. Betterresults have been obtained with an anterior

approach. In their large series, Hsu and Leongreported exceiient results with anterior cervicaldebridement and fusion, combined withantituberculous chemoterapy. All patients were freeof clinical and radiographic evidence of disease by12 months (9,13). As is apparent1y true innontuberculous osteomyelitis, bone grafts cansurvive and fuse in the presence of infectionprovided that mu ch of the infected bone is remove dand the patient is given appropriate antibiotics(5,13).

The spinal cord at the at1anto-axial region is atrisk either because of mechanical compression by atuberculous abscess or because of instability causedby destruction of ligamentous structures and bone,allowing at1anto- axial subluxation andi or upwardtranslocation of the dens. Any lesion at the atlanto­axial region reguires urgent investigation andtreatment. Transoral debridement has proved to bea simple procedure both for the purpose ofdecompression and to obtain a biopsy , it has a lowmorbidity. We also have chosen the transoralapproach.

A one-stage anterior surgical debridement andfusion of the at1anto-axial junction has beenrecommended but has a 50% failure rate and is

technically more difficult than a posterior fusion (6).We did not prefer anterior fusion.

Transoral biopsy and decompression foiiowedby an orthosis has been recommended when no

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Turkish Neurosurgery 8: 50 - 52, 1998

displacement of CLon C2 exists but when there isan anterior displacement of CL on C2, besidetransoral biopsy and decompression a posteriorfusion has also been recommended (lO,l1).

In our case there was no displacement of CLon C2; therefore, only decompression anddebridement were performed.

Correspondence: Ertug ÖzkalSelçuk University Medical SchoolNeurosurgery DepartmentKonya, Turkey

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Özkal: Transoral Approach to Cervical Pott's Disease

osteomyelitis with paralysis. J Bone Joint Surg Am65:19-29,1983

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