Cervical tuberculosis

      The tubercle bacillus mainly enters the vertebral body through the arterial system from the primary lesion, and a few enter through the venous system and lymphatic vessels. When the body's resistance decreases, the bacterial栓 enters the vertebral body and forms a focus of disease. The majority (about 90%) of cases have only one vertebral body focus. In a few cases, the focus is in two or more places. The intervertebral disc has no blood supply, so there is no primary intervertebral disc tuberculosis, but it is easily destroyed by the tubercle bacillus.

　　What diseases can cervical tuberculosis complicate? Briefly described as follows.

　　1. Cervical tuberculosis often forms cold abscesses. The tuberculous granulation tissue, inflammatory exudates, and necrotic tissue in the lesion of the cervical vertebral body form pus, penetrate the cortical layer of the vertebral body, and gather under the periosteum on one side of the vertebral body, forming a localized paravertebral abscess. As the lesion continues to develop, the pus increases, and the pus can break through the periosteum and anterior longitudinal ligament of the vertebral body, gathering in front of the vertebral body periosteum and behind the longus colli muscle of the neck. In lesions above C4, the abscess is often located behind the pharynx, hence also known as retropharyngeal abscess. In lesions below C5, the abscess is often located behind the esophagus. A large retropharyngeal abscess can push the posterior wall of the pharynx forward, close to the root of the tongue, causing the patient to snore loudly during sleep and even leading to difficulty in breathing and swallowing. The pus in the lower cervical lesions can descend along the longus colli muscle to the upper mediastinum on both sides, causing the shadow of the upper mediastinum to expand, resembling the appearance of a tumor. Retropharyngeal and esophageal abscesses can also penetrate the pharynx or esophagus, forming internal fistulas, allowing pus and dead bone fragments to be swallowed or vomited from the mouth. The pus in the lateral lesions of the vertebral body can also form abscesses on both sides of the neck or flow into the supraclavicular fossa along the prevertebral fascia and scalene muscles. The abscesses in this area can break through to the outside to form sinus tracts. Sinus tracts often fail to heal for a long time and are very difficult to treat when there is mixed infection.

　　The pus, granulation tissue, caseous material, dead bone, and necrotic intervertebral disc produced by cervical tuberculosis can protrude into the spinal canal, compressing the nerve roots and spinal cord. Dislocation or subluxation of the affected vertebral body can also compress the spinal cord, causing spastic paralysis in the patient.

　　The symptoms of cervical tuberculosis are briefly described as follows.

　　1. General Symptoms

　　Patients often have general discomfort, fatigue, decreased appetite, weight loss, low fever in the afternoon, night sweats, increased heart rate, palpitations, and irregular menstruation, among other mild symptoms of poisoning and functional disorders of the autonomic nervous system. If mixed infection occurs with abscess formation, high fever may appear. Children with the disease may have more pronounced fever and are often irritable, not fond of playing, crying when held, and experiencing night-time screams. Most patients have malnutrition and anemia. If the patient has pulmonary tuberculosis in conjunction, symptoms such as cough, sputum, hemoptysis, or difficulty breathing may occur. In cases with urinary system tuberculosis, symptoms such as frequent urination, urgency, dysuria, and hematuria may appear.

　　2. Local Symptoms

　　Mild persistent dull pain in the neck, which intensifies when extending the neck, worsens after fatigue, and can be relieved by resting in bed. Nighttime pain is not obvious, and most patients can sleep well, which is different from malignant tumors. When the lesion worsens and stimulates or compresses the nerve roots, pain can radiate to the shoulder, upper limb, or posterior occiput. The affected part has tenderness and percussion pain.

　　Stiffness of the neck, limited movement in all directions, bending the head to see objects while turning the trunk together, is often due to protective spasm of the muscle groups around the diseased vertebrae after pain. Some patients often have torticollis deformity; some patients lean forward, the neck is shortened, and they prefer to hold the chin with both hands to avoid increasing pain during movement, which is also known as the Rust sign. The atlantoaxial joint is responsible for the rotational movement of the head, and after being affected, most of the rotational function of the head is lost, and the kyphotic deformity is often not obvious, mostly the physiological curvature becomes flat.

　　Some patients may form a cervical anterior abscess, which can cause discomfort in the throat, changes in voice tone, loud snoring during sleep, and in severe cases, difficulty in breathing and swallowing. A few patients may vomit pus, dead bone fragments, and caseous material from the mouth, which is caused by the rupture of the posterior pharyngeal abscess or esophageal abscess into the pharynx or esophagus. During physical examination, abscesses can be seen and felt in the posterior pharynx and both sides of the neck. The fluctuating abscess in the posterior triangle of the neck often suggests a cold abscess, but it must be differentiated from tuberculosis of the lymph nodes.

　　When cervical spondylotic tuberculosis causes compression of the spinal cord, patients may present with spastic paralysis. In cases with mild compression, incomplete paraplegia may occur, which can only have motor impairment, or may be accompanied by sensory impairment and sphincter dysfunction. In cases with severe compression, complete paraplegia with significant sensory impairment level may occur, with increased patellar reflexes and pathological reflexes such as Babinski sign mostly positive.

　　The prevention of cervical spondylotic tuberculosis first requires the thorough treatment of the primary disease, preventing the spread of tuberculosis bacteria from the primary focus to the cervical region, or making the tuberculosis bacteria that have spread to the cervical region be rapidly eliminated and not develop into a focus. For patients with established cervical spondylotic tuberculosis, early diagnosis and early treatment should be carried out to shorten the course of treatment, reduce disability, and prevent deformity. After the lesion is cured, attention should also be paid to nutrition, avoid overwork, prevent the decline of the body's resistance, and reduce the recurrence rate. Since cervical spondylotic tuberculosis is a secondary lesion, the vast majority of which are secondary to respiratory and digestive system tuberculosis, the key to prevention still lies in the prevention of the primary disease.

　　1. Improve the Prevention and Treatment Institutions: In recent years, the incidence of tuberculosis has shown an increasing trend, reminding people that the prevention and treatment of tuberculosis cannot be relaxed. It is necessary to strengthen publicity and education, popularize the prevention and treatment methods of tuberculosis, establish and improve the prevention and treatment institutions of tuberculosis at all levels, ensure human and material resources, so as to detect tuberculosis in a timely manner and implement standardized and standardized treatment.

　　2. Strengthening Exercise to Protect Susceptible Individuals: Enhance physical exercise, strengthen physical fitness, and actively improve the body's resistance. Especially the elderly, children, and patients with various immune damage should pay more attention to physical exercise to prevent the infection or recurrence of tuberculosis. Carry out the vaccination of BCG vaccine to make susceptible individuals resistant to the disease.

　　4. Block the infection route: Strengthen disinfection and isolation, block the infection route. Thoroughly disinfect and dispose of the excreta of tuberculosis patients. Do a good job of isolating tuberculosis patients and try to reduce contact between healthy people and patients.

　　3. Eliminate the source of infection: Early detection and complete treatment of patients with open pulmonary, intestinal, bone and joint, renal, or lymphadenitis tuberculosis, so that these lesions are cured and the patients no longer discharge bacteria.

　　What examinations should be done for cervical tuberculosis, a brief description is as follows.

　　1. Routine examination

　　Including blood routine, urine routine, stool routine, and liver and kidney function tests, etc. Hemoglobin is low, white blood cells are generally not high, and there is a significant increase in other bacterial infections. The proportion of lymphocytes is generally higher than normal. Routine urine and stool tests can understand whether there is concomitant tuberculosis infection in the urinary system and intestines. Liver function is often slightly damaged, and there is generally hypoalbuminemia, an inverted albumin globulin ratio. Serum electrophoresis examination shows that when the lesion tends to chronicity, albumin decreases while alpha and gamma globulins can increase. The use of anti-tuberculosis drugs can change this condition, but it is ineffective for drug-resistant patients.

　　2. Tuberculin test

　　As a diagnostic method, it has a certain reference value and is helpful for early diagnosis in children under 5 years old who have not been vaccinated with BCG. A negative result indicates that the child has not been infected with tuberculosis bacteria, while a positive result indicates that the child has been infected with tuberculosis. If the result changes from negative to positive, it indicates that the tuberculosis infection has occurred recently. As for children and adults over 5 years old, most are positive, and this test is not very helpful for diagnosis. However, when a strong positive reaction occurs, it should be paid enough attention.

　　3. Tuberculosis culture

　　It takes a long time, and the general positive rate is 50% to 60%. Therefore, relying on pus culture to confirm the diagnosis of cervical tuberculosis is not very high.

　　4. Animal inoculation test

　　The positive rate is relatively high and is helpful for diagnosis, but the procedure is complex, takes a long time, and is expensive. It can be adopted when necessary and under conditions.

　　5. Pathological biopsy

　　It is of great value for determining the diagnosis and can be adopted by puncture needle aspiration biopsy and surgical exploration for biopsy. Puncture needle aspiration biopsy often has a small amount of material and is difficult to diagnose. If pus or caseous material is found during surgical exploration, it can often be diagnosed as tuberculosis. If there is still doubt, the pathological diagnosis can decide.

　　Actively supplement nutrition, providing palatable, easy to digest, and nutritious food. For those with poor nutritional status, cod liver oil, vitamin B, C, and other supplements can be provided. For anemia, iron, vitamin B12, folic acid, and other agents can be administered.

　　The history of treatment for vertebral tuberculosis can be traced back to the 17th century, when the effective treatment methods were limited to long-term bed rest and rest. With the clinical application of anti-tuberculosis drugs and the further development of surgical techniques, especially since the 1960s, the improvement of treatment methods for cervical tuberculosis has greatly increased the cure rate. Cervical tuberculosis is also a local manifestation of systemic tuberculosis infection, so when treating this disease, it should not be ignored that systemic treatment is also necessary. While emphasizing surgical treatment, it should not be ignored that effective non-surgical therapies should also be used.

　　1. Non-surgical treatment: Cervical spine with rich blood supply not only has a low incidence rate but also has fast absorption of lesions and strong repair ability. Therefore, many cases can be cured through non-surgical treatment.

　　1. General treatment: Cervical tuberculosis often has symptoms such as decreased appetite, weight loss, anemia, or hypoproteinemia. The overall condition of the patient is closely related to the improvement or deterioration of the lesion. Rest and nutrition are an important step in improving the overall condition and are indispensable for the treatment of cervical tuberculosis. Rest can reduce the metabolic activity of the body, decrease consumption, lower body temperature, increase weight, and is conducive to physical recovery. Therefore, patients need to have enough rest and sleep. At the same time, it is also very important to improve the nutritional status. Nutritional supplements should be actively taken, and palatable, easily digestible, and nutritious foods should be provided. For those with poor nutritional status, cod liver oil, vitamin B, C, etc., can be provided. For those with anemia, iron, vitamin B12, folic acid, etc., can be given. For patients with severe anemia, blood transfusion can be given intermittently, 1-2 times a week, each time 100-200ml. For those with poor liver function, liver-protecting treatment is needed. For those with concurrent infection, broad-spectrum antibiotics can be given, or sensitive drugs can be given based on drug sensitivity tests. For patients with paraplegia, nursing care should be strengthened to prevent bedsores, and to prevent pulmonary and urinary tract infections.

　　2. Local immobilization: In order to alleviate, prevent the increase of deformity, avoid the spread of the lesion, reduce physical consumption, and enable the patient to rest in time, cervical immobilization is very important. For patients with severe illness, neck collars, supports, or plaster casts can be used for protection. For patients with severe illness or those who have already developed paraplegia, absolute bed rest is required. If necessary, occipitomandibular traction or cranial traction can also be performed. Occipitomandibular traction is suitable for children and patients with a short illness course and weak muscle strength, with a traction weight of 1-2kg. The traction can be temporarily removed during meals to facilitate opening. Cranial traction is safer and more comfortable, and can provide a larger traction weight, with adults using a weight of 5kg, and children's weight can be reduced accordingly. After the correction of deformity, 2kg can be used to maintain. During traction, the patient can lie on their back with a thick quilt under them, the occipital region placed on the bed, so that the cervical spine is in an extended position. For patients who have been using traction treatment for a long time, attention should be paid to preventing bedsores at the occipital bony tubercle. The method of prevention is to turn over regularly, place an air ring under the occipital bony tubercle, and massage regularly with alcohol.

　　3. Antituberculosis drug treatment: The application of antituberculosis drugs plays an important role in the treatment of cervical tuberculosis, which can improve the efficacy and promote the healing of the lesions. The commonly used first-line drugs include isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin. Second-line drugs include amikacin, capreomycin, kanamycin, cephapirin, ethionamide, and para-aminosalicylic acid, etc.

　　Isoniazid (INH) has the strongest early bactericidal action and is the best choice for preventing drug resistance. It is rapidly absorbed orally and easily penetrates the pleural, peritoneal, cerebrospinal fluid, and synovial fluids, and can penetrate into cells, thus it can also kill the tuberculosis bacteria within cells. The daily dose for adults is 300mg, taken in three divided doses. For children, the dose is 10-20mg per kg of body weight per day. Isoniazid can damage liver function and may cause neuritis and psychiatric symptoms. During the period of taking the medicine, attention should be paid to regular liver function checks, and vitamin B6 can be added if taken in large doses.

　　② Rifampin (RFP) has the strongest sterilizing effect. After oral administration, it is absorbed through the intestines and can maintain a high concentration in the blood for a relatively long time, and it can pass through the blood-brain barrier into the cerebrospinal fluid. Rifampin has a good therapeutic effect on tuberculosis. The adult dose is 450 to 600mg per day, which can be taken on an empty stomach in the morning or divided into two doses. The pediatric dose is generally 20mg per kilogram body weight per day. Rifampin has side effects such as liver function damage, gastrointestinal reactions, skin reactions, influenza-like reactions, etc. Therefore, it should not be used in patients with severe liver damage and biliary obstruction, and it should be used with caution in the elderly, children, and malnourished individuals.

　　③ Pyrazinamide (PZA) has a special sterilizing effect on acidophilic intracellular tuberculosis flora. The combination of PZA and RFP has the strongest sterilizing effect. The adult daily dose is 1 to 1.5g, taken 2 to 3 times orally. The toxic effect is liver function damage and can cause joint pain.

　　④ Ethambutol (EMB) has strong antituberculosis activity and can spread to various tissues in the human body. The adult dose is 750mg per day, taken all at once to achieve a peak blood concentration. Side effects include visual impairment. If color vision impairment occurs early, the medication should be discontinued.

　　⑤ Streptomycin (SM) is a bacteriostatic drug that only has a killing effect on extracellular tuberculosis bacteria. It is not easily absorbed by oral administration and can penetrate into various tissues through intramuscular injection, but it cannot or rarely pass through the blood-brain barrier. Long-term use can cause auditory nerve damage and renal dysfunction, so regular renal function checks are recommended. The adult dose is 1g per day, administered twice by intramuscular injection. The pediatric dose is 15 to 30mg/kg body weight per day.

　　The principles of using antituberculosis drugs are early, adequate, combined, and regular use. Currently, there are many combined drug regimens used in clinical practice. Some studies have shown that the combined use of INH, RFP, and PZA can exert their respective and synergistic effects on three different metabolic flora and intracellular and extracellular flora. The drugs achieve bactericidal and sterilizing effects at different pH levels, thereby greatly shortening the treatment time. The course of treatment is generally 6 to 9 months. Pay attention to observe adverse reactions during medication and adjust treatment regularly.

　　II. Surgical treatment: Under the control of antituberculosis drugs, timely and thorough removal of the tuberculosis focus can greatly shorten the course of treatment, prevent the occurrence of deformity or paraplegia, and significantly improve the cure rate of cervical tuberculosis. At the same time, it should be emphasized that the indications for surgery should not be overused.

　　1. Indications for surgery: ① Presence of a large cold abscess; ② Radiological evidence of dead bone and cavity formation within the focus; ③ Symptoms of spinal cord compression; ④ Chronic sinus tract; ⑤ Local focus is stable, and the patient's general condition allows for surgery.

　　2. Preoperative preparation: In addition to the routine preoperative preparation, systemic antituberculosis drugs should be used to make the lesion relatively stable and to bring body temperature and erythrocyte sedimentation rate close to normal. For patients with poor general condition, nutrition should be enhanced as much as possible to correct anemia and hypoproteinemia, and blood transfusion, human serum albumin, and other measures may be necessary. For patients with cervical spondylodiscitis who have dislocation and severe deformity, preoperative traction therapy should be performed to correct the dislocation and deformity.

　　3. Anesthesia and precautions: For the surgery of cervical tuberculosis patients, general anesthesia with tracheal intubation and intravenous anesthesia is commonly used. Tracheotomy and intubation can be performed if necessary. Cervical tuberculosis patients are generally weak, especially those with high-level paraplegia and post-pharyngeal abscess, which brings certain difficulties to anesthesia. Limited cervical movement makes it difficult to expose the glottis; severe bone destruction of the cervical vertebral bodies may lead to cervical dislocation, and improper force can cause spinal cord transection and life-threatening conditions; excessive force during tracheal intubation or laryngoscopy, and rupture of the post-pharyngeal abscess can lead to asphyxial death; patients with high-level paraplegia have extremely poor cardiopulmonary compensation function and poor tolerance to anesthetic drugs. Therefore, the intubation should be carefully performed, and awake intubation should be performed for those with post-pharyngeal abscess and paraplegia. For those with large post-pharyngeal abscesses, aspirate the pus before intubation.

　　4. Surgical methods: The surgical treatment for cervical tuberculosis is mainly the excision of the tuberculosis lesion. Depending on the different conditions, excision and bone grafting, excision and exploration of the spinal canal, simple abscess incision and drainage, and occiput-cervical fusion can be performed.

　　The excision of the C1-C2 tuberculosis lesion is located mostly in the anterior arch of the atlas and the odontoid process of the axis. Most cases can be absorbed after traction, rest, and treatment with anti-tuberculosis drugs. If conservative treatment is ineffective, the excision of the lesion can be performed via the oral route. Starting 3 days before the operation, clean the mouth and use a broad-spectrum antibiotic throat spray. The patient lies on their back with the neck hyperextended during the operation. First, perform a tracheotomy and intubation under local anesthesia to provide general anesthesia. Use an oral opener to open the mouth wide. Disinfect the mucosa of the oral cavity and the posterior wall of the pharynx with thymol mercury solution. Suture the uvula to the soft palate with silk thread and use a tongue depressor to push the root of the tongue downward. Before cutting, use a long gauze strip to block the esophagus and trachea to prevent pus and blood from flowing in. Make a longitudinal incision in the most prominent middle part of the abscess on the posterior wall of the pharynx, about 4 cm long, and bleeding is usually not severe. After cutting through the abscess wall, immediately aspirate the pus. Extend a small spatula through this incision to scrape clean the caseous necrotic material, dead bone, and granulation tissue. When scraping the lesion on both sides, be careful to avoid damaging the vertebral arteries and veins. After clearing the lesion, rinse it, inject anti-tuberculosis drugs, and finally suture the incision in two layers.

　　The excision of lesions in the 2nd to 7th cervical vertebrae is generally performed via the anterior approach. After the anesthetic effect is achieved, the patient lies on their back with the neck hyperextended. A transverse incision in front of the neck or an incision along the anterior edge of the sternocleidomastoid muscle is chosen. For the cold abscess in the posterior triangle of the neck, an incision above the clavicle can be used. After exposing the abscess via the anterior cervical approach, protect the skin and normal tissues, use fingers to palpate the soft tissues in front of the vertebral bodies to determine the location and extent of the abscess, and use a syringe needle to puncture for confirmation if necessary. Cut the abscess in the middle to avoid damaging the cervical sympathetic and phrenic nerves located para-vertebrally. After cutting through the abscess wall, aspirate the pus thoroughly, and completely remove dead bone, necrotic intervertebral discs, granulation tissue, and caseous material. The wall of the abscess should be removed as cleanly as possible. The vertebral lesions should be completely cleared until healthy bone tissue around the vertebrae starts to bleed. If there are multiple affected vertebral bodies, the intervertebral discs between them that have not been affected should also be removed simultaneously. After rinsing the lesion site, place anti-tuberculosis drugs. If necessary, autologous iliac or rib bone blocks can be implanted. After placing a rubber semi-tube drain, suture the incision in layers. The drain is removed within 24 to 48 hours after surgery.

　　③ For other surgical operations, such as the removal of the focus in atlantoaxial tuberculosis, to maintain the stability of the cervical spine, most patients undergo fusion surgery at C1-C2 or occiput-cervical fusion after half a year. For large cold abscesses that are difficult to remove or some patients who cannot tolerate surgery for a long time, simple abscess incision and drainage can be performed. For severe lesions causing spinal canal stenosis, excision of the vertebral body focus and exploration of the spinal canal can be performed. The posterior approach excision and fusion surgery is currently not recommended.

　　5. Postoperative Management and Rehabilitation: Generally, patients need to rest on a hard bed after surgery. Children may need plaster immobilization. It usually takes about a month, and it is best to undergo X-ray examination to prove that the patient's focus has stabilized. Bone graft fusion has occurred, and the erythrocyte sedimentation rate has returned to normal before they are allowed to walk. When walking, a neck collar or brace is required for protection, usually for 10 to 16 weeks. Antituberculosis drugs should continue to be used postoperatively, and appropriate chemotherapy plans and medication schedules should be formulated based on the patient's overall condition and the stability of the focus. To prevent infection, antibiotics can be added for 7 to 10 days after surgery. Strengthen nutrition and systemic supportive treatment. The liver and kidney function, erythrocyte sedimentation rate, and X-ray films should be re-examined every 3 months to understand the healing of the focus and the stability of the lesion. Encourage patients to build confidence in overcoming diseases and strengthen functional exercises. Patients with cervical tuberculosis who undergo various treatment and management have a high cure rate, with approximately 95%.