Spinal Decompression with 360˚ Instrumented Fusion for Unstable Tuberculous Quadriplegia in a Young Adult—A Case Report

Background: Tuberculosis of the spine is common in Nigeria. It commonly causes neurological deficit especially when the lesions are higher up in the spine. Objective: To report a case of a young man who had C4 quadriplegia from tuberculous destruction of C3 to C5 vertebral bodies and their intervening discs, aretropharyngeal prevertebral abscess and associated segmental kyphosis. He had received prior antituberculous therapy with no improvement. Results: He recovered completely neurologically when he had adequate decompression and 360˚ instrumented f u-siondone in a 3-stage surgery that involved drainage and debridement of the retropharyngeal prevertebral abscess, anterior corpectomy of C3 and C4 with fusion using a titanium mesh cage, and posterior fusion of C3 to C6 using titanium rods and lateral mass screws. Surgical treatment was supported with skull traction and antituberculous therapy. Conclusion: This case shows that complete neurologic recovery is feasible in spinal quadriplegia that fails to respond to antituberculous therapy when adequate decompression and fusion are done.


Introduction
Tuberculosis of the spine has been recognized since as far back as 100-300 BC when Hippocrates first described the disease [1]. Also known as Pott's disease [2] and tuberculous spondylitis, the incidence of the condition varies throughout the world [3], being common in Nigeria [4]. The cervical spine is less affected than the thoracic, thoracolumbar and lumbar spine [1] [5]. Neurological deficits are a common complication of the disease with the frequency increasing with higher lesions [1] [3] [6]. Decompressive surgery along with antituberculous therapy is the best mode of treatment for the disease [7], though patients with no or minimal neurological deficit are known to have been managed non-surgically [8]. This report highlighted the case of a young man who had tuberculous quadriplegia.

Case Report
A 27-year-old male unemployed university graduate was referred from a State Specialist Hospital. He presented to the neurologist with insidious dull aching non-radiating progressive neck pain associated with low grade fever and night sweats of 18 months, and progressive weakness and paraesthesia in all limbs. He had become quadriplegic 6 months before presentation. He had no sphincteric or erectile dysfunction, nor did he have cough or history of ingestion of unpasteurized milk.He had antituberculous therapy and conservative treatment in various hospitals but his condition continued to deteriorate. He also had no past medical, drug, family and social history of note, and no additional symptoms on systemic review.
He looked chronically ill, was anicteric, acyanosed, and had neither digital clubbing nor peripheral lymph node enlargement. His vital signs were normal. He had reduced muscle bulk globally, spastic quadriplegia, a T1 sensory level and tenderness at the cervical spine. His other body regions were essentially normal.
His full blood count, electrolytes, urea and creatinine were within normal limits. His erythrocyte sedimentation rate was 40 mm/hr using the Westergren method. Plain cervical spine X-ray (Figure 1) showed destruction of C3 to C5 vertebral bodies and their intervening discs as well as segmental kyphosis. A Magnetic Resonance Imaging scan of his cervical spine (Figure 2) further showed a retropharyngeal prevertebral abscess.
A working diagnosis of C4 quadriplegia secondary toan extradural cervical cord compression from Pott's  disease was made. He was continued on antituberculous therapy along with a rigid cervical collar by the neurologist. A spine surgery consultation was then requested. He was initially placed on skull traction using Gardner Wells tongs and had other supportive care with some improvement of the power in all his limbs. He was managed with a 3-stage surgery that involved drainage and debridement of the retropharyngeal prevertebral abscess as the 1 st stage and anterior corpectomy of C3 and C4 with fusion using a titanium mesh cage as the 2 nd stage (Figure 3). Spine stability was maintained between the 1 st and 2 nd stages using skull traction. Following this, he recovered completely neurologically, and a 3 rd stage procedure-posterior instrumented fusion of C3 to C6 using titanium rods and lateral mass screws-was done, completing a 360˚ fusion (Figures  4-6). Figure 7 shows the patient and and displays his surgical scars. He also continued the antituberculous therapy for 12 months and is being followed up at the surgical outpatient department. No organisms were detected in specimens taken. Histopathology report showed tissue with extensive area of necrosis and islands of diffuse granuloma composed of epithelial cells with cuff of lymphocytes and plasma cell. The patient has remained well with neurological recovery sustained and is displayed in Figure 8, playing a football.

Discussion
Tuberculosis is the most common granulomatous spine infection worldwide [3] and was described by Sir Percivall Pott (after whom Pott's disease is named) in 1779 as a cause of paraplegia [2]. The disease mostly affects adults [9] but may also affect children and adolescents [10]. It has also been reported in a 3-month-old child [11]. Haematogenous spread from primarily infected organs is the most common route of spread to the spine [12], though spread may also be from contiguous skeletal lesions and may be a direct extension from visceral lesions [3]. The vertebral body is more commonly affected than the posterior elements [7] [13], leading to kyphosis if there is bone collapse. This affectation of the anterior elements is usually an extension of the abscess beneath the anterior longitudinal ligament and periosteum [12]. Spinal tuberculosis is the commonest cause of kyphosis in many parts of the world and this kyphosis tends to be the rule rather than the exception [1] [14]. The posterior elements of the spine may also be affected [15] and isolated spinous process and laminae involvement have been reported [16].
Back pain and neurological deficits are common features of the disease [6] [9] [14] [15]. Involvement of the cervical spine results in quadriparesis or quadriplegia whereas, thoracic and thoracolumbar spine disease result in paraparesis or paraplegia [1]. Hemiparesis resulting from cervical spine involvement has also been reported [17]. Other clinical features include spine deformities, fever, weight loss and night sweats [9] [18] [19].
Imaging of the spine is an essential part of investigation in Pott's disease. Possible findings include destruct    [20]. Retropharyngeal collections are common in patients with cervical spine disease [3]. Other imaging findings include thecal compression and spinal deformities [21] [22]. Treatment is aimed at eradicating the infection, treating clinically significant spinal cord compression, and preventing or treating deformity or instability of the spine with chemotherapy being an integral aspect of this [3]. Surgical treatment of spine tuberculosis has evolved over the years [1] and has a role in patients with neurological deficit, spine deformities and instability, large paraspinal collections, and also where chemotherapy fails [2] [3]. This role is more significant in cervical spine affectation. Immobilization in skeletal traction should be done for patients with fractures, kyphosis, or spinal instability to realign the spine and thus decompress and protect the cord before surgery [3]. Radical debridement and reconstruction of the spine is has been shown to be an effective surgical treatment [23]- [27]. Kalafong procedure which combines anterior debridement with decompression of the spinal cord (Hodgson and Stock [23]), osteotomy and/or soft tissue release, and a vascular rib pedicle bone graft (Rose, Owen and Sanderson [28]; Bradford [29]) improves bony fusion following surgical management [30].

Conclusion
Tuberculosis of the spine could be severely disabling as was the case in our patient. This case shows that complete neurologic recovery is feasible in spinal quadriplegia that fails to respond to antituberculous therapy when adequate decompression and fusion are done. Since tuberculous spondylitis is common in Nigeria, effort should always be made towards adequate treatment, aiming for an outcome as rewarding as our patient's.