Exploring New Horizons: Endoscopic Innovations in Managing C4–5 Cervical Tuberculous Spondylitis (Pott Disease) With Anterior Cervical Corpectomy and Fusion (E-ACCF)

Article information

J Minim Invasive Spine Surg Tech. 2025;10(1):91-99

Publication date (electronic) : 2025 April 30

doi : https://doi.org/10.21182/jmisst.2024.01739

Adam Moeljono, Natalia Susanti, Muhammad Adam Darmawan, Gabriel Nugraha Andika, Asa Ibrahim Zainal Asikin

Department of Orthopedic Surgery and Traumatology, UGM Academic Hospital, Yogyakarta, Indonesia

Corresponding Author: Adam Moeljono Department of Orthopedic Surgery and Traumatology, UGM Academic Hospital, Jl. Kabupaten, Kranggahan I, Trihanggo, Kec. Gamping, Kabupaten Sleman, Daerah Istimewa Yogyakarta 55291, Indonesia Email: adam_moeljono@ugm.ac.id

Received 2024 August 26; Revised 2025 January 20; Accepted 2025 February 10.

Abstract

INTRODUCTION

Tuberculosis is one of the main health problems in many developing countries worldwide. Extrapulmonary tuberculosis can occur in various organs, including the spine. Tuberculosis affecting the spine often involves more than one vertebra and predominantly occurs in the cervical segment, a condition also known as tuberculous spondylitis. It is considered the most dangerous extrapulmonary manifestation of tuberculosis [1]. This event can lead to structural changes in the cervical column, causing spine deformity (Gibbus deformity) and narrowing of the spinal canal. Tuberculous spondylitis can produce classic symptoms indicating cervical spondylitis and spinal cord compression, such as neck pain, neck stiffness, fever, night sweats, weight loss, and other neurological symptoms (such as paresis or paresthesia of the extremities). Paraspinal abscesses can also occur in cases of tuberculous spondylitis. Some of these cases can significantly lower the patient’s quality of life and may require a surgical approach [2].

Surgical approaches to cervical tuberculous spondylitis are undertaken in individuals with vertebral body destruction or those presenting with spinal cord or nerve root compression, aiming to decompress spinal canal stenosis or stabilize the affected spine to increase sagittal stability of the segment. Early surgery, combined with antituberculosis chemotherapy, can lead to better outcomes for the patient [1]. Anterior cervical corpectomy and fusion (ACCF) is one of the methods used to treat cervical spondylotic myelopathy [3]. Traditional ACCF involves open surgery with a 5- to 6-cm incision in the lateral cervical area. However, this method carries the risk of injuring adjacent important structures such as the recurrent laryngeal nerve, esophagus, and vascular sheath, leading to potential vascular injury. The open incision unavoidably damages the skin, soft tissue (due to retraction), and requires dissection of the longus colli muscle. In the modern era, the endoscopic approach for surgery has become a popular choice and is now the primary option for several operations, including ACCF surgery. Endoscopic surgery is considered safer and offers significant improvements in preserving the skin due to its relatively small incision (approximately 1 cm) and faster postoperative recovery [3,4]. The overall occurrence of clinically symptomatic complications is under 10%. The most complications were minor, while life-threatening such as thromboembolism, sepsis, severe bleeding, or pulmonary complications are less common compared to open surgery [5]. The endoscopic approach can also be performed using various anesthesia techniques, including both general and regional anesthesia. [6].

CASE REPORT

1. Clinical Presentation

A 45-year-old woman presents with progressing tetraparesis within 1 month. The patient initially complains of neck stiffness, followed by a decrease in sensory sensation in the upper extremities. These sensory disturbances then progress to the lower extremities. The complaints worsen over time, and the patient becomes unable to move both arms and legs. Additionally, she experiences incontinence for both urination and defecation. The patient is bedridden, with a motor function examination showing 2/2/2/2. She denies any history of trauma or tuberculosis infection. However, she has a history of diabetes mellitus and undergoes hemodialysis due to hyperkalemia. The Japanese Orthopedic Association score for this patient is 7, classified as grade III [7] (Figure 1).

Figure 1.

Preoperative American Spinal Injury Association Score (ASIA Score) for spinal cord injury. UEMS, upper extremity motor score; LEMS, lower extremity motor score; LT, light touch; LTR, LT right; LTL, LT left; PP, pin prick; PPR, PP right; PPL, PP left.

2. Diagnostic Assessment

The TB blood tests (IGRA : interferon-gamma release assay) examination shows a negative result for tuberculosis infection. Magnetic resonance imaging (MRI) of the spinal cord reveals compression on the body of cervical vertebra 4, a burst fracture on the body of cervical vertebra 5, and severe compression of the spinal cord at the VC4–5 level. Additionally, a paracentral intervertebral disc protrusion is found at the C4–5 level, causing spinal canal stenosis. Paramedullary and paraspinal edema are also observed at the same level. Postoperative histopathological examination of C4 vertebra tissue reveals nonspecific granulomatous spondylitis (Figure 2).

Figure 2.

Preoperative magnetic resonance imaging. (A) Horizontal (axial MRI view) shows destruction of the corpus vertebrae C4, the C45 disc and C5 from right to left, with accumulation of pus in the longus colli muscle. (B) Sagittal view shows destruction of partial C4 corpus , the C45 disc, and corpus vertebrae C5, with kyphotic deformity.

3. Management and Surgical Technique

Endoscopic ACCF at the C4–5 level was performed on this patient under general anesthesia with tracheal intubation. The patient was positioned supine with the neck extended. The corpectomy process began with preoperative confirmation marking of the site using a C-arm (Figures 3 and 4)

Figure 3.

Patient positioning and draping technique.

Figure 4.

Operation site marking using C-arm radiography.

An approximately 1-cm incision was made, involving the platysma muscle in the anterolateral cervical region. An 18-G needle was inserted between the carotid sheath and esophagus, followed by the insertion of a guide wire. Identification of the C4 vertebra was performed by the operator's finger after blunt dissection. Vulnerable adjacent structures, such as the trachea, were pushed to the opposite side, and vascular structures were pushed laterally. The operator's finger reached the anterior part of the target disc and continued with the entry of the endoscopic dilator, specifically between the carotid artery and esophagus. After inserting the working channel, the dilator was removed. The endoscope position was also confirmed using the C-arm (Figure 5).

Figure 5.

Endoscope insertion site. Note that it is medial to the carotid sheath and lateral from the esophagus and trachea.

After the endoscope placement and installation of the endoscope system, debridement of granulation tissue and the destructed corpus of the C4 vertebrae were performed. The irrigation system in spinal surgery utilizes a constant stream of saline solution to clear the camera field and minimize heat damage to the tissue (Figures 6 and 7).

Figure 6.

(A) Endoscopic view, shows soft tissue and bony dissemination of C4 vertebrae, C45 disc, and C5 vertebrae due to Potts disease. (B) C-arm lateral view with scope and the 2 mm kerrison rongeur taking the disseminated soff tissue and bony from C4 to C5. (C) Healthy bone of C3 to C6 after the debridement of the C4, C45 discs, and C5 in endoscopic view.

Figure 7.

Endoscopic view of the cage preparation process.

The corpectomy was conducted, and the results were rechecked using the C-arm. The surgeon then selected the appropriate cage size. The cage was filled with bone graft before placement. A titanium mesh with bone graft was placed in the corpus, and the placement of the cage was rechecked using the C-arm. Mild dilation of the incision was performed only to facilitate cage placement. Decompression endoscopic surgery was also performed to release the exiting and transversing root in the right intervertebral space L2–3 and L3–4. The surgery was completed without measurable blood loss, intraoperative complications, and was entirely conducted via an endoscopic approach. Wound closure was performed in a standard manner. The patient was also given an antituberculosis therapy regimen by a pulmonology consultant (Figures 8-10).

Figure 8.

Final endoscopic view (A) and C-arm imaging after C4 vertebra corpectomy (B).

Figure 9.

Dilation of the initial incision to facilitate cage placement.

Figure 10.

C-arm imaging showing cage placement. The oblique placement of the cage is due to the pattern of the bone destruction. The straight cage placement will destroy more healthy bone, resulting in an increased probability of instability and bleeding. (A) Anterior view. (B) Lateral view.

5. Radiographic Outcomes

A postoperative x-ray was conducted, revealing the placement of the titanium mesh and successful vertebral fusion. Improvement in the sagittal alignment of the vertebral column was observed. Before the surgery, the patient's posture appeared kyphotic due to tuberculous spondylitis. However, the cage placement helped correct the kyphotic deformity evident in preoperative imaging. There were no signs of cage displacement. The oblique cage position was intended to preserve more healthy bone and minimize the risk of bleeding (Figure 11).

Figure 11.

Postoperative anteroposterior (A) and lateral (B) x-ray view of the patient.

6. Follow-up

The patient has regained the ability to walk after a 1-month postsurgery follow-up. They can perform full flexion, abduction, and adduction of the shoulder joint. However, extension and rotation still appear to be restricted. Additionally, the patient can perform flexion and extension of the cubital joint and can grip normally. There have also been improvements in the movements of the neck, such as rotation, extension, and flexion. Furthermore, the incision has shown good wound healing (Figures 12-14).

Figure 12.

Patient’s walking ability at a 1-month postoperative follow-up visit. (A) The patient is standing in front of the door without assistance. (B) The patient can walk freely (distance from the door become farther) without assistance (screenshot from videos).

Figure 13.

(A-D) Postoperative upper extremity range of motion.

Figure 14.

(A-D) Neck mobility improvement at a 1-month follow-up visit.

DISCUSSION

We present a case of a 45-year-old woman admitted with progressing tetraparesis, which we managed using endoscopic ACCF. Surgical management for tuberculous spondylitis (Pott disease) has been utilized extensively worldwide. While the common method for treating cervical spinal disorders is anterior cervical discectomy and interbody fusion, traditionally performed through open surgery, the introduction of new endoscopic technology offers several advantages. These include minimal damage to adjacent tissues, reduced blood loss, and shorter recovery times due to smaller incisions. Many studies have also reported excellent clinical results following endoscopic operations for single-level spondylosis cases [3].

The patient's diagnosis was established through a combination of history-taking, physical examination, and supporting examinations using MRI and computed tomography (CT) scans. Both MRI and CT scans provide high sensitivity and specificity, aiding in the diagnosis and assisting in the planning of the surgical approach strategy, including determining the start point, trajectory, and potential access points for the surgery [8]. One of the challenges in endoscopic surgery is restricted visualization. To address this issue, comprehensive preoperative and intraoperative radiographic imaging plays an integral role in endoscopic spinal surgery [9]. The patient is also prescribed antituberculosis medication. Indications for surgery in patients with cervical spondylosis/Pott disease include severe deformities, severe neurological symptoms, cervical abscess, extensive spine involvement (more than 3-disc level), or the need for fusion surgery due to vertebral fracture/collapse, with no signs of recovery after conservative therapy [10,11]. Corpectomy was preferred because this patient has a severe burst fracture of the C5 vertebra. Corpectomy involves resecting the vertebral body after discectomy [12]. Whereas discectomy involves removing the disc without interfering normal structures [3].

The anterior approach was chosen to facilitate easier access to the anterior column, which is considered the gold standard in surgical management. This approach was utilized in this case and in many cervical spondylosis cases because it allows for direct visualization of the lesion and direct treatment, while minimizing damage to muscular tissue compared to the posterior approach. However, these advantages require meticulous preparation due to the proximity of many important structures. The operator must carefully avoid the trachea, esophagus, vascular structures, and the recurrent laryngeal nerve [12,13].

Anticipation and prevention of risks were also conducted. Marking and approach strategy were carefully planned before the surgery with the assistance of imaging examination results. Patient and material preparation were conducted in a sterile manner. Prevention measures for protecting adjacent structures were also planned. A nasogastric tube was inserted into the patient to prevent damage to the esophagus. Damage to the vascular sheath and neurovascular structures near the insertion of instruments was prevented by using the operator’s finger to carefully split and push the soft tissues around them. An assistant was also assigned to hold the scope to prevent damage by the endoscope. This surgery was performed at Academic Hospital UGM, which has access to vascular surgeons and digestive surgeons prepared in case adjacent structures were injured. Additionally, the patient needed to be examined for vocal cord palsy. If this condition was detected before surgery, the approach should be taken from the same side as the palsy [12].

Various literature has stated that most patients who undergo corpectomy surgery show improvement over time [14]. Anterior spinal surgery allows for rapid relief of symptoms, typically within 3–4 months, and this relief usually persists for over 12 months [12]. The progression of symptoms in this patient was relatively rapid. While the average symptom onset to diagnosis described in the literature is 3 months, this patient was diagnosed within 1 month from the onset of symptoms. Although our patient did not show improvement in sensory examination, there was significant improvement in motor function. Postoperation motor examination showed improvement from 2/2/2/2 to 4/4/4/4. The patient was bedridden upon admission. However, by the 1-month postsurgery follow-up, the patient was already able to walk and had regained motor ability in the upper extremities, as well as full range of motion for her neck.

CONCLUSION

Tuberculous spondylitis (Pott disease) is a rare yet dangerous condition. However, the severity of this disease can be managed with early diagnosis and appropriate treatment. The endoscopic approach, when combined with antituberculosis therapy, can be a safe choice for individuals experiencing cord compression symptoms. Endoscopic ACCF have great potential for managing spinal tuberculosis cases and minimizing soft tissue trauma when performed by an experienced spine surgeon. Preoperative planning and evaluation are crucial for the success of the procedure, reducing risks, and increasing patient satisfaction.

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