A 50-years-old retired man came to our institution with a 1-year history of neck stiffness and muscle weakness. He reported the feeling on the cotton while walking and the patient's bilateral tendon hyperreflexia and Hoffmann's sign were positive. His family and medical history were not significant. Laboratory results showed a normal erythrocyte sedimentation rate (5 mm) and C-reactive protein (1.2 mg/L). The cervical spine Magnetic resonance imaging (MRI) demonstrated that the cervical disc at the level of C3/4 was herniated to the left from the median, and the spinal cord was obviously compressed (Figures 1A, 2A,C). Chest CT showed an old foci of pulmonary TB in the upper lobe of the left lung (Figure 1B). A preoperative enhanced MRI ruled out the possibility of a tumour in the patient's cervical spine (Figures 3A-D). Thus, the patients were considered to be cervical spondylotic myelopathy (Figure 4A).
The patient then underwent an anterior cervical discectomy and fusion (ACDF) at the C3/4 segment in hope of a cure. The patient's herniated cervical disc was carefully removed and the bleeding was stopped. The implant was allogeneic bone-filled polyetheretherketone (PEEK). On the second day postoperatively, an x-ray examination (Figure 4B) confirmed the decompression of the spinal cord, and the implant structure was stable and the position was correct. Postoperative MR of the patient's C3/4 and C4/5 segments showed good postoperative decompression and no vertebral body infection (Figures 2B,D). Postoperative laboratory results showed normal erythrocyte sedimentation rate (5 mm) and C-reactive protein (4.1 mg/L). The preoperative CT showed no infection in the cervical vertebrae (Figures 5A,B). The postoperative cervical spine CT showed successful surgical decompression, stable endophytes and no signs of infection in the vertebral body (Figures 5C,D). One week postoperatively, the patients didn't show any complaints and can walk independently when leaving the hospital.
However, 2 weeks postoperatively, the patient developed neck pain, which was worsened when lying down and turning to the left. He came to our department again on 2021.8.16. Since the onset of the disease, The patients did not show any symptoms of TB infection such as low-grade fever, night sweats, occasional fatigue, insomnia, and no obvious abnormality in limb movement and sensation. The cervical spine MRI imaging 2 months after surgery (Figures 1C,D, 4C) showed bone erosion at the C4/5 vertebral body edge with swelling of the paravertebral soft tissue, and inflammatory manifestations of the C4/5 intervertebral disc and vertebral body. The patient's pain was not relieved after 48 h of empiric antibiotic (ceftriaxone) treatment. Although vancomycin was used to upgrade the antibiotics, after 48 h, there was still no obvious improvement. The elective surgery was arranged for the patient immediately. Six hours before the operation, the patient reported insomnia and night sweats for the past 2 days. After follow-up, the patient was found to have a low fever. New assay results showed neutrophil percentage 52.10%; lymphocyte percentage 41.1%; tuberculosis -infected T cell culture (TBA: 13sfc/2.5*10e5; TBB: 6 sfc/2.5*10e5) was positive and IFN release was detected -gamma-specific lymphocytes.
After out-of-hospital consultation, the patient was diagnosed with cervical spine TB, and received anti-tuberculosis drug treatment: isoniazid (INH) 0.3 g QD, rifampicin (RMP) 0.45 g QD, ethambutol (EMB) 0.75 g QD, levofloxacin 0.5 g QD. One-week post-treatment, the patient's neck pain was relieved, and he requested to be discharged home for treatment after informed consent. The patient was instructed to continue the course of anti-tuberculosis treatment, with cervical collar fixation to avoid activities involving neck movement and weight-bearing for 3 months.
The patient was kept regular follow-ups. On June 16, 2022, the patient underwent a cervical spine x-ray examination and the results showed (Figure 4D) that the C3/4 and C4/5 segments were fused, and the paravertebral soft tissue swelling disappeared. The patient's neck pain improved significantly, and it is recommended to continue anti-tuberculosis treatment.