A 45-year-old woman suffered from occipital and back, neck pain, which was worse on the left side for about 11 months. The symptoms were accompanied with low-grade fever and repeated night sweats. The patient underwent conservative treatment in a local hospital but the symptoms persisted and began to further deteriorate for a month before being referred to our hospital. In addition, she showed signs of dysphagia. During the course of the disease she had loss of appetite and her weight significantly decreased by approximately 15 kg. The patient had no chest band tightness but felt like she was "walking on cotton." Her trunk and limb movements were normal.
Her cervical curvature was straight and her cervical muscles were strained. Regarding neurological examinations, she had a slight enhancement in biceps, triceps, and radial reflex. All other physical examinations were normal.
The patient's liver, kidney, coagulation function, and blood electrolytes were in the normal range. Erythrocyte sedimentation rate (ESR) was 67 mm/h and hemoglobin (Hb) was 107 g/L which suggested mild anemia.
C-spine x-ray is presented in Fig. 1 and exhibited a reverse slip of C3 vertebral body. Computed tomography (CT) and magnetic resonance imaging (MRI) showed destruction of C5, C6, C7 vertebral body and formation of paravertebral abscess. The following diagnosis was made; multilevel cervical TB and abscess presence; reverse slip of C3 vertebral body; bone destruction of C5, C6, and C7 vertebral body.
The patient was treated with anti-TB drug therapy (isoniazide, 300 mg, Qd, intravenous drip; rifampicin, 0.45 g, taken orally, Qd; pyrazinamide, 0.75 g, taken orally, Qd; ethambutol, 0.75 g, taken orally, Qd) for 1 week with ESR follow-up and the relevant laboratory examinations, until these indicators were in the normal range.
The surgery was performed in 2 stages. Intraoperative images are presented in Fig. 2.
The first stage of the surgery was the posterior cervical internal fixation and the length interception of the vascularized fibular. Patient was immobilized using the cephalostat in the prone position. The posterior region of the neck and left leg was disinfected and skin incision was performed at the level of the posterior midline. The muscles, vessels, and fascia were dissected to expose the lateral mass of the C2 to C7 vertebral body. C2 and C7 were immobilized using 2 pairs of pedicle screws and C4 and C6 VB were immobilized using lateral mass screws. A titanium rod was inserted based on the physiological curvature and inserted into the groove with screws and fixed with pedicle screw caps and subsequently the surgery wound was closed.
Ten days postoperation, stage 2 of the surgery was performed. This stage was divided into 2 steps. The first step was the removal of the fibular. The fibular was harvested for the appropriate length and vascular pedicle under the guidance of an air pressure tourniquet. An incision about 15 cm was made along the posterior margin of the fibular and then the intramuscular space of the soleus and peroneus longus was exposed by dissecting skin and muscles carefully. Using the intramuscular space as point of entry, the peroneal artery and vein was located at the back of the tibialis posterior and inner side of the flexor hallucis longus and carefully protected. The peroneus longus and brevis were dissected carefully while preserving the straticulate sleeve on the fibula. Approximately, 9.5 cm of the fibula was excised by osteotomies. The middle and distal part of the fibula was selected as the graft because the diameter of this section was small and uniform as well as for the preserving of the vascular pedicle. A uniform, thin fibular graft is advantageous because it decreases the risk of tracheal and esophagus compression. After step 1, the patient was placed in a supine position and step 2 of the surgery was performed. Preoperative disinfection was performed in the anterior region of the neck. Incision was made at the left side of the anterior cervical and avoided the trachea and carotid artery. Precautions were taken to protect the trachea and esophagus during the dissection of the sternocleidomastoid and omohyoid. The mass of destruction of all intervertebral discs and vertebras were exposed. The C3 vertebra had spondylolysis combined with the failure and instability of C4, C5, and C6. The fluctuation would be felt after drawing back the lower jaw using a drag hook. The drained was about 25 mL. After performing these steps, we performed corpectomis and then the C3, C4, C5, and C6 vertebras and adjoining intervertebral discs (IVDs) were decompressed and debrided. During this process, most of the posterior longitudinal ligaments were dissected and the endorhachis was exposed for complete decompression. The surgical area was irrigated using hydrogen peroxide and normal saline combined with anti-tuberculosis drugs. The vascularized fibula was grooved into a trapezoid shape in the C2 and C7 vertebral bodies and then the fibular graft was shaped based on the defect of the recipient area. The fibular graft was inserted tightly in front of the cervical. The graft was fixed using 17 mm screws on the upper and lower surface. After surgery, C-shaped x-ray was performed and showed that the fixation and embedding of the graft was satisfactory. Next, we performed vessel anatomosis. The transverse cervical artery and external jugular vein were located at the superior border of the omohyhoid. Full dissociation must be performed carefully to retain the integrity of vessel pedicle. The free artery and vein were excised and ligated at the distal end. Anatomosis was performed between the transverse cervical artery and peroneal artery together with the peroneal vein and external jugular vein. The vessels were checked to be unobstructed by recanalization. There was no vessel thrombosis and vasospasm after 30 minutes of observation. The retropharyngeal and throat were filled with gelatin sponges that released isoniazid and streptomycin. A drainage tube was placed and the wound was closed.
The duration of the surgery was 6 hours. After the surgery, blood pressure at the supradavicular area of the anterior cervical returned to normal.
After the surgeries were completed, the patient was treated using anti-TB drugs for 2 weeks as well as liver-protecting therapy simultaneously. The dose of anti-TB drugs were the same as that administered pre-op. Postoperatively, the patient recovered from low-grade fever and symptoms of occipital and back-neck pain improved. X ray and CT scans postsurgery revealed that the location of the fixation system and fibular graft were not displaced or extruded. The patient began functional exercises out of bed with the assistant of a cervical orthosis by day 10 postsurgery and was discharged after 27 days. After 3 months, the patient was followed-up with CT scans and x-rays. The results showed good fibular graft incorporation. At 6, 18, and 28 months' of follow-up, CT scans and x-rays (Figs. 3-5) showed complete incorporation of the fibular grafts. In addition, the patient had a good range of motion and functionally recovered after surgery. The patient was able to perform moderate lateral bending, anteflexion as well as rear protraction with no signs of abnormal sensation or pain in the upper limbs. Radiography showed excellent cervical fusion. In addition, after each follow-up, there were no signs of complications or pain in the donor site, as well as any recurrence of infection.