Cervical tuberculosis lesions are mainly in the cervical space and invade the adjacent vertebral bodies at the same time, causing cervical instability and kyphosis. The diseased tissue invades the spinal canal backward, compresses the spinal cord, and causes dysfunction [9]. Abscesses can break through the anterior longitudinal ligament and accumulate behind the longus cervix muscle and its fascia, forming abscesses in the throat wall and posterior esophagus [10]. The objective of surgical treatment of cervical tuberculosis is to remove the lesion, restore spinal cord function, correct cervical kyphosis, reconstruct the physiological curvature, and maintain stability [11].

Because Mycobacterium tuberculosis mainly invades the anterior and central columns of the cervical spine, and cervical spinal cord compression comes from the ventral side of the spinal cord, anterior debridement, spinal cord decompression, correction of kyphosis, and cervical stability reconstruction are the main surgical methods [12]. Wang et al. proposed a treatment protocol of Xiangya Institutes of Medical Sciences cervical tuberculosis grading system: conservative treatment for grade 1, anterior debridement and fusion for grade 2, and a combined anterior–posterior approach for grade 3 lesions) [8]. The anterior approach allows direct access to the lesion and relatively complete removal of the abscess, dead bone, and granulation tissue [13]. Anterior surgical methods include simple debridement, debridement and bone grafting, anterior one-stage debridement and bone grafting, and anterior internal fixation. In most cases of spinal tuberculosis with indications for surgery, anterior debridement and bone graft fusion can be performed without involvement of the posterior adnexa [14]. Anterior internal fixation is more effective than posterior internal fixation in correcting deformity and reconstructing stability, and can be considered in all cases without special circumstances [15]. In our opinion, thorough debridement of the lesion involves removal of all necrotic tissue, pus, caseous matter, dead bone, granulation tissue, necrotic intervertebral discs in the lesion area, and preservation of healthy and subhealthy tissues. Extensive resection, especially of the entire vertebral body, should be avoided because it aggravates trauma and bone defects, which is not conducive to the repair of tuberculosis lesions. Some scholars also believe that when the scope of tuberculosis transformation exceeds two vertebral bodies and the scope of anterior reconstruction crosses three vertebral spaces, it is recommended to adopt phased posterior and anterior combined surgery, with posterior fixation decompression in the first stage and anterior decompression and reconstruction fixation in the second stage [16]. The purpose of posterior surgery is to enhance the stability of the cervical spine and restore the curvature of the cervical spine through the posterior nail rod system. However, the nutritional status of tuberculosis patients is poor, and the greater trauma of combined anterior and posterior surgery will further increase the difficulty and risk of surgery, and the choice should be careful. In this group of patients, anterior debridement was performed, which could directly reach the lesion. The abscess, dead bone, caseous tissue, and granulation tissue were removed under direct vision, and spinal cord compression was completely relieved. Therefore, neurological function of the patients improved to varying degrees.

Complications of anterior cervical surgery include surgical approach-related complications, decompression-related complications, bone graft fusion-related complications, and internal fixation-related complications. However, laryngeal nerve and recurrent laryngeal nerve injury are the most common complications, with an incidence of 2.18% and 0.97%, respectively, and aggravating spinal cord and nerve damage is the most serious complication of anterior cervical surgery [17, 18]. There are important anatomical structures, such as nerves, blood vessels, trachea, and esophagus, in front of the cervical spine. Long-term excessive traction during the operation will lead to early esophageal injury, and long-term friction between the anterior plate and esophagus will also lead to delayed esophageal perforation [19]. In our experience, loosening the retractor or adjusting the position of the retractor after 0.5 h of intraoperative esophageal traction can avoid esophageal perforation caused by prolonged esophageal traction. In this study, hoarseness occurred in three patients (6.25%, 3/48) after the operation, and the symptoms disappeared after nutritional nerve treatment. Mild pain in the iliac crest area was left in eight patients (16.67%, 8/48), and the pain in the iliac crest area disappeared in six patients at the last follow-up. These may be related to the longer operation time, larger operation scope, and need to take a large iliac crest during the operation. For such patients, a more elaborate operation is required to reduce the incidence of these complications. In conclusion, careful preoperative planning, comprehensive perioperative management, and skilled surgical techniques are considered the most important factors for reducing complications and residual symptoms.

At present, research on anterior surgery for cervical tuberculosis has shown that the operation has achieved different degrees of short-term or long-term efficacy, and the postoperative deterioration or recurrence in patients is mostly caused by the insufficient time of chemotherapy and the failure to control the lesion [20, 21]. Therefore, regular postoperative reexamination of liver and kidney function, ESR and X-ray, regular full course of antituberculosis drugs, full understanding of lesion healing and stability, and strict postoperative chemotherapy can ensure the effect of surgery. In this study, the patients were treated with antituberculous drugs strictly before and after surgery and achieved good clinical efficacy at the last follow-up. In our opinion, the prognosis of patients with cervical tuberculosis is not only related to surgical management, but more importantly, regular antituberculosis drug treatment in the early, full, combined, and appropriate principles.

The use of implants is very important in cervical tuberculosis surgery, and their main role is to achieve osseous fusion of the lesion site to provide structural support [22]. The effect of bone graft fusion directly affects the effect of surgery; therefore, whether the choice of implant is reasonable directly affects whether the bone graft fusion can achieve the ideal state. The most commonly used implant in clinical practice is the autogenous iliac bone, which is generally a three-sided cortical iliac bone block that has a good three-dimensional support effect and is conducive to improving the fusion rate [23]. Raja et al. performed anterior cervical decompression and autologous iliac bone graft fusion in 44 patients with cervical tuberculosis. All patients had good neurological function after surgery, and no postoperative complications were found [24]. However, the autogenous iliac crest also has some drawbacks, such as pain and infection at the site of bone retrieval and the risk of neurovascular and urethral injury. Injury to the pelvis can also lead to pelvic fractures and instability. In view of the above problems, Zhang et al. attempted to use a vascularized autologous fibula as an implant in the treatment of a patient with multilevel cervical tuberculosis. The cervical spine function of the patient recovered well after surgery, and the fibula as an implant has more advantages in terms of length [25]. Therefore, this method may provide a new treatment strategy for long-segment cervical tuberculosis. Pain after autogenous iliac crest removal does not affect its status in bone graft fusion, and the autogenous iliac crest remains the gold standard for endografts in cervical tuberculosis surgery. Proper treatment of bone extraction sites, mature bone extraction techniques, and the development of minimally invasive surgery have improved the effect of bone extraction and reduced the incidence of postoperative pain. The cervical spine is characterized by abundant blood supply, high drug concentration, and abundant soft tissue, and the autogenous iliac bone graft has the advantages of good bone conductivity, inductance, and osteogenic activity [26]. The results of this study indicate that autogenous iliac bone can be safely used for structural support therapy after removal of cervical tuberculosis lesion under effective antituberculosis therapy. Short segmental fixation preserves the uninvolved bone parts above and below the affected vertebra to insert the internal fixation, thereby preserving the adjacent healthy intervertebral space and vertebral body, minimizing the injury of cervical tuberculosis lesion removal, and facilitating healing and bone fusion [13].

In recent years, the advantages of titanium as a bone graft fusion material have also become increasingly prominent, with good effects on restoring the physiological curvature of the cervical spine, rebuilding the stability of the cervical spine, promoting bone graft fusion, and improving the cure rate of cervical tuberculosis [27]. However, the subsidence phenomenon of titanium cages after implantation is worth further study [28]. A recent study investigated the effectiveness of allograft bones combined with poly-ether-ether-ketone (PEEK) cages or titanium mesh cages (TMCs) in the management of cervical spinal tuberculosis, and they found that allograft bone combined with PEEK cages and TMCs could bring about favorable clinical results in patients with cervical spinal tuberculosis. This method could be an alternative to autologous bone grafting method in the management of certain cases [29]. In recent years, many new technologies have emerged, for example, three-dimensional printing-assisted cervical anterior bilateral pedicle screw fixation of artificial vertebral body for cervical tuberculosis [30].

This study had some limitations. First, this was a retrospective study, which inevitably resulted in selection bias. Second, the overall postoperative follow-up time was short, which may have underestimated the incidence of mechanical complications, such as aseptic loosening and screw fracture. Third, this was a small-sample study, and a large-scale study in multiple centers is needed. Finally, the effect on bone growth needs to be confirmed with a longer follow-up period.