Surgical management of craniocervical junction tuberculosis with atlanto-axial dislocation - A case report and review of the literature

Abstract

Background: There are few guidelines on how to best manage craniovertebral junction (CVJ) tuberculosis (TB). Certainly, timely tissue diagnosis, immobilization of the neck, and decompression of CVJ with appropriate stabilization are the mainstays of treatment for TB at the CVJ.

Case description: Three patients, ages 16-68, presented with CVJ TB with atlanto-axial dislocation responsible for progressive quadriparesis/plegia. Based on X-rays, magnetic resonance, and computed tomography studies, patients underwent timely decompressions and fusions followed by antitubercular drug treatment.

Conclusion: Early diagnosis, proper decompression with fusion, treated with anti-TB drug for proper period were keys to managing TB involving the craniocervical junction in these three patients.

Keywords: Anti-tubercular therapy; Atlanto-axial dislocation; Craniovertebral junction; Kyphotic deformity; Tuberculosis.

Figure 1:

(a) X-ray cervical spine lateral view showing increased atlanto dental interval (13 mm) with radio dense shadow in between. (b) Magnetic resonance imaging cervical spine in sagittal T1-weighted image and contrast showing prevertebral retro-oropharyngeal abscess. (c) Immediate postoperative cervical X-ray days showed beautiful correction.

Figure 2:

(a) X-ray cervical spine lateral view showing increased atlanto dental interval (16 mm) with radio dense shadow in between, (b and c) computed tomography (CT) cervical spine lateral (b), coronal (c) view showing osteolytic lesion at C2 body. (d and e) Magnetic resonance imaging (MRI) cervical spine in sagittal T2-weighted image (T2WI) (d) and T1-weighted image (e) showing prevertebral retrooropharyngeal abscess. (f and g) Postoperative cervical X-ray after 15 days, (h) CT cervical spine sagittal after 1 month, and (i) MRI of the cervical spine in sagittal T2WI after 3 months showed complete resolution of abscess, correction of kyphotic deformity.

Figure 3:

X-ray cervical spine dynamic view showing C1/2 instability, (b) Computed tomography (CT) cervical spine in sagittal view, showing partial erosion of C1 lateral mass and C2 body, (c, d, e) Magnetic resonance imaging (MRI) of the cervical spine, contrast enhancing extradural mass at C1–3 levels causing obliteration of the anterior CSF column and prevertebral collection of abscesses. (f) Postoperative X-ray of the cervical spine at 1 month, showing spinal fixation between C1 lateral mass, C2 pedicle, and C3 lateral mass with screws and rods, (g) MRI of the cervical spine at 6-month complete resolution of abscess and significant decompression of cord.