Craniovertebral Tuberculosis Research Articles

Pathogenesis and Staging of Craniovertebral Tuberculosis: Radiographic Evaluation, Classification, and Natural History.

Retrospective cohort. To radiographically evaluate Craniovertebral junction (CVJ) tuberculosis infection pathogenesis and to propose a modification to the Lifeso classification. A cohort of patients with radiologically or microbiologically identified CVJ tuberculosis treated at a single tertiary referral center in a TB endemic area was queried for characteristics about clinical presentation, treatment, and radiographic evidence of bone destruction and abscess formation were included. Disease was classified according to the Lifeso grading system and bony lesions were classified as either type 1 (preservation of underlying structure) or type 2 (damage of underlying structure). 52 patients were identified (mean age 28.5 ± 13.4yr, 48% male; 14% with a prior history of tuberculosis). All presented with neck pain at presentation, 29% with rotatory pain, and 37% with myelopathy. Comparison by Lifeso type showed Lifeso III lesions had longer symptom durations (P = .03) and more commonly had periarticular or predental abscess formation (P < .05), spinal cord compression (P < .01), and more commonly involved the C2 body and atlanto-dental joint. Underlying bony destruction was more common for lesions of the lateral atlantoaxial joints and atlanto-dental joints in Lifeso III cases than in either Lifeso I or II (all P < .05). The radiologic findings of the present series suggest CVJ TB infection may originate in the periarticular fascia with subsequent invasion into the adjacent atlanto-dental and lateral atlantoaxial joints in later disease. To reflect this proposed etiology, we present a modified Lifeso classification to describe the radiologic pathogenesis of CVJ TB.

Craniovertebral tuberculosis in children: experience of 23 cases and proposal for a new classification.

The aim of this study was to review cases of paediatric patients with craniovertebral junction (CVJ) tuberculosis with a view to try and stratify the cases into different groups which would help plan treatment and hence develop a protocol for treatment of a fairly uncommon condition still widely seen in the developing world. Twenty-three cases of paediatric craniovertebral tuberculosis had their clinical features and radiology reviewed. The treatment plan in each case was analyzed according to their presentation. The results of treatment after 1 year were assessed in each case. The clinical presentations varied from neck pain with hypoglossal nerve palsy to frank spastic quadriparesis, and frank instability at the atlanto-axial junction was seen in five out of 23 patients. Cold abscesses were seen in 18/23 cases, and severe torticollis was the presentation in 6/23. We graded the children with this condition into three groups: 1) those with instability and gross neurodeficit who required early operative intervention (1 needed trans-oral decompression with posterior fixation and 4 required posterior fixation) 2) those who had severe torticollis and large cold abscesses who were treated with trans-oral aspiration of cold abscess followed by neck immobilization (6/23) and 3) those who did not have significant neck muscle spasm or torticollis and who were treated with immobilization alone (12/23). Only one child in group 3 required delayed intervention for instability which developed after completion of the course of anti-tubercular medication. We concluded that children with craniovertebral tuberculosis should be treated according to their clinical presentation coupled with evidence of radiological instability. Those with gross deficit and instability need early stabilization, those with minimal deficit and no instability but severe pain or torticollis need aspiration of the cold abscess with external immobilization, whereas those without deficit, instability or severe pain may be managed by external orthoses alone. Of course, medical treatment for tuberculosis is necessary in each case.

Endoscopic, endonasal decompression of spinal stenosis with myelopathy secondary to cranio-vertebral tuberculosis: two cases

Tuberculosis can cause extensive osseo-ligamentous destruction at the cranio-vertebral junction, leading to atlanto-axial instability and compression of vital cervico-medullary centres. This may manifest as quadriparesis, bulbar dysfunction and respiratory insufficiency. We report two patients presenting with spinal stenosis and cord compression secondary to cranio-vertebral tuberculosis, who were successfully decompressed via an endoscopic, endonasal approach. Two case reports. Both patients were successfully decompressed via an endoscopic, endonasal approach which provided access to the cranio-vertebral junction and upper cervical spine. An endoscopic, endonasal approach is feasible for the surgical management of cranio-vertebral junction stenosis; such an approach minimises surgical trauma to critical structures, reducing post-operative morbidity and the duration of hospital stay.

An Unusual Case of Craniovertebral Junction Tuberculosis in an Infant

We present, to the best of our knowledge, the first reported case of craniovertebral junction tuberculosis with complete quadriplegia in an infant. To describe report of an unusual case and discuss the difficulties and peculiarities of diagnosis, management, and follow-up of craniovertebral tuberculosis in an infant. Spinal tuberculosis is prevalent in areas where tuberculosis is endemic, and its incidence is on the rise in developed nations with the rising incidence of HIV/AIDS. Although common in children and young adults, spinal tuberculosis is rare in infants. Again, craniovertebral tuberculosis is one of the rarest forms of spinal tuberculosis. The infant presented to us at the age of 9 months with Grade IV quadriplegia. Among many of the clinical differential diagnoses, craniovertebral tuberculosis was suspected only on MRI and proved after fine needle aspiration cytology demonstrated granulomas. The patient was subjected to transoral debridement, immobilized with help of a pair of pillows by either side of the head and multidrug antitubercular treatment was started, which continued for duration of 12 months. At the last follow-up of 1 year, the patient had recovered fully and caught up with the milestones suitable for her age. Craniovertebral tuberculosis is difficult to diagnose and treat in infants. A high index of suspicion is essential for a prompt diagnosis and treatment, which is all the more crucial in this age group.

Craniovertebral Tuberculosis

Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively. To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature. Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively. A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months. All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases. We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Craniovertebral junction tuberculosis: a review of 29 cases.

The purpose of this work was to describe the various imaging findings in craniovertebral tuberculosis and the importance of imaging in treatment in these patients. A retrospective review of MR and CT scans in 29 patients with craniovertebral tuberculosis was performed. The images were reviewed, paying special attention to both bony (skull base, atlas, and axis) and soft tissue involvement in addition to atlantoaxial dislocation, lateral subluxation of the dens, and compression of the spinal cord. Suboccipital pain with neck stiffness was the most common presenting symptom in our patients. The skull was involved in 19 of the 29 cases, clivus involvement was seen in 11 patients, and occipital condyle involvement was present in 14 patients. Detailed analysis of atlas involvement due to tuberculosis showed the lateral masses to be predominantly affected. The dens was involved in 18 cases (62%). Soft tissue masses in the prevertebral area were seen in 22 patients, paravertebral in 27 patients, and epidural involvement in 25 patients was identified. Atlantoaxial displacement was present in seven cases, lateral mass-dens subluxation in five, and superior subluxation of the dens through the foramen magnum compressing the medulla was seen in two cases. Spinal cord compression with intrinsic cord changes was noted in 12 cases. All patients received multidrug antituberculous therapy for 1 year. The presence of neurologic deficit and instability of the atlantoaxial complex was pivotal in further management in these patients. A high degree of clinical suspicion is necessary when confronted with patients with neck stiffness and tenderness over the upper cervical vertebrae. MRI in these patients provides a sensitive method for the diagnosis of craniovertebral tuberculosis.