Craniovertebral Junction Tuberculosis Research Articles

Tuberculosis of the Craniovertebral Junction: Is Surgery Necessary?

Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978-1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987-1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999-2004), all patients (n = 16) in all stages (Stages I-III) have been managed without surgery by a rigid external immobilization. Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.

Management of craniovertebral junction tuberculosis

Background Tuberculosis of the craniovertebral junction (CVJ) is extremely rare. However, recent evidence suggests that the incidence of this condition may be increasing. The diagnosis is often difficult despite advances in imaging using magnetic resonance imaging. The transoral approach to the anterior CVJ provides excellent access to this region, has low mortality and morbidity, and enables biopsy of lesions and decompression of the neuraxis. Management of associated atlantoaxial instability, with regard to timing and method of stabilization, is controversial. Methods We report 24 cases of CVJ tuberculosis. Prominent manifestations of the disease included neck pain and stiffness, swelling of the retropharyngeal soft tissues, quadriparesis, osteolytic erosions, and atlantoaxial subluxation. Seven patients had acute presentation. All patients received antituberculous drug treatment for 18 months. Four patients were managed conservatively, 5 underwent only transoral biopsy, 9 patients underwent transoral decompression and posterior fusion, and 6 patients underwent only posterior fusion. Results Histopathologic analysis of biopsy material revealed abscess only in 5 cases, granulation tissue only in 6, abscess with granulation tissue in 4, granulation tissue with chronic osteomyelitis in 5, and chronic inflammation in 2. All patients improved, with mean improvement in Nurick grading of 1.71. Even patients with spinal cord signal intensity changes on magnetic resonance images showed improvement. Conclusions Although CVJ tuberculosis is a rare disease, the outcome of treatment is good. Antituberculous drug therapy remains the mainstay of treatment after confirming the diagnosis. The surgical management options include transoral decompression with or without posterior fusion, depending upon the presence and persistence of atlantoaxial instability.

Craniocervical Tuberculosis: Protocol of Surgical Management

OBJECTIVE Craniovertebral junction tuberculosis (CVJ-TB) is rare and occurs in only 0.3 to 1% of patients with tuberculous spondylitis. In the available literature, the treatment options offered for this entity have ranged from a purely conservative approach to radical surgery without well-defined guidelines. In this study, we attempt to establish the most effective strategy for the management of this condition. METHODS Twenty-five patients with CVJ-TB were treated during the past 8 years. Severe neck pain, restricted neck movement, and myelopathy were the predominant symptoms. The patients were graded according to their disability as follows: Grade I (n = 7), only neck pain with no pyramidal tract involvement; Grade II (n = 8), independent with minor disability; Grade III (n = 1), partially dependent on others for assistance with activities of daily living; and Grade IV (n = 9), completely dependent on others for assistance with all activities of daily living. Nine patients in Grade IV also had severe respiratory compromise. In all patients, lateral radiographs of the CVJ in flexion and extension were used to determine the presence of atlantoaxial dislocation (AAD). Bony destruction, paraspinal abscess, and thecal compression were seen on intrathecal contrast computed tomographic scans (n = 9) and magnetic resonance imaging studies (n = 22). Under the cover of antituberculous therapy (ATT) administered for 18 months, the patients were placed under a management protocol that took into account the patient’s preoperative grade, the presence of mobile or fixed AAD, bony destruction and retropharyngeal abscess formation at the CVJ, and the clinicoradiological response to ATT within 3 months. Thus, 14 patients were kept on conservative management, with their neck movements stabilized with an external orthosis; 4 patients underwent a single-stage transoral decompression and posterior fusion procedure; and 7 patients underwent direct posterior fusion. RESULTS In a follow-up period that ranged from 6 months to 7 years (mean, 2.5 yr), the patients in Grades I and II maintained their neurological status. The single patient in Grade III improved to Grade II. Seven of the nine patients in Grade IV returned to normal, and one improved to Grade II. Neck pain improved in all patients. The only death in the series occurred as a result of aspiration pneumonitis leading to septicemia in a child in Grade IV with poor respiratory status and multilevel tuberculous involvement who had undergone transoral decompression and posterior fusion for fixed AAD. CONCLUSION This study discusses the clinicoradiological presentation as well as the management of CVJ-TB, in which ATT is administered for 18 months. In the patients with minor deficits (Grades I and II), conservative neck stabilization is adopted; in the patients with severe deficits (Grades III and IV) due to significant cervicomedullary compression caused by fixed AAD or bone destruction and granulation, anterior decompression and posterior fusion are performed. Patients with persistent reducible AAD undergo direct posterior fusion. A significant improvement is possible even in poor-grade patients with judicious use of the surgical options and ATT.

Outcome in neurologically impaired patients with craniovertebral junction tuberculosis: results of combined anteroposterior surgery.

The authors studied the immediate and long-term outcome after transoral decompression, occipitocervical fusion, and antituberculous therapy (ATT) in patients who had neurological deficits due to craniovertebral junction (CVJ) tuberculosis. In this retrospective study, the authors reviewed the management and outcome in nine consecutive patients in whom features of spinal cord compression were observed and CVJ tuberculosis was diagnosed between 1993 and 1999. They ranged in age from 9 to 55 years. Onset of symptoms was acute or subacute and rapidly progressive (median 4 months, range 1-12 months). Patients presented with neck pain (89%), progressive limb weakness (89%), sensory symptoms (22%), and urinary dysfunction (33%). The mean preoperative functional grade based on the Nurick Scale was 3.4 (range 1-5). The disease caused reducible atlantoaxial dislocation (AAD) in three patients (33%), irreducible AAD in two (22%), basilar impression (BI) in one (11%), AAD with BI in one (11%), and C-2 vertebral body (VB) destruction without dislocation in two (22%). Surgery was performed in all cases. Five patients (56%) underwent transoral odontoidectomy, two (22%) transoral decompression of retropharyngeal abscess and granulation tissue, and two (22%) transoral decompression of abscess and diseased parts of the C-2 VB. All patients then underwent occipitocervical (occiput-C3) fusion in which a contoured Steinmann pin and iliac bone grafts were used. Postoperatively, A17 was prescribed for 18 months. In the immediate postoperative period, function in these patients improved from a mean Nurick grade of 3.4 to 2.3 (p < 0.01). At long-term follow-up examination (median 18.8 months, range 7-46 months) function improved from a mean Nurick grade of 3.4 to 0.3 (range 0-2) (p < 0.001). Patients with CVJ tuberculosis with features of cervical myelopathy are ideally managed with transoral decompressive procedures followed by occipitocervical fusion because this therapy provides immediate neurological improvement, stability, and allows early mobilization. The long-term prognosis in patients with this disease is excellent provided it is treated with appropriate surgical intervention(s) and with adequate duration of ATT.