Craniovertebral junction Pott's disease

Abstract

Pott's disease of the craniovertebral junction is extremely rare. The authors studied the immediate and long-term outcome after transoral decompression, occipitocervical stabilization with fusion and antitubercular therapy (ATT) in patients who had neurological deficits due to craniovertebral junction (CVJ) tuberculosis. This is a retrospective study of the management and outcome in 10 consecutive patients in whom features of spinal cord (with or without) compression were observed, and CVJ tuberculosis was diagnosed in two different neurological departments between 1990 and 2002. They ranged in age from 15 to 72 years. The onset of symptoms was either acute or subacute. Patients presented with neck and occipital pain (90%), progressive tetraparesia (40%), sensory symptoms (40%), neck stiffness (30%) and urinary dysfunction (20%). The disease caused spinal cord compression in six patients, atlantoaxial dislocation in five patients, basilar impression in one and upper vertebral column destruction without dislocation in three. Two patients presented with multiple spinal tuberculosis. Antitubercular therapy was used in all cases for 15 months. Surgical treatment performed in all patients. Four patients underwent transoral drainage of retropharyngeal abscess with granulation tissue and one odontoidectomy. Six patients then underwent occipitocervical (occiput -C3 or -C4) fusion with insertion of titanium plate and screw. Postoperatively, ATT was prescribed for 15 months. At long-term follow-up (median 50.2 months), functional status considerably improved. Two patients died 2 months later due to myocardial infarction. Patients with CVJ with features of cervical myelopathy are ideally treated 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 and with adequate duration of ATT. This approach provides excellent access to this region, with a low operative morbidity and no mortality.

Tuberculosis of the craniovertebral junction

“…The sum of major studies about exclusive surgical treatment of craniocervical junction tuberculosis includes patients who fulfil the criteria of instability, others do not [6,8,9,17,22,23]. Arunkumar et al [6] proposed surgical treatment in spinal tuberculosis only in cases with neurological deficits due to craniovertebral junction disease.…”

Craniovertebral Junction Tuberculosis with Atlantoaxial Dislocation : A Case Report and Review of the Literature

“…Diagnosis may be difficult and management can be challenging, requiring different treatment modalities depending on the clinical symptoms or radiological features. Treatment options are also controversial without well-defined guidelines, including a conservative approach (anti-tuberculosis medication and external fixation), relatively simple surgery (posterior fusion and fixation), or radical surgery (debridement, decompression and stabilization) [1][2][3][4][6][7][8][9][10][11][12][13][15][16][17][18]20) . The authors present a case of CVJ tuberculosis with atlantoaxial dislocation (AAD) and retropharyngeal abscess.…”

“…The spread of tuberculosis infection usually takes a retrograde route, reaching the craniovertebral joints. Subsequently, the infection causes destruction of the bony and ligamentous structures, and eventually produces cervicomedullary neural compression and occipitocervical or atlantoaxial instability 12) . The occipitoatlanto-axial complex has a wide range of motion, accounting for approximately 80 degrees of rotation and significant flexion 21) .…”

“…The treatment options for CVJ tuberculosis have been controversial, from an absolute conservative approach to radical extirpation 1,2,4,[6][7][8][9][10][11][12][13][15][16][17][18]20) . This inconsistency is mainly due to the absence of well-proposed guidelines; however, it is also true that the symptomatic or radiological features of this disease may be diverse enough to justify several definite treatment modalities.…”

Institutional experience of tuberculosis of craniovertebral junction

“…12,21 This abnormal mobility persists even after ATT. Compression of vital structures in brainstem may lead to death of the patient.…”