Hemiplegic/monoplegic presentation of cervical spine (C1-C2) tuberculosis

Abstract

Tuberculosis of the craniovertebral region is very rare. Neural deficit in this region is reported in between 24% and 64% of cases, and mainly takes the form of quadriparesis. Hemiplegic and monoplegic presentation among this set of patients is rarer. Out of 32 patients treated at our institution between May 1989 and February 2001, only one had hemiplegia, while two had monoplegia. These three cases are discussed. Case 1 involved a 45-year-old woman who presented with hemiplegia following a trivial fall. Plain radiographs and computed tomographic (CT) scans of the skull appeared normal, but CT scans of C1-C2 and the craniovertebral junction revealed destruction of the dens and atlantoaxial subluxation. The patients in cases 2 and 3 had monoplegia. Plain radiographs in both cases showed an increased prevertebral soft tissue shadow in front of C1-C2. CT in case 2 and magnetic resonance imaging (MRI) in case 3 revealed destruction of the arch of C1 and the dens, with subluxation. All three patients were successfully treated with rest, skull traction, anti-tubercular drugs and suitable braces. Case 3 required stabilization. All three patients achieved complete neural recovery. Patients 1, 2 and 3 had 22, 48 and 4 months' follow-up respectively. Patient 3 was subsequently transferred to a neurosurgery ward for stabilization of the occipito-C3 vertebrae. Hemi/monoplegic presentation is extremely rare; no author in the literature is able to give reason for the rarity or the pathomechanics of the condition. We believe that if medullary cervical junctional involvement extends slightly higher (in rare circumstances), with involvement of one of the branches of the vertebral or lower basilar artery, medial medullary syndrome will occur, sparing medial lemniscus and emerging hypoglossal nerve fibres. Thus the pyramids will be involved, causing contralateral hemiparesis, and if the pyramids are selectively involved, it will cause contralateral monoparesis.

Tuberculosis of the craniovertebral junction

“…Literature is quite divided on management of patients with tuberculosis involvement of the craniovertebral junction [4,7,[9][10][11][12]14]. Some people recommend conservative treatment only [1,2,5,11,22], others recommend surgery in all patients [3,6,8,23].…”

An unusual case of atlanto-axial and basi-occipital TB with prevertebral abscess and epidural abscess

“…Figures in the literature suggest neurological involvement in 24 to 64% of cases of cervico-cranial TB with quadraparesis being the most common outcome [15]. Our case had significant anterior epidural abscess with MRI signs of cord compression, however the patient was neurological intact, suggesting that MRI changes not be foregone for clinical assessment.…”

“…TB spine carries a significant risk of neurological involvement [15]. Figures in the literature suggest neurological involvement in 24 to 64% of cases of cervico-cranial TB with quadraparesis being the most common outcome [15].…”

“…Cranio-cervical TB carries the significant risk of neurological involvement [15] and hence recognition and intervention are critical. The following is a case report of an unusual case of atlanto-axial and basi-occipital TB with a prevertebral abscess and an anterior epidural abscess without any neurological symptoms.…”

One-stage surgical management for tuberculosis of the upper cervical spine by posterior debridement, short-segment fusion, and posterior instrumentation in children

“…The spinal cord in this region in patients with tuberculosis is threatened by atlantoaxial subluxation, compression by an abscess, or by direct tuberculous invasion. Dhammi [10] reported one patient had hemiplegia while two had monoplegia out of 32 patients who suffered from tuberculosis of the craniovertebral region treated at his institution. Therefore, to be decompressed, a debridement is necessary.…”