Cases Caries Cervical Spine (C1-C2) - Punjab Orthopaedic ...

Cases Caries Cervical Spine (C1-C2) - A Case Report
Jaswinder Pal Singh Walia MS* , Ravinder Pal Kaur MD**, Rakesh Kumar MBBS***,
Sonam Kaur Walia MBBS**** Sargun Singh*****
*Professor, **Ex. Professor, ***Junior Resident, ****Intern, *****Undergdatuate Student
Department of Radio Diagnosis
Government Medical College and Rajendera Hospital, Patiala
Department of Orthopaedics,
Government Medical College and Rajendera Hospital, Patiala
ABSTRACT
Osteoarticular tuberculosis is not a public health problem in most of developed countries, however, in
developing countries it continues to pose one of the major health problems. Vertebral tuberculosis is the most
common form of skeletal tuberculosis and constitutes about 50% of all cases. In the present report, we discuss
the clinical features, diagnostic modes, treatment options and follow-up of upper cervical spine tuberculosis
in a 42 year old male patient.
Keywords: Tuberculosis, Cervical spine, Anti Tubercular Therapy
INTRODUCTION
Osteoarticular tuberculosis with all its antecedent complications
continues to pose one of the major health threats in the
developing world. Vertebral tuberculosis is the most common
form of skeletal tuberculosis and constitutes about 50% of all
cases.
While most cases are localized to the dorsal and the lumbar
spine, the involvement of cervical spine accounts for about
12% of the cases and even out of that, involvement of upper
cervical spine is extremely rare. However upper cervical
involvement gains importance because of its potential fatal
consequences if not treated adequately and timely 1 .
CASE SUMMARY
A 36 years old man, college lecturer by profession,
presented to us with complaint of neck pain and stiffness;
with pain radiating to right upper limb. The pain and
stiffness were progressing in spite of him taking analgesics.
Examination revealed mild tenderness over upper cervical
spine; along with painful restriction of cervical movements at
the extremes.
X-rays of cervical spine did not show any abnormality
(Figure 1). MRI was done and it showed Pre- vertebral soft
Corresponding Author :
Dr. JPS Walia, Professor of Orthopaedics,
19, Phulkian enclave, Patiala, Punjab.
E-mail : doc_jpswalia@yahoo.co.in
tissue mass with epidural extension at C1/C2 level (Figure 2).
Granulation tissue was infiltrating into the soft tissue of the
skull base and posterior pharyngeal wall. Bony architecture
was studied using CT scan of cervical spine, which revealed
Fig. 1:X-rays showing lateral and AP view
Fig. 2: MRI showing Erosions at C1-C2
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Walia et al
erosion of the dens, left occipital condyle, left lateral mass of
Atlas and articular facet of Axis. ESR was 100 mm at end of 1st
hour and ELISA for tuberculosis was positive.
Patient was diagnosed as a case of caries spine C1-2 and
was started anti-tubercular therapy which was continued for
18 months. Cervical traction with 5 kg for two months was
given to immobilize the cervical spine; this was followed by
cervical collar to facilitate mobilization of patient.
Patient responded well with Anti-Tubercular Therapy.
The follow-up MRI after 1 year of follow-up showed
complete resolution of pre-vertebral abscess and no
compression of thecal sac or cord displacement was seen at
the end of 1 year (Figure 3).
Fig. 3: Follow-up MRI showing consoilation achieved at C1-C2 with
ATT
DISCUSSION
Vertebral tuberculosis is the commonest form of skeletal
tuberculosis. It is most common during first three decades of
life. Pain and stiffness are earliest complaints. Neck rigidity
and torticollis are seen in severe cases, pain over vertebrae
referred to occiput or arms aggravated by pressure on top of
head, loss of normal lordosis, paralysis of arms and other
neurological symptoms due to compression are seen in all the
cases. Cervical tuberculosis has high complication rate. Hsu
and Leong reported 42.5% spinal cord compression rate in 40
patients 2 . In extreme cases, death may occur due to C 1-2
dislocation 3 .
There is no clear-cut consensus regarding conservative
or operative treatment. Lifeso recommended various treatments
for three different stages of C1-2 tubercular infection: Stage I
with minimal bone and ligamentous destruction is treated by
trans-oral decompression and immobilization; Stage II with
moderate involvement requires reduction by halo traction
followed by C1-2 posterior fusion; and Stage IIII with severe
involvement is treated by posterior fusion of occiput to C3 4 .
Certain authors recommend surgery for both diagnostic
and therapeutic purposes. It enables not only bacteriological
sampling but also medulla decompression and spinal
stabilization, thereby optimizing neurologic and functional
recovery. Surgery enhances local access for antibiotics, by
removing a fibrous barrier 5,6 [9] A.K. Jain, Treatment of
tuberculosis of the spine with neurologic complications, Clin
Orthop Relat Res 398 (2002), pp. 75–84. View Record in Scopus
| Cited By in Scopus (33). Gupta et al. concluded that the
surgery was not necessary, even in patients with advanced
stage of disease (retropharyngeal abscess with or without
Atlanto-Axial Dislocation, gross bony destruction or
angulation) on the basis of their experience of more than 3
decades 7 . Chadha et al. studied craniovertebral tuberculosis
patients managed non-operatively and found that
consolidation was achieved in all cases, without neurologic
deterioration, with anti-tubercular therapy 8 .
In our patient also, good results were seen after nonoperative
treatment. We conclude that Anti Tubercular
Therapy combined with cervical immobilization without need
for surgical intervention is suitable for patients without neural
deficit.
REFERENCES
1. Tuberculosis of the skeletal system. Tuli SM. J.P. Brothers. 3 rd
edition;2004.
2. Hsu LCS, Leong JCY. Tuberculosis of lower cervical spine: a report
of 40 cases. J Bone Joint Surg 1984;66B:1.
3. Orthopaedics. Turek Samuel L. J.P. Brothers, 4 th edition; 1984.
4. Lifeso R. Atlanto-axial tuberculosis in adults. J Bone Joint Surg
1987;69B:183.
5. George W, Wood II, Campbell’s operative orthopaedics. Mosby,
New York 10 th edition; 2003.
6. A.K. Jain, Treatment of tuberculosis of the spine with neurologic
complications, Clin Orthop 398 (2002), 75–84.
7. S.K. Gupta, S. Mohindra, B.S. Sharma, R. Gupta, R. Chhabra and
K.K. Mukherjee et al., Tuberculosis of the craniovertebral junction:
is surgery necessary, Neurosurgery 58 (2006), 1144–1150.
8. M. Chadha, A. Agarwal and A. Pal Singh, Craniovertebral
tuberculosis. A retrospective review of 13 cases managed
conservatively, Spine 32 (2007), 1629–1634.
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