Craniocervical junction tuberculosis: A rare but dangerous disease

BACKGROUND Mycobacterium tuberculosis of the cervical spine is a rare but d angerous manifestation of extra-pulmonary tuberculosis. The clinical pictur e ranges from early, nonspecific, insidious symptoms to severe neurological complications and death, attributed to craniocervical junction instability and cervicomedullary compression. The different lines of management includ e antituberculous medication with traction and external fixation or adjunct ive surgery (debridement and stabilization) in patients with severe or pers istent neurological complications and/or vertebral instability. METHODS We describe two patients with advanced craniocervical junction tube rculosis. The early clinical picture was non-specific in Case 1 and obscure d by psychiatric illness in Case 2. The detailed clinical and radiological findings, and the management, will be described. Involvement of the occipit al condyles and foramen magnum, which has not been reported previously, wil l be demonstrated. RESULTS Both cases underwent transoral biopsy, aspiration, and debridement of retropharyngeal abscess (granuloma). Histological and tissue culture stu dies proved the abscesses were tuberculous and anti-tuberculous medications were started. Case 1 showed complete resolution of the clinical and radiol ogical findings. Case 2 developed cardiorespiratory arrest while in a halo jacket. He was resuscitated but remained quadriplegic and semiconscious; he developed nosocomial gram negative pneumonia. He was referred back to his local hospital where he died 1 year later. CONCLUSIONS Tuberculosis is an infrequent but notable cause of cervicomedul lary compression. It should be suspected in patients with infective spondyl itis who are immunocompromised or reside in an area highly endemic for tube rculosis. Management strategies include antituberculosis medication, transo ral biopsy and drainage of the abscess, traction and external fixation, pos terior decompression, and internal fixation, according to the clinical and radiological findings. (C) 1999 by Elsevier Science Inc.