title: Surgical management and outcome of tuberculous atlantoaxial dislocation: a 15-year experience.
abstract: OBJECTIVE
  Tuberculous atlantoaxial dislocation is a rare disease entity. However, tuberculosis continues to be endemic in developing countries. Its earliest clinical presentation may be nonspecific, and delay in diagnosis may lead to irreversible neurological deficit. The management of tuberculous atlantoaxial dislocation includes ventral cervicomedullary decompression, occipitocervical arthrodesis, and administration of antituberculous medications.
  
  
  METHODS
  Eighteen patients with tuberculous atlantoaxial dislocation who presented with neck pain and/or occipital headache, restriction of neck movement, difficulty swallowing, and signs of myelopathy were studied. Four patients had evidence of associated pulmonary tuberculosis. Plain x-rays of the cervical spine, computed tomographic scans, and magnetic resonance images were obtained in all patients for diagnosis and to assess the degree of dislocation and cervicomedullary compression. Simultaneous anterior neural decompression, via a transcervical retropharyngeal approach, and posterior arthrodesis were performed on all patients while they remained under anesthesia. Antituberculous chemotherapy was continued for 18 months.
  
  
  RESULTS
  Histopathological analysis of excised tissue was consistent with tuberculosis in all patients. However, Ziehl-Neelsen staining for acid-fast bacilli was positive in two cases, and culture for Mycobacterium tuberculosis was negative in all patients. Patients with severe myelopathy experienced marked improvement. One patient died of fulminant resistant tuberculous meningitis.
  
  
  CONCLUSIONS
  The transcervical retropharyngeal approach to the craniovertebral junction provides direct access to the lesion and avoids the potential bacterial contamination of the oral and pharyngeal cavity. It also prevents the development of persistent fistulae. Posterior stabilization should be performed directly after anterior neural decompression, while the patient remains under anesthesia, to prevent neurological deterioration before subsequent posterior fixation. This technique also is helpful for early mobilization of patients. The aim of surgical treatment should be to obtain biopsy tissue and to perform radical excision of epidural granulation tissue/abscess and infected bone using microsurgical technique. Antituberculous medication must be continued for 18 months with four drug regimens, and continuous monitoring of drug toxicity should be performed throughout the course of treatment.
authors.affiliation: Department of Neurosurgery, G.B. Pant Hospital, Maulana Azad Medical College, University of Delhi, New Delhi, India. ssinha@vsnl.net
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Sinha
authors.forename: Anil Kumar
authors.initials: AK
authors.lastname: Singh
authors.forename: Vikas
authors.initials: V
authors.lastname: Gupta
authors.forename: Daljit
authors.initials: D
authors.lastname: Singh
authors.forename: Masakazu
authors.initials: M
authors.lastname: Takayasu
authors.forename: Jun
authors.initials: J
authors.lastname: Yoshida
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000008:administration & dosage; D001268:Atlanto-Axial Joint / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D019299:Decompression, Surgical; D003906:Developing Countries; D005260:Female; D020773:Headache Disorders / Q000209:etiology; D006801:Humans; D007194:India; D004204:Joint Dislocations / Q000175:diagnosis / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000209:etiology; D009460:Neurologic Examination; D013117:Spinal Cord Compression / Q000175:diagnosis / Q000601:surgery; D013123:Spinal Fusion; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014399:Tuberculosis, Spinal / Q000175:diagnosis / Q000601:surgery*
chemical_list: D000995:Antitubercular Agents