title: Management of craniovertebral junction tuberculosis.
abstract: BACKGROUND
  Tuberculosis of the craniovertebral junction (CVJ) is extremely rare. However, recent evidence suggests that the incidence of this condition may be increasing. The diagnosis is often difficult despite advances in imaging using magnetic resonance imaging. The transoral approach to the anterior CVJ provides excellent access to this region, has low mortality and morbidity, and enables biopsy of lesions and decompression of the neuraxis. Management of associated atlantoaxial instability, with regard to timing and method of stabilization, is controversial.
  
  
  METHODS
  We report 24 cases of CVJ tuberculosis. Prominent manifestations of the disease included neck pain and stiffness, swelling of the retropharyngeal soft tissues, quadriparesis, osteolytic erosions, and atlantoaxial subluxation. Seven patients had acute presentation. All patients received antituberculous drug treatment for 18 months. Four patients were managed conservatively, 5 underwent only transoral biopsy, 9 patients underwent transoral decompression and posterior fusion, and 6 patients underwent only posterior fusion.
  
  
  RESULTS
  Histopathologic analysis of biopsy material revealed abscess only in 5 cases, granulation tissue only in 6, abscess with granulation tissue in 4, granulation tissue with chronic osteomyelitis in 5, and chronic inflammation in 2. All patients improved, with mean improvement in Nurick grading of 1.71. Even patients with spinal cord signal intensity changes on magnetic resonance images showed improvement.
  
  
  CONCLUSIONS
  Although CVJ tuberculosis is a rare disease, the outcome of treatment is good. Antituberculous drug therapy remains the mainstay of treatment after confirming the diagnosis. The surgical management options include transoral decompression with or without posterior fusion, depending upon the presence and persistence of atlantoaxial instability.
authors.affiliation: Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore 560029, India.
authors.forename: Dhaval
authors.initials: D
authors.lastname: Shukla
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mongia
authors.forename: B Indira
authors.initials: BI
authors.lastname: Devi
authors.forename: B A
authors.initials: BA
authors.lastname: Chandramouli
authors.forename: Bhavani Shanker
authors.initials: BS
authors.lastname: Das
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000601:surgery; D001269:Atlanto-Occipital Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D001706:Biopsy; D002648:Child; D019299:Decompression, Surgical; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000175:diagnosis / Q000601:surgery; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D013123:Spinal Fusion; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014399:Tuberculosis, Spinal / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery*
chemical_list: D000995:Antitubercular Agents