title: The results of nonoperative treatment of craniovertebral junction tuberculosis: a review of twenty-six cases.
abstract: BACKGROUND
  There is scarce information on craniovertebral junction tuberculosis even in developing countries. The pendulum of treatment in craniovertebral junction tuberculosis has periodically vacillated between nonoperative management and radical surgery.
  
  
  METHODS
  We performed a retrospective review of prospectively collected clinical and radiographic data on twenty-six consecutive patients with craniovertebral junction tuberculosis who were treated nonoperatively in our institution. The patients who had weakness of the limbs, pyramidal signs, or evidence of atlantoaxial dislocation and/or basilar invagination were immediately managed with immobilization with Crutchfield tongs traction (Group A), followed by halo-vest application. Patients without a neurological deficit, pyramidal signs, or atlantoaxial dislocation or basilar invagination were treated with cervical immobilization with early application of a halo vest (Group B).
  
  
  RESULTS
  The common presenting features were neck pain, restriction of neck movement, and spastic weakness of limbs. A retropharyngeal purulent fluid collection and osseous involvement of the dens and lateral mass of the atlas were the common radiographic findings. Twelve patients were partially or completely dependent on others for activities of daily living, and marked ligamentous and bone destruction with displacement at the atlantoaxial level was seen in eight patients at the time of presentation. The twenty patients in group A had cervical traction for a mean of 5.9 weeks, and a halo vest was applied for a mean of 6.9 months with antitubercular therapy for eighteen months. The mean follow-up period was 25.2 months (range, eighteen to forty-two months). All of the patients were independent in activities of daily living at the time of the last follow-up.
  
  
  CONCLUSIONS
  In the Indian subcontinent, the disease process of craniovertebral junction tuberculosis is usually quite advanced at the time of presentation. On the basis of our study, patients with craniovertebral junction tuberculosis can be managed successfully with nonoperative treatment even with advanced involvement of bone or soft tissues at this spinal level.
  
  
  METHODS
  Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India. mamc_309@yahoo.co.in
authors.forename: Sumit
authors.initials: S
authors.lastname: Arora
authors.forename: Dhananjaya
authors.initials: D
authors.lastname: Sabat
authors.forename: Lalit
authors.initials: L
authors.lastname: Maini
authors.forename: Sumit
authors.initials: S
authors.lastname: Sural
authors.forename: Vinod
authors.initials: V
authors.lastname: Kumar
authors.forename: V K
authors.initials: VK
authors.lastname: Gautam
authors.forename: Ajay
authors.initials: A
authors.lastname: Gupta
authors.forename: Anil
authors.initials: A
authors.lastname: Dhal
mesh_terms: D000293:Adolescent; D000328:Adult; D001269:Atlanto-Occipital Joint / Q000000981:diagnostic imaging / Q000473:pathology; D002648:Child; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000209:etiology; D014057:Tomography, X-Ray Computed; D014399:Tuberculosis, Spinal / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000628:therapy*; D055815:Young Adult