title: Craniovertebral junction instability as an extension of cocaine-induced midline destructive lesions: case report.
abstract: With the increasingly widespread illicit use of cocaine, a broad spectrum of clinical pathologies related to this form of drug abuse is emerging. The most frequently used method of administration of powdered cocaine is intranasal inhalation, or "snorting." Consequently, adverse effects of cocaine on the nasal tract are common. Habitual nasal insufflations of cocaine can cause mucosal lesions. If cocaine use becomes chronic and compulsive, progressive damage of the mucosa and perichondrium leads to ischemic necrosis of the septal cartilage and perforation of the nasal septum. Occasionally, cocaine-induced lesions cause extensive destruction of the osteocartilaginous structures of the nose, sinuses, and palate and can mimic other diseases such as tumors, infections, and immunological diseases. In the literature currently available, involvement of the craniovertebral junction in the cocaine-induced midline destructive lesions (CIMDLs) has never been reported. The present case concerns a 44-year-old man who presented with long-standing symptoms including nasal obstruction, epistaxis, dysphagia, nasal reflux, and severe neck pain. A diagnosis of CIMDL was made in light of the patient's history and the findings on physical and endoscopic examinations, imaging studies, and laboratory testing. Involvement of the craniovertebral junction in the destructive process was evident. For neurosurgical treatment, the authors considered the high grade of atlantoaxial instability, the poorly understood cocaine-induced lesions of the spine and their potential evolution overtime, as well as cocaine abusers' poor compliance. The patient underwent posterior craniovertebral fixation. Understanding, classifying, and treating cocaine-induced lesions involving the craniovertebral junction are a challenge.
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Carlo
authors.initials: C
authors.lastname: Brembilla
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Luigi Andrea
authors.initials: LA
authors.lastname: Lanterna
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Andrea
authors.initials: A
authors.lastname: Risso
authors.affiliation: Infectious Diseases.
authors.forename: Enrico
authors.initials: E
authors.lastname: Bombana
authors.affiliation: Anesthesia and Intensive Care.
authors.forename: Paolo
authors.initials: P
authors.lastname: Gritti
authors.affiliation: Pathology, and.
authors.forename: Rosangela
authors.initials: R
authors.lastname: Trezzi
authors.affiliation: Neuroradiology, Pope John XXIII Hospital, Bergamo, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Bonaldi
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Francesco
authors.initials: F
authors.lastname: Biroli
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000473:pathology* / Q000503:physiopathology / Q000601:surgery; D003042:Cocaine / Q000009:adverse effects*; D019970:Cocaine-Related Disorders / Q000175:diagnosis / Q000473:pathology*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D064847:Multimodal Imaging; D009300:Nasal Septum / Q000187:drug effects / Q000473:pathology*; D013122:Spinal Diseases / Q000139:chemically induced* / Q000473:pathology*; D015898:Tomography Scanners, X-Ray Computed
chemical_list: D003042:Cocaine
keywords: CIMDL = cocaine-induced midline destructive lesions; GPA = granulomatosis with polyangiitis; HNE = human neutrophil elastase; VAS = visual analog scale; c-ANCA = cytoplasmic antineutrophil cytoplasmic antibody; cervical; cocaine-induced midline destructive lesions; craniovertebral junction fixation; craniovertebral junction instability; p-ANCA= perinuclear ANCA