- Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia
Shaun Previn Appaduray
Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia
DOI:10.4103/2152-7806.166801Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Appaduray SP, Lo P. Nonoperative management of craniovertebral junction and cutaneous tuberculosis. Surg Neurol Int 06-Oct-2015;6:157
How to cite this URL: Appaduray SP, Lo P. Nonoperative management of craniovertebral junction and cutaneous tuberculosis. Surg Neurol Int 06-Oct-2015;6:157. Available from: http://surgicalneurologyint.com/surgicalint_articles/nonoperative-management-of-craniovertebral-junction-and/
Background:Craniovertebral junction (CVJ) and cutaneous tuberculosis (TB) are both rare, each occurring in 0.3-1.0% of patients. To our knowledge, there are no existing cases reporting these manifestations of TB simultaneously. We report a case of TB involving the left CVJ as well as the skin, and discuss our management while providing a review of the literature.
Case Description:An adult patient was presented with progressive nocturnal neck pain associated with the development of several skin lesions. Investigations revealed multiple osseous lesions including the left CVJ. Biopsy of the CVJ lesion was unamenable due to proximity of the vertebral artery; therefore, the patient underwent biopsy of the other sites. Histological examination demonstrated features consistent with TB infection and the patient commenced 12 months of standard anti-TB therapy with cervical spine immobilization. At 2-month review, the patient was well with a near-complete resolution of neck pain and cutaneous lesions. Repeat imaging at 6 months follow-up demonstrated a stable C1 lesion with no evidence of instability.
Conclusion:CVJ TB may be treated solely with anti-TB therapy and immobilization to good effect if there is no gross instability or neurological deficit. Similarly, cutaneous TB responds well to standard anti- TB therapy. Our experience suggests that co-existing tuberculous lesions in the CVJ and skin can be simultaneously managed with standard therapy without significant alterations to treatment regimes or prognosis.
Keywords: Craniovertebral junction, cutaneous tuberculosis, spinal, tuberculosis
Craniovertebral junction (CVJ) tuberculosis (TB) is, especially uncommon and accounts for 0.3–1.0% of spinal TB, as illustrated in a review by Gupta et al. which found only 51 cases of CVJ TB from 1978 to 2004.[
A 31-year-old male of Indian extraction was presented with a 2-month history of progressive nocturnal neck pain and 8 months of multiple skin lesions, but no neurological deficit. He had visited India 12 months previously and had received routine bacillus Calmette–Guérin vaccinations before immigrating to Australia at 21 years of age.
Skin examination revealed; a 4.5 cm solid mass overlying the right deltoid, a 1.5 cm mobile mass on the left chin, and a 1.5 cm mobile mass on the dorsum of the left foot. Although he had a positive QuantiFERON Gold assay (titer 11.68 IU/ml), his chest X-ray was normal. Cervical computerized tomography (CT) showed destructive bony changes at the left atlanto-occipital junction (between the left occipital condyle and superior articular facet of the left lateral mass of C1); there was a soft tissue mass between these plus left-sided lateral subluxation of C1–C2 [Figures
(a) Axial and (b) Sagittal cervical spine computerized tomography with bony changes as described in
He was immobilized in a halo vest. A CT of the chest, abdomen, and pelvis showed lytic and sclerotic bony lesions in the ribs, pelvis, sacrum, and right acromion [
Craniovertebral junction tuberculosis
CVJ TB predominantly affects the anterior structures of the vertebrae. The infection destroys bony and ligamentous structures, resulting in neuraxial compression and instability.[
Treatment options for CVJ TB are controversial due to the absence of well-established guidelines.[
Cutaneous TB is reported in <1% of cases.[
The site of the lesion was impacted upon our management decisions. Biopsy was unamenable due to the risk of damaging the adjacent vertebral artery and its associated sequelae. The cutaneous lesions in this case were multifocal, solid subcutaneous nodules with no evidence of exudation. This was consistent with the typical features of lupus vulgaris. As there was no overt instability or compression, we elected for biopsy of the other osseous sites as well as the cutaneous lesions and commenced ATT for treatment. These biopsies indeed demonstrated PCR findings consistent with TB and eventually produced a positive culture.
The long-term outcome of nonoperative management of both CVJ and cutaneous TB is excellent.[
In summary, we present a manifestation of extrapulmonary TB presenting with CVJ and cutaneous lesions, both of which are rare occurrences. We concur with the findings in the literature that CVJ TB can be managed nonoperatively, particularly in the absence of cervical instability or neurological deficit.[
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Conflicts of interest
There are no conflicts of interest.
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