Management of CVJ tuberculosis: the changing paradigm
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ORIGINAL ARTICLE - INFECTION
Management of CVJ tuberculosis: the changing paradigm Sandeep Mohindra 1
&
Manjul Tripathi 1,2 & Aman Batish 1 & Satyawati Mohindra 3 & Shaurya Mahendru 4
Received: 1 May 2020 / Accepted: 30 July 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Abstract Background The literature seems fractured for the management of craniovertebral junction (CVJ)-tuberculosis (TB). Presently, non-surgical management has been in vogue for neurologically intact patients. On the contrary, severely disabled cases of CVJTB continue to attract discussion, tilted towards surgical intervention. We present our experience with the non-surgical management of CVJ-TB tailored to their neurological status. Methods Authors managed 37 cases (2004–2019; age 1–57 years, mean 36 years) of CVJ-TB, of which eighteen (18/37, 48.6%) were severely disabled (Nurick grade ≥ 3) with a mean follow-up of 84 months (48–192 months). Irrespective of the clinical status and radiological findings, all patients were managed on medical management only. Needle aspiration established pathology in 23 (62.2%) cases, while 9 (24.3%) cases required drainage of an abscess. All patients received 18 months of antitubercular therapy (ATT). In patients with Nurick grade ≥ 3 and documented AAD, we applied halo vest for 12 months to achieve cervical immobilization. Only hard cervical collar for 3 months was prescribed in patients with no documented AAD. Results All minimally disabled cases (Nurick grade ≤ 2, n = 19) responded favorably (n = 18) to ATT, except for an infant, who succumbed to irreversible hypoxic brain damage due to the obstructed aero-digestive gateway. Of the severely disabled cases (Nurick grade ≥ 3, n = 18), 16 cases had favorable outcomes with only external orthosis (12) and 18-month ATT. One patient succumbed to multiple cerebral infarcts, while one required realignment surgery at CVJ due to fusion in malaligned position. Conclusion The authors conclude that the disability grading of CVJ-TB is pertinent only for assessing the functional disability of patients at presentation, with minimal relevance in deciding its management strategy. Irrespective of neurological disability, almost all patients respond favorably to external immobilization and ATT. Keywords Anti-tubercular therapy . Atlantoaxial dislocation . Craniovertebral junction . External immobilization . Fixation . Non-surgical
Introduction A bizarre range of movements is possible at the craniovertebral junction (CVJ), on account of its unique bony and ligamentous This article is part of the Topical Collection on Infection * Sandeep Mohindra [email protected] 1
Present address: Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
2
National Institute for Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
3
Department of Otolaryngology-Head Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4
Dayanand Medical
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