Odontoid process pathologic fracture in spinal tuberculosis

Atlantoaxial dislocation with associated type II odontoid fracture in adolescent with cervical spondylitis tuberculosis: A case report

INTRODUCTION AND IMPORTANCE

Atlantoaxial dislocation is a loss of joint stability between the C1 (atlas) and C2 (axis) spine and could be associated with type II odontoid fracture. In a few previous studies, atlantoaxial dislocation with odontoid fracture has been reported to be the complication of upper cervical spondylitis tuberculosis (TB).

CASE PRESENTATION

A 14-year-old girl came with sudden neck pain and difficulty moving her head that has worsened in the last 2 days. There was no motoric weakness in her limbs. However, tingling in both hands and feet was felt. X-ray examination showed atlantoaxial dislocation with odontoid fracture. Traction and immobilization using Garden-Well Tongs obtained the reduction of the atlantoaxial dislocation. Transarticular atlantoaxial fixation using cerclage wire and cannulated screw with an autologous graft from the iliac wing was performed through the posterior approach. A postoperative X-ray showed stable transarticular fixation with excellent screw placement.

CLINICAL DISCUSSION

The application of Garden-Well tongs as a treatment for cervical spine injury has been documented in the previous study with a low rate of complications such as pin loosening, the asymmetrical position of the pin, and superficial infection. The reduction attempt did not significantly improve Atlantoaxial dislocation (ADI). Thus surgical treatment of atlantoaxial fixation using cannulated screw and c-wire with the application of an autologous bone graft is performed.

CONCLUSION

Atlantoaxial dislocation with an odontoid fracture in cervical spondylitis TB is a rare spinal injury. The use of traction with surgical fixation is needed to reduce and immobilize atlantoaxial dislocation and odontoid fracture.

Odontoid fracture complicating ankylosing spondylitis presenting with cervical canal stenosis and quadriparesis: A case report with 5-year follow-up and review of the literature

Introduction and importance

Spinal fractures, especially cervical fractures, are more common in patients with ankylosing spondylitis in comparison with unaffected patients. However, odontoid fractures are relatively rare in these patients. Also, neurological symptoms are not common in odontoid fractures due to the larger diameter of the spinal canal at this level.

Case presentation

Here, we presented a 41 year-old man known case of ankylosing spondylitis who develop odontoid fracture and severe cervical stenosis after falling trauma. Quadriparesis and positive Hoffman sign as well as significant thoracolumbar kyphosis were diagnosed in further investigation. Laminectomy and posterior fixation were executed primary and pedicular subtraction osteotomy was performed two years later to manage the kyphosis and sagittal imbalance. On the follow-up period of five years the patient was fully functional.

Clinical discussion

There are a few cases of odontoid fractures complicating ankylosing spondylitis in the literature. Neurological symptoms are relatively uncommon in odontoid fractures; however, cases with AS can present with neck pain, weakness, and hyperreflexia when having unstable fractures.

Conclusion

Although there is not any gold standard for the treatment of the odontoid fracture in AS, surgical intervention is preferred.

•

The occurrence of the odontoid fracture is rare in patients with AS.

•

Neurological deficits are more common in posterior subluxation of the odontoid process compared to anterior subluxation.

•

The optimal treatment approach for odontoid fracture in cases with AS is unknown; however, surgical management is preferred.

Cervical tuberculosis associated with cervical pain and neurologic deficit: a case report and literature review

BACKGROUND CONTEXT

Isolated tuberculosis (TB) of posterior elements of the cervical spine is extremely rare. Only few cases are reported in literature, but none describe isolated spinous process and laminae involvement without TB in any other part of the body.

PURPOSE

To report a case of isolated TB involvement of the spinous process and right laminae of C2 combined with atlantoaxial luxation.

STUDY DESIGN

A case report of isolated spinous process and right laminae TB of C2 combined with atlantoaxial luxation.

PATIENT SAMPLE

A 20-year-old male farmer complained about a 2-month history of aggravating neck pain, a 1-month history of a slowly growing lump at the back of the neck, and numbness and weakness of the right arm that had gradually progressed to involve all the limbs for 2 weeks before presentation.

OUTCOME MEASURES

X-ray and computed tomography of cervical spine and Frankel grading of neural function are included to evaluate the therapeutic efficiency.

METHODS

Computed tomography scans showed flake-like bony destruction located in the spinous process and at the right laminae of C2. Magnetic resonance imaging (MRI) showed a large swelling posterior to C2 and atlantoaxial luxation-induced distinct compression of the spinal cord. The patient underwent 2 weeks of skull traction and quadruple anti-TB treatment before surgery.

RESULTS

The patient underwent surgical treatment that included posterior radical debridement, decompression, internal fixation with a screw-rod system from C1 to C4, autologous bone grafting, and fusion. The patient gained normal neural function and returned to work 1 year after surgery.

CONCLUSIONS

Tuberculosis of the posterior elements of the upper cervical spine is very rare and potentially dangerous. Computed tomography and MRI are very useful and important for correct diagnosis. Prompt medical and surgical treatment may avert potential catastrophic event in these cases.

Structural odontoid lesions in craniovertebral tuberculosis: a review of 15 cases

STUDY DESIGN

A retrospective chart review.

OBJECTIVE

To describe the presentation and the rationale for management of pathological odontoid fracture and complete odontoid destruction in craniovertebral junction tuberculosis (CVJ TB).

SUMMARY OF BACKGROUND DATA

Presentation of CVJ TB ranges from minor osteomyelitic changes to severe structural damage leading to instability. Structural damage to the odontoid process is poorly characterized in the literature. Inadequate knowledge about the radiological presentations has led to controversy in the management of CVJ TB.

METHODS

The cohort consisted of 15 consecutive patients with CVJ TB, with structural damage to the odontoid process in the form of either odontoid fracture (n = 7) or complete odontoid destruction (n = 8). These patients presented with pain, neurological deficit, torticollis, dysphagia, or respiratory distress. The cause of neurological deficit was craniocervical instability characterized as anterioposterior (n = 15), rotatory (n = 4), and vertical (n = 6). Displacement reduced anatomically in 13 patients. Apart from antibiotics, all patients were treated surgically by either C1-C2 fusion (n = 7) or occipitocervical fusion (n = 8).

RESULTS

Average duration of follow-up was 3.6 years (range, 1.5-8 yr). All patients achieved normal neurological status. No complications were noted, except for 1 case, who had a loss of reduction after the use of Hartshill rectangle for occipitocervical fusion. Postoperative computed tomographic scan showed nonunion of odontoid fracture in 2 of 4 patients. No patient of odontoid destruction, of the 5 investigated, revealed structural reformation of the dens.

CONCLUSION

CVJ TB can severely damage the odontoid process, resulting in atlantoaxial dislocation. In these patients, surgery restores and maintains the craniocervical alignment and has a predictable outcome compared with conservative therapy. Pathological odontoid fractures have the potential to go into nonunion. Odontoid process once destroyed completely is rarely restored after antibiotic therapy.