Pathogenesis and Staging of Craniovertebral Tuberculosis: Radiographic Evaluation, Classification, and Natural History.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To radiographically evaluate Craniovertebral junction (CVJ) tuberculosis infection pathogenesis and to propose a modification to the Lifeso classification. METHODS: A cohort of patients with radiologically or microbiologically identified CVJ tuberculosis treated at a single tertiary referral center in a TB endemic area was queried for characteristics about clinical presentation, treatment, and radiographic evidence of bone destruction and abscess formation were included. Disease was classified according to the Lifeso grading system and bony lesions were classified as either type 1 (preservation of underlying structure) or type 2 (damage of underlying structure). RESULTS: 52 patients were identified (mean age 28.5 ± 13.4yr, 48% male; 14% with a prior history of tuberculosis). All presented with neck pain at presentation, 29% with rotatory pain, and 37% with myelopathy. Comparison by Lifeso type showed Lifeso III lesions had longer symptom durations (P = .03) and more commonly had periarticular or predental abscess formation (P < .05), spinal cord compression (P < .01), and more commonly involved the C2 body and atlanto-dental joint. Underlying bony destruction was more common for lesions of the lateral atlantoaxial joints and atlanto-dental joints in Lifeso III cases than in either Lifeso I or II (all P < .05). CONCLUSIONS: The radiologic findings of the present series suggest CVJ TB infection may originate in the periarticular fascia with subsequent invasion into the adjacent atlanto-dental and lateral atlantoaxial joints in later disease. To reflect this proposed etiology, we present a modified Lifeso classification to describe the radiologic pathogenesis of CVJ TB.

Application of the modified lifeso radiographic staging system to the management and outcomes for craniocervical tuberculosis.

OBJECTIVE: To describe a management algorithm for cervicovertebral junction (CVJ) TB based upon disease severity and neurological status at presentation. METHODS: Retrospective cohort study of 52 patients treated for microbiologically or clinically-diagnosed CVJ TB at a tertiary referral center in a TB endemic area were identified. Data were gathered about presenting symptoms, baseline neurological status, management strategy, and management outcomes. Patients were categorized by a modified Lifeso Stage. RESULTS: Fifty-two patients were included (Mean age 28.5 ± 13.4 yr, 48% male): 18 Lifeso Stage I, 15 Stage II, and 19 Stage III. All presented with pain, 19 (37%) with neurological symptoms, and 5 with inability to ambulate. Stage II and III patients were more commonly myelopathic at presentation (p < 0.01) than Stage I patients. Only Stage II/III lesions required traction or surgical intervention; Stage III lesions more commonly required surgery than Stage II lesions (100% vs. 73%; p = 0.03). Among surgically-treated Stage II and III lesions, Stage III lesions had longer symptom prodromes (5.1 ± 2.2 vs. 3.3 ± 1.4mo; p = 0.03), more commonly had lateral mass collapse at presentation (58 vs. 9%; p = 0.02), and more commonly required occipitocervical fusion (68 vs. 9%; p < 0.01). CONCLUSION: Based upon these data, Stage I lesions may be treated conservatively, unless presenting with a neurological deficit. Conversely, Stage III lesions require open reduction and instrumentation due to irrevocable underlying bony damage. Reducible Stage II lesions with absent or mild neurological symptoms can be treated conservatively, but irreducible lesions and those with concomitant neurological deficits merit surgery.

Extensive cervicothoracic posterior arch defects from C1 to T6 leading to myelopathy due to thoracic kyphosis in an adolescent boy.

PURPOSE: Limited dorsal myeloschisis, a form of cervical spinal dysraphism, is a rare anomaly and is typically associated with spinal cord tethering. The objective is to illustrate a rare dysraphic anomaly in the cervicothoracic spine causing myelopathy, not due to tethering but secondary to progressive kyphosis. To our knowledge, such an anomaly has not been described in the literature. STUDY DESIGN: Case report METHODS: A 16-year-old boy presented with lower extremity spastic paraparesis due to progressive cervicothoracic deformity. The imaging studies revealed extensive posterior arch defects from C1 to T6. The cervical spinal cord and meninges had herniated out of the spinal canal in the hyperlordotic cervical spine, and the thoracic spinal cord was stretched and compressed over the T4/5 kyphotic apex. Free-floating spinous processes were found compressing the cord at the T4-5 level. Tethering was not detected. RESULTS: The patient underwent a posterior vertebral column resection at T5 and excision of the free-floating spinous processes. The patient made a complete neurological recovery. At 8 year follow-up, he was asymptomatic and his deformity was stable. CONCLUSION: We present a rare congenital cervical dystrophic anomaly causing myelopathy secondary to progressive kyphosis. We speculate that this anomaly was due to the sclerotomal cells' failure to migrate dorsally to the neural tube and fuse in the midline.

Anterior transoral atlantoaxial release and posterior instrumented fusion for irreducible congenital basilar invagination.

PURPOSE: Recently, it has been demonstrated that anterior release of tight structures via a transoral approach can assist posterior distraction-reduction technique in restoring the cranio-cervical anatomy in irreducible atlantoaxial dislocations. Our aim was to evaluate the radiological and clinical outcome of anterior release and posterior instrumentation for irreducible congenital basilar invagination. METHODS: A consecutive series of 15 patients (2007-2009) with irreducible congenital basilar invagination were treated with anterior release using transoral approach. A retrospective chart review was performed. All patients presented with myelopathy. Dislocation was treated as irreducible if acceptable reduction was not achieved with traction under general anesthesia and neuromuscular paralysis. The anterior release comprised of transverse sectioning the longus colli and capitis, C1-C2 joint capsular release and intra-articular adhesiolysis with or without anterior C1 arch excision. Cantilever mechanism using posterior instrumentation was used to correct any residual malalignment. RESULTS: Mean age was 21.4 (10-50) years. Average duration of follow-up was 28 (24-40) months. The average preoperative JOA score was 11.4 (8-16), which improved to 15.4 (10-18) after surgery. Anatomical reduction was achieved in thirteen patients. Fusion was documented in all patients. Complications included persistent nasal phonation in one, and superficial wound dehiscence in one. CONCLUSION: We believe that a significant number of irreducible dislocations can be anatomically reduced with this procedure thus avoiding odontoid excision. Encouraging results from this short series have given us a new perspective in dealing with these challenging problems.

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.

Reconstruction of large iliac crest defects after graft harvest using autogenous rib graft: a prospective controlled study.

STUDY DESIGN: Prospective controlled study analyzing the donor site morbidity after reconstruction of full thickness iliac crest defects, using autologous rib grafts. OBJECTIVE: To compare the pain and cosmetic outcomes of patients with iliac crest reconstruction with those who have had no reconstruction of the iliac crest. SUMMARY OF BACKGROUND DATA: Chronic donor site pain and poor cosmesis have been the major deterrents in using iliac crest for long-segment spinal reconstructions. Iliac crest reconstruction with rib has been reported but most studies are uncontrolled and retrospective. MATERIALS: Patients with iliac defects <25 mm after graft harvest were excluded. Twenty patients were reconstructed using autogenous rib graft harvested during the anterolateral approach to spine. Rib graft of the appropriate contour was impacted into the notches created in the iliac crest defect. The control group comprised 16 patients without reconstruction of the iliac crest. The pain, cosmesis, and functional disability were assessed on the basis of visual analog scores and a predesigned questionnaire. Judet iliac views were used to assess the incorporation of the rib graft. Evaluation was performed at 1.5, 3, 6, and 12 months, respectively. RESULTS: Intensity and incidence of pain was significantly lower in the reconstructed group. Cosmetic outcome was also significantly better in this group. Patients in control group had significant complications related to the tenting of skin over the defect such as bursitis and skin necrosis. Radiologic incorporation was documented in 95% of patients with 1 patient having resorption of the rib graft. CONCLUSION: Rib graft reconstruction provides a cheap and effective alternative for iliac crest reconstruction. Patients undergoing thoracotomy or thoraco-phrenico-lumbotomy for spinal reconstruction, the unutilized rib graft should be used to reconstruct the iliac defect. Reduced donor site morbidity and better cosmesis are the major benefits of reconstruction.

Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases.

This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.