Calcium pyrophosphate dihydrate crystal deposition disease and MRSA septic arthritis of the atlantoaxial joint in a patient with Tourette syndrome.

A 45-year-old male patient with Tourette syndrome presented to the emergency department with worsening neck pain and stiffness of 1-week duration. Associated symptoms included headache, hoarse voice, trismus and odynophagia. The patient was haemodynamically stable without fevers or leucocytosis. He exhibited cervical spinal and paraspinal tenderness with very limited range of motion. Erythrocyte sedimentation rate and C reactive protein were elevated, and blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Lumbar puncture was unremarkable. CT and MRI of the neck showed calcification of the longus colli, fluid and capsular distention of C1-C2 joints, enhancement of the joint capsule and retropharyngeal oedema suggestive of septic arthritis. Fluid was aspirated from C1 to C2 joint by interventional radiology and showed calcium pyrophosphate crystals and heavy MRSA colonisation, consistent with both pseudogout and septic arthritis of the cervical vertebrae. The patient was started on a 6-week course of daptomycin and showed gradual improvements in neck pain and mobility.

Atlanto-axial infection after acupuncture.

A 67-year-old man presented with neck cellulitis following acupuncture for cervical spondylosis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus Increased neck pain and bacteraemia prompted MRI, which showed atlanto-axial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlanto-axial joint, thus making direct extension of infection unlikely. It is more likely that haematogenous spread of infection resulted in seeding in the atlanto-axial joint, with the proximity of the arthritis and acupuncture site being coincidental. Acupuncture is a treatment option for some indolent pain conditions. As such, acupuncture services are likely to be more frequently utilised. A history of acupuncture is rarely requested by the admitting doctor and seldom offered voluntarily by the patient, especially where the site of infection due to haematogenous spread is distant from the needling location. Awareness of infectious complications following acupuncture can reduce morbidity through early intervention.

Acute neck pain caused by septic arthritis of the lateral atlantoaxial joint with subluxation: a case report.

INTRODUCTION: Crystal-induced arthritis of the lateral atlantoaxial joint may be intimately involved in acute neck pain in the elderly. Patients typically have a good prognosis, and symptoms usually subside within a few weeks. On the other hand, septic arthritis of the lateral atlantoaxial joint requires early diagnosis and antibiotic treatment. Diagnostic delay is a risk factor for an unfavorable outcome of vertebral osteomyelitis. Even though septic arthritis of the lateral atlantoaxial joint is a very rare clinical entity, it is important to differentiate septic arthritis from crystal-induced arthritis. CASE PRESENTATION: A 53-year-old Japanese man presented with neck pain, stiffness, and loss of power of his left upper extremity which started 20 days before his visit to our hospital. A physical examination revealed a limited range of motion of his neck, with rotation being especially very restricted. Atlantoaxial subluxation was seen on plain radiography of his cervical spine. During puncture of the lateral atlantoaxial joint, clear yellow fluid was collected. Cultures later grew methicillin-sensitive Staphylococcus aureus. He was diagnosed with septic arthritis of the lateral atlantoaxial joint with atlantoaxial subluxation. After diagnosis, intravenous administration of antibiotics was begun. The atlantoaxial region was stabilized with the Brooks procedure. Plain radiography showed complete bone union 8 months after operation. At a follow-up evaluation 7 years after initial onset, he had complete relief of neck pain, and there were no neurological abnormalities. CONCLUSIONS: A patient with septic arthritis of the lateral atlantoaxial joint with subluxation presenting with acute neck pain was successfully treated with antibiotics and fusion surgery. In patients with persistent neck pain, septic arthritis of the lateral atlantoaxial joint should be considered and further examinations performed.

Tuberculous altantoaxial subluxation: a case report with review of literature.

Involvement of upper cervical and craniovertebral junction is rare but might lead to lethal consequences if the diagnosis is delayed. We present a case of atlantoaxial joint tuberculosis, resulting in gross instability of the joint. The patient was treated with antitubercular medication combined with posterior decompression and transarticular screw fixation. Patient improved neurologically, and clinical and radiological improvements were maintained at the latest follow-up of 2 years.

Atlantoaxial rotatory fixation in a case of tubercular lymphadenitis.

Atlantoaxial fixation is a relatively rare cause of torticollis which may be easily missed in practice. Early diagnosis is important as this indicates a compromised atlantoaxial complex with the potential to cause neural damage or even death. Here, we report a case of atlantoaxial rotatory fixation in a 13 yr old male with torticollis for two years and history of defaulting treatment for tubercular lymphadenitis. In this case, the odontoid peg view revealed asymmetric distance between the odontoid and lateral mass of atlas which was confirmed with Fluoroscopy and Computed Tomography (CT) scan. Magnetic Resonance Imaging (MRI) was also done which showed hyperintensity in alar ligaments with posterior inclination of the odontoid peg along with cervical lymphadenopathy.

Nontraumatic subluxation of the atlanto-axial joint as rare form of acquired torticollis: diagnosis and clinical features of the Grisel's syndrome.

STUDY DESIGN: Case report and review of the literature. OBJECTIVE: We report a case of Grisel's syndrome with a delayed diagnosis. The patient's first presentation in our pediatric orthopedics department was 2 month after surgery (cochlea implantation) with a persistent torticollis. Radiographs revealed a subluxated atlantoaxial joint. We treated our patient with manual repositioning and calculated antibiotics, which lead to a restitutio ad integrum within a short time. SUMMARY OF BACKGROUND DATA: Grisel's syndrome is synonymous with rare nontraumatic, rotational subluxation of the atlantoaxial joint (C1-C2). All formerly reported cases showed a clear association to infection or were related to head and neck surgery. Still, there is a lack of understanding about pathogenetic features and causative agents. In 1977 Fielding proposed a classification of the atlantoaxial subluxation and stage-related therapy was recommended. METHODS: Our patient was a 11-year-old girl with a torticollis after insertion of a cochlea implant. After surgery, physiotherapy was performed because of her wryneck. As the symptoms did not improve, she was presented in our clinic. Our radiographs revealed a subluxated atlantoaxial joint. RESULTS: In general anesthesia we performed a manual repositioning and she was temporarily immobilized with a cervical collar for 2 weeks. In addition, we administered calculated antibiotics, although CRP and leukocytes were not elevated. The follow up showed a good repositioning within a short time. CONCLUSION: At least in this case, our treatment led to shorter recovery and avoidance of halo fixation. Our new therapeutic approach to patients with Grisel's syndrome might lead to a shorter recovery.

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively.

STUDY DESIGN: Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively. OBJECTIVE: To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature. SUMMARY OF BACKGROUND DATA: Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively. METHODS: A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months. RESULTS: All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases. CONCLUSIONS: We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Septic arthritis of the atlantoaxial joint: case report.

Bacterial epidural abscess formation of cervical spine was rarely seen and all these cases were associated with osteomyelitis of the odontoid process. To the author's knowledge, only 1 case of septic arthritis of the C1-C2 lateral facet joint has been reported in the English literature. A 76-year-old woman presented with progressive neck pain and stiffness in the left side of her neck with fever. Coronal computed tomography clearly demonstrated destructive change of the atlantoaxial joint. Contrast magnetic resonance imaging demonstrated infection of the atlantoaxial joint resulting in epidural abscess formation. Because of lack of neurologic deficit, we treated her with halo-fixation together with appropriate antibiotics administration. The patient was successfully treated with antibiotics and immobilization. Septic arthritis of the lateral atlantoaxial joint should be added to the differential diagnosis of severe neck pain with fever, although it is very rare clinical entity. Early analysis of computerized tomography and magnetic resonance imaging although maintaining a high suspicion for this disease is mandatory to avoid delayed diagnosis and subsequent morbidity.

Complete osteolysis of the dens with atlantoaxial luxation caused by infection with Staphylococcus aureus: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVES: To present a case of complete osteolysis of the dens and accompanying luxation of the atlantoaxial joint, on the basis of a Staphylococcus aureus infection. SUMMARY OF BACKGROUND DATA: To date, complete osteolysis of the dens followed by atlantoaxial dislocation has only been reported as a rare complication in patients with tuberculosis but not as secondary to a Staphylococcus aureus infection. METHODS: Because of emerging neurological complications in both upper extremities, we chose closed reduction and temporary Halo-fixation together with appropriate antibiotic coverage as primary treatment followed by an operative stabilization with Magerl fusion (Galli fusion combined with transarticular screw fixation of C1 and C2). RESULTS: After the operative procedure (Magerl fusion), immediate pain relief was achieved as well as almost complete resolution of neurological deficits. CONCLUSIONS: To our knowledge, this presents the first reported case of a complete destruction of the dens, as a result of a purulent bacterial infection leading to atlantoaxial luxation. Our case demonstrates that infections of the atlantoaxial region are difficult to diagnose and are seen mostly in immunocompromised patients, such as patients with diabetes. Furthermore, it proves that other infections besides tuberculosis can lead to complete osteolytic destruction of the atlantoaxial joint.

Craniocervical junction tuberculosis: a rare but dangerous disease.

BACKGROUND: Mycobacterium tuberculosis of the cervical spine is a rare but dangerous manifestation of extra-pulmonary tuberculosis. The clinical picture ranges from early, nonspecific, insidious symptoms to severe neurological complications and death, attributed to craniocervical junction instability and cervicomedullary compression. The different lines of management include antituberculous medication with traction and external fixation or adjunctive surgery (debridement and stabilization) in patients with severe or persistent neurological complications and/or vertebral instability. METHODS: We describe two patients with advanced craniocervical junction tuberculosis. The early clinical picture was nonspecific in Case 1 and obscured by psychiatric illness in Case 2. The detailed clinical and radiological findings, and the management, will be described. Involvement of the occipital condyles and foramen magnum, which has not been reported previously, will be demonstrated. RESULTS: Both cases underwent transoral biopsy, aspiration, and debridement of retropharyngeal abscess (granuloma). Histological and tissue culture studies proved the abscesses were tuberculous and anti-tuberculous medications were started. Case 1 showed complete resolution of the clinical and radiological findings. Case 2 developed cardiorespiratory arrest while in a halo jacket. He was resuscitated but remained quadriplegic and semiconscious; he developed nosocomial gram negative pneumonia. He was referred back to his local hospital where he died 1 year later. CONCLUSIONS: Tuberculosis is an infrequent but notable cause of cervicomedullary compression. It should be suspected in patients with infective spondylitis who are immunocompromised or reside in an area highly endemic for tuberculosis. Management strategies include antituberculosis medication, transoral biopsy and drainage of the abscess, traction and external fixation, posterior decompression, and internal fixation, according to the clinical and radiological findings.

Conservative therapy of atlantoaxial osteomyelitis. A case report.

STUDY DESIGN: A rare case of C1-C2 vertebral osteomyelitis treated conservatively is described. The radiologic findings as well as the follow-up evaluation are reported. OBJECTIVE: To increase knowledge about the pathogenesis and treatment of vertebral osteomyelitis in the high cervical region. SUMMARY OF BACKGROUND DATA: This is one of the first cases reported of successful conservative treatment of osteomyelitis at this level. METHODS: In a 58-year-old man with lumbar staphylococcal infection, a subsequent cervical infection developed. Because the lumbar spondylitis was treated promptly, the cervical osteomyelitis was treated at a very early stage of development. RESULTS: Operative decompression is the treatment most often used in osteomyelitis at the C1-C2 level. This is an extremely unusual circumstance in which early treatment of the infection negated the need for surgery. CONCLUSION: Conservative treatment of osteomyelitis at the C1-C2 level can be efficacious in the correct setting.