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Nonoperative Management of Craniovertebral Junction and Cutaneous Tuberculosis Shaun Previn Appaduray, Patrick Lo

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Nonoperative Management of Craniovertebral Junction and Cutaneous Tuberculosis Shaun Previn Appaduray, Patrick Lo OPEN ACCESS Editor: Surgical Neurology International James I. Ausman, MD, PhD For entire Editorial Board visit : University of California, Los http://www.surgicalneurologyint.com Angeles, CA, USA Case Report Nonoperative management of craniovertebral junction and cutaneous tuberculosis Shaun Previn Appaduray, Patrick Lo Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia E‑mail: *Shaun Previn Appaduray ‑ [email protected]; Patrick Lo ‑ [email protected] *Corresponding author Received: 20 June 15 Accepted: 03 September 15 Published: 06 October 15 Abstract 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 Access this article online with cervical spine immobilization. At 2‑month review, the patient was well with a Website: near‑complete resolution of neck pain and cutaneous lesions. Repeat imaging at 6 www.surgicalneurologyint.com months follow‑up demonstrated a stable C1 lesion with no evidence of instability. DOI: 10.4103/2152-7806.166801 Conclusion: CVJ TB may be treated solely with anti‑TB therapy and immobilization Quick Response Code: 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. Key Words: Craniovertebral junction, cutaneous tuberculosis, spinal, tuberculosis INTRODUCTION and 8 months of multiple skin lesions, but no neurological deficit. He had visited India 12 months previously Craniovertebral junction (CVJ) tuberculosis (TB) is, and had received routine bacillus Calmette–Guérin especially uncommon and accounts for 0.3–1.0% of spinal vaccinations before immigrating to Australia at 21 years TB, as illustrated in a review by Gupta et al. which found of age. only 51 cases of CVJ TB from 1978 to 2004.[4‑6,9,10,12] We report our experience in managing a patient with TB 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, involving the left CVJ as well as the skin and discuss our tweak, and build upon the work non-commercially, as long as the author is credited and strategies while reviewing the literature. the new creations are licensed under the identical terms. For reprints contact: [email protected] CASE REPORT How to cite this article: Appaduray SP, Lo P. Nonoperative management of craniovertebral junction and cutaneous tuberculosis. Surg Neurol Int 2015;6:157. A 31‑year‑old male of Indian extraction was presented http://surgicalneurologyint.com/Nonoperative-management-of-craniovertebral- with a 2‑month history of progressive nocturnal neck pain junction-and-cutaneous-tuberculosis/ © 2015 Surgical Neurology International | Published by Wolters Kluwer - Medknow Surgical Neurology International 2015, 6:157 http://www.surgicalneurologyint.com/content/6/1/157 Skin examination revealed; a 4.5 cm solid mass overlying no acid‑fast bacilli on smear), while the TB polymerase the right deltoid, a 1.5 cm mobile mass on the left chin, chain reaction (PCR) was positive. Diagnosed with and a 1.5 cm mobile mass on the dorsum of the left foot. disseminated TB, he commenced a 1‑year course of Although he had a positive QuantiFERON Gold assay standard anti‑tuberculous therapy (ATT): For example, (titer 11.68 IU/ml), his chest X‑ray was normal. Cervical rifampicin, isoniazid, pyrazinamide, and ethambutol; computerized tomography (CT) showed destructive bony Lowenstein–Jensen culture confirmed mycobacterium changes at the left atlanto‑occipital junction (between TB with full drug sensitivities. At 2‑month review, his the left occipital condyle and superior articular facet neck pain and cutaneous lesions had resolved. Spinal of the left lateral mass of C1); there was a soft tissue immobilization was maintained for 6 months after which mass between these plus left‑sided lateral subluxation of cervical CT and flexion‑extension X‑rays confirmed C1–C2 [Figures 1 and 2]. C1/C2 stability [Figure 4]. He was immobilized in a halo vest. A CT of the chest, abdomen, and pelvis showed lytic and sclerotic bony DISCUSSION lesions in the ribs, pelvis, sacrum, and right acromion [Figure 3]. As cervical CT angiogram precluded a biopsy Craniovertebral junction tuberculosis of the cervical lesions (e.g., proximity of the vertebral CVJ TB predominantly affects the anterior structures artery), biopsies were obtained from the skin lesions of the vertebrae. The infection destroys bony and (left pelvis and the right acromion). These revealed ligamentous structures, resulting in neuraxial compression necrotizing granulomatous inflammatory changes (but and instability.[4,6,10,12,16,17] Diagnosis is difficult due to nonspecific features including suboccipital pain, neurological deficit, and CVJ complex instability.[4,5,11,12] Tissue biopsy is imperative to confirm the diagnosis and obtain drug sensitivities. PCR is used to make a provisional diagnosis due to its high (>90%) sensitivity and specificity.[6,12] a b Figure 1: (a) Axial and (b) coronal cervical spine computed tomography (bony windows) demonstrating destructive bony changes centered in the left atlanto-occipital junction between the base of the left occipital condyle and the superior articular facet of the left lateral mass of C1 a b Figure 2: (a) Axial and (b) Sagittal cervical spine computerized tomography with bony changes as described in Figure 1. The presence of an associated soft tissue mass between these bony changes and left-sided lateral subluxation of C1 with respect to C2 is also appreciated Figure 3: Coronal computerized tomography chest, abdomen, and pelvis (bony windows) revealing poorly-defined sclerotic lesions in a b the left half of the S1 vertebral body, right iliac body, left inferior Figure 4: (a) Flexion and (b) extension cervical spine X-rays at pubic ramus, left ischial tuberosity, and in the left iliac body, abutting 6-month review demonstrate no spondylolisthesis or vertebral the sacroiliac joint slippage with stable atlanto-dens interval Surgical Neurology International 2015, 6:157 http://www.surgicalneurologyint.com/content/6/1/157 Treatment options for CVJ TB are controversial due to the In summary, we present a manifestation of absence of well‑established guidelines.[1,3,12,14,16] In cases with extrapulmonary TB presenting with CVJ and cutaneous minimal instability or neurological deficit, conservative lesions, both of which are rare occurrences. We concur treatment with empirical ATT for 12–18 months is with the findings in the literature that CVJ TB can be recommended.[1,3,6,8,10,12,16] The most common surgical managed nonoperatively, particularly in the absence of intervention following decompression and/or biopsy is cervical instability or neurological deficit.[1,3,9,10,12,14,17] Our anterior cervical fusion to stabilize the spine.[6,10,12,13,16,17] experience suggests that co‑existing tuberculous lesions The transoral approach is ideal for biopsy of lesions in the skin and other osseous sites can be simultaneously and decompression of the neuraxis as it gives access to managed with standard ATT without any significant the median and both lateral atlanto‑axial joints.[6,7,10] alterations to treatment regimes or prognosis. Immobilization of the cervical spine for 3–6 months is Financial support and sponsorship recommended to facilitate bony stability as an adjunct to Nil. both nonoperative management and surgery.[1,3,6,7,9,14,17] Conflicts of interest Cutaneous tuberculosis There are no conflicts of interest. Cutaneous TB is reported in <1% of cases.[2,8] The three most prevalent types of cutaneous TB are scrofuloderma, REFERENCES lupus vulgaris, and TB verrucosa cutis.[2,8,15,18] Scrofuloderma is a multibacillary form of cutaneous TB. 1. Arora S, Sabat D, Maini L, Sural S, Kumar V, Gautam VK, et al. The results of Lesions present as firm, red‑brown nodules overlying a nonoperative treatment of craniovertebral junction tuberculosis: A review bone or joint.[2,8] Lupus vulgaris is a paucibacillary form of of twenty-six cases. J Bone Joint Surg Am 2011;93:540-7. cutaneous TB and is the most common form of cutaneous 2. Banashankari GS, Rudresh HK, Harsha AH, Bharathi R, Kamble P. An unusual presentation of cutaneous tuberculosis for surgeons-review of literature. TB. Lesions occur in normal skin originating from an Indian J Surg 2012;74:314-7. underlying TB focus and are solitary, reddish‑brown 3. Chadha M, Agarwal A, Singh AP. Craniovertebral tuberculosis: A retrospective nodules with a gelatinous consistency.[2,8] TB verrucosa review of 13 cases managed conservatively. Spine (Phila Pa 1976) cutis is another paucibacillary form of cutaneous TB 2007;32:1629-34. 4. Dhammi IK, Singh S, Jain AK. Hemiplegic/monoplegic presentation of cervical and occurs after direct inoculation of TB into the skin. spine (C1-C2) tuberculosis. Eur Spine J 2001;10:540-4. It manifests as a purplish plaque that forms exudative 5. du Plessis J, Andronikou S, Theron S, Wieselthaler N, Hayes M. Unusual forms fissures.[8] Isolation on the culture is difficult; PCR of spinal tuberculosis. Childs Nerv Syst 2008;24:453-7.
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