Craniovertebral junction tuberculosis: a new comprehensive therapeutic strategy

To establish a scoring system and management algorithm for patients with diagnosed craniovertebral junction tuberculosis. The specific goals were: 1) to avoid new neurological deficits; 2) to avoid morbidity and compromise in the quality of life associated with prolonged, rigid, cumbersome external immobilization, such as with a sternal occipital mandibular immobilizer brace and halo traction; and 3) to prevent sudden death.

All patients diagnosed with craniovertebral junction tuberculosis were studied prospectively over a 3-year period. The initial severity of the disease was evaluated with clinicoradiological grading, and patients were divided into 3 grades. Overall performance status was assessed with disability scoring. Patients with Grade 1 and 2 severity were managed conservatively. Grade 3 patients underwent transoral decompression and posterior fixation. The patients' neurological recovery was evaluated every 4 weeks with disability scoring, along with x-rays, for the initial 3 months and every 2 months thereafter.

Of 71 patients, there were 27 Grade 1, thirty-six Grade 2, and 8 Grade 3 patients. Children and young adults comprised 70% of the study population. All Grade 3 patients underwent early surgery. Five Grade 1 and 2 patients (8%) required delayed surgery for reducible atlantoaxial dissociation. The remaining 58 patients (82%) were effectively managed conservatively. The mean follow-up duration was 18.5 +/- 6.2 months. There was no mortality.

Use of our proposed scoring system and management protocol allowed both speedy recovery and early mobilization. All patients had good clinicoradiological outcomes regardless of the grade.