Craniovertebral junction tuberculosis: A review of 29 cases

Purpose: The purpose of this work was to describe the various imaging findings in craniovertebral tuberculosis and the importance of imaging in treatment in these patients. Method: A retrospective review of MR and CT scans in 29 patients with craniovertebral tuberculosis was performed. The images were reviewed, paying special attention to both bony (skull base, atlas, and axis) and soft tissue involvement in addition to atlantoaxial dislocation, lateral subluxation of the dens, and compression of the spinal cord. Results: Suboccipital pain with neck stiffness was the most common presenting symptom in our patients. The skull was involved in 19 of the 29 cases, clivus involvement was seen in 11 patients, and occipital condyle involvement was present in 14 patients. Detailed analysis of atlas involvement due to tuberculosis showed the lateral masses to be predominantly affected. The dens was involved in 18 cases (62%). Soft tissue masses in the prevertebral area were seen in 22 patients, paravertebral in 27 patients, and epidural involvement in 25 patients was identified. Atlantoaxial displacement was present in seven cases, lateral mass-dens subluxation in five, and superior subluxation of the dens through the foramen magnum compressing the medulla was seen in two cases. Spinal cord compression with intrinsic cord changes was noted in 12 cases. All patients received multidrug antituberculous therapy for 1 year. The presence of neurologic deficit and instability of the atlantoaxial complex was pivotal in further management in these patients. Conclusion: A high degree of clinical suspicion is necessary when confronted with patients with neck stiffness and tenderness over the upper cervical vertebrae. MRI in these patients provides a sensitive method for the diagnosis of craniovertebral tuberculosis.