C1–C2 tuberculosis: a case report Ibet Marie Y. Sih MD FAFN MD FAFN, Vladimir D. Hufana MD MD, Kheng Kooi Tan MBBS FRCS (NS) MBBS FRCS (NS) National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433 Singapore Summary Tuberculosis of the atlantoaxial spine is a rare condition that is often overlooked and remains a diagnostic dilemma. We re- port the rare case of a 56-year-old woman with cervical myelopathy secondary to a lytic lesion of C1–C2 complex with a histological diagnosis of tuberculosis. ª 2003 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(3), 341–343 0967-5868/$ - see front matter ª 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0967-5868(03)00144-9 Keywords: spinal tuberculosis, craniocervical tuberculosis, craniovertebral tuberculosis Received 20 January 2003 Accepted 27 April 2003 Correspondence to: Kheng Kooi Tan, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433 Singapore. Tel.: +65-6537-7191; Fax: +65-6537-7137; E-mail: kheng_kooi_tan@ttsh.com.sg INTRODUCTION Tuberculosis of the atlantoaxial spine is a rare condition that is often overlooked and remains a diagnostic dilemma. Although there are case reviews on spinal tuberculosis, these amount to less than ten and mostly include the whole craniovertebral junction. 1–5 CASE REPORT This 56-year-old woman presented with dramatically progressive quadriparesis, with more pronounced weakness of the upper ex- tremities, over 1 week period. There was bilateral cervical pain for 3 weeks. She denied bowel or bladder incontinence. Neurological exam showed quadriparesis, with motor strength of 3/5 on the right and 4/5 on the left. There was decreased sen- sation on the right. Also noted were Lhermitte’s sign and left temporal hemianopsia. The patient, 10 years ago had a previous right hemithyroi- dectomy for a multinodular goiter and presently has a recurrent large nodular anterior cervical mass. Computed tomography (CT)/magnetic resonance imaging (MRI) brain showed a mass lesion in sellar–suprasellar area with broad based dural attachment consistent with meningioma. The magnetic resonance angiography (MRA) revealed that the left posterior inferior cerebellar artery (PICA) was compressed and compromised with cerebellar infarct and right pontomedullary edema. There was a C1–C2 soft tissue enhancing mass causing compression of the cervicomedullary junction (Fig. 1). Cervical CT showed erosion at dens and base of dens involving the left C2 vertebral body (Fig. 2). Involved bone appeared ex- panded and part of cortex breached. Increased atlantoaxial distance was noted with part of C2 vertebral displaced, compromising the cervical canal. Laboratory investigations including tumor markers, rheuma- toid factors were non-contributory except for a raised erythrocyte sedimentation rate (ESR) level. In view of the medullary cervical cord compression, the patient underwent transoral decompression and posterior occipitocervical fusion. A prophylactic tracheostomy was done and a thyroidec- tomy had to be performed because of the size of the goiter. These were done all in one sitting. The patient was placed on lateral decubitus position and lateral tilting of table (20°) was done accordingly (Figs. 3(A) and (B)). Initially, an anterior decompression procedure was done via a transoral pharyngeal vertical incision and submu- cosal dissection to expose the C1 anterior arch. C1 was partly eroded by the lesion at its inferior and superior aspects with note of egress of serous fluid. Specimen was obtained for culture sensitivity studies (later on revealing Pseudomonas sp. Fig. 1 T2 weighted magnetic resonance imaging (sagittal section) of the cervical spine showing a soft tissue C1–C2 lesion, eroding the atlantoaxial complex and indenting the cervicomedullary junction. Fig. 2 Computed tomography (sagittal section) of the atlantoaxial complex showing erosion at the dens and base of dens. There is also note of a marked diminution of spinal canal at this level. ª 2003 Elsevier Ltd. All rights reserved. Journal of Clinical Neuroscience (2004) 11(3) C1–C2 tuberculosis 341