Study design: A retrospective chart review.
Objective: To describe the presentation and the rationale for management of pathological odontoid fracture and complete odontoid destruction in craniovertebral junction tuberculosis (CVJ TB).
Summary of background data: Presentation of CVJ TB ranges from minor osteomyelitic changes to severe structural damage leading to instability. Structural damage to the odontoid process is poorly characterized in the literature. Inadequate knowledge about the radiological presentations has led to controversy in the management of CVJ TB.
Methods: The cohort consisted of 15 consecutive patients with CVJ TB, with structural damage to the odontoid process in the form of either odontoid fracture (n = 7) or complete odontoid destruction (n = 8). These patients presented with pain, neurological deficit, torticollis, dysphagia, or respiratory distress. The cause of neurological deficit was craniocervical instability characterized as anterioposterior (n = 15), rotatory (n = 4), and vertical (n = 6). Displacement reduced anatomically in 13 patients. Apart from antibiotics, all patients were treated surgically by either C1-C2 fusion (n = 7) or occipitocervical fusion (n = 8).
Results: Average duration of follow-up was 3.6 years (range, 1.5-8 yr). All patients achieved normal neurological status. No complications were noted, except for 1 case, who had a loss of reduction after the use of Hartshill rectangle for occipitocervical fusion. Postoperative computed tomographic scan showed nonunion of odontoid fracture in 2 of 4 patients. No patient of odontoid destruction, of the 5 investigated, revealed structural reformation of the dens.
Conclusion: CVJ TB can severely damage the odontoid process, resulting in atlantoaxial dislocation. In these patients, surgery restores and maintains the craniocervical alignment and has a predictable outcome compared with conservative therapy. Pathological odontoid fractures have the potential to go into nonunion. Odontoid process once destroyed completely is rarely restored after antibiotic therapy.