Challenges in Diagnosis and Treatment of Atlantoaxial Tuberculosis, a Form of Spinal TB
Nikhil Prasad Fact checked by:Thailand Medical News Team Jan 29, 2025 1 day, 2 hours, 37 minutes ago
Medical News: Understanding a Rare and Complex Condition
Atlantoaxial tuberculosis (TB) is a form of spinal TB that affects the first two cervical vertebrae of the spine, known as the atlas and axis. Once considered rare, the incidence of spinal tuberculosis has been increasing in recent years.
Challenges in Diagnosis and Treatment of Atlantoaxial Tuberculosis, a Form of Spinal TB
Diagnosing this condition is particularly challenging due to its unusual symptoms and the absence of typical TB indicators. A recent study conducted by Taiwanese researchers from Taichung Veterans General Hospital, National Chung Hsing University, National Taichung University of Science and Technology, and Jen-Teh Junior College of Medicine, Nursing and Management sheds light on the difficulties in diagnosing and treating this rare disease.
This
Medical News report focuses on a case involving a 70-year-old immunocompetent woman who experienced neck pain, stiffness, and headaches for four weeks before seeking medical attention. Initially, her condition was not linked to TB as she showed no fever, night sweats, or weight loss. A biopsy identified a nonfermenting Gram-negative bacillus, but there was no immediate evidence of TB infection. Following a five-week antibiotic course, the patient underwent posterior spinal fusion surgery to stabilize the affected area. However, two years later, she developed myelopathy - a condition affecting spinal cord function - necessitating a second biopsy, which ultimately confirmed TB spondylitis.
Challenges in Diagnosis
TB of the spine is notoriously difficult to diagnose because it often mimics other spinal infections or tumors. Unlike pulmonary TB, spinal TB typically does not present with common systemic symptoms such as fever, weight loss, or persistent cough. Instead, patients may experience localized pain, stiffness, and neurological deficits if the infection progresses.
In this case, the first biopsy failed to confirm TB, which is not uncommon due to the slow-growing nature of Mycobacterium tuberculosis. TB cultures and smear tests require weeks to yield definitive results. The case report highlights that characteristic MRI features, such as smooth-walled abscesses, subligamentous spread, severe vertebral destruction, and heterogeneous contrast enhancement, may help differentiate TB from bacterial infections.
Study Findings on Imaging and Diagnosis
Imaging plays a crucial role in detecting spinal TB. MRI scans in this patient revealed osteolytic damage in the second cervical vertebra (C2), soft tissue infiltration, and spinal instability. Despite these findings, TB was not initially suspected due to the lack of classical symptoms. Two years later, when neurological symptoms worsened, further imaging showed the development of an atlantoaxial abscess causing spinal cord compression. A second biopsy performed through a transoral approach revealed TB-associated granulomatous inflammation, confirming the diagnosis.
Surgical and Medical Treatment Approaches
t;
Once TB was confirmed, the patient underwent an emergency transoral decompression surgery to remove the abscess. This approach was chosen to avoid damage to vital structures surrounding the spinal cord. Following surgery, the patient was placed on a 12-month anti-TB regimen, including ethambutol, rifampin, pyrazinamide, and isoniazid for three months, followed by rifampin and isoniazid for nine months. Regular follow-ups showed significant neurological improvement and a reduction in the size of the abscess.
Importance of Early Detection
Delays in diagnosing spinal TB can lead to severe complications, including spinal instability, nerve damage, and permanent disability. This study emphasizes the importance of considering TB in cases of unexplained spinal infections, particularly in regions where TB is prevalent. Early MRI detection and the use of advanced nucleic acid amplification (NAA) tests could improve diagnosis rates and prevent unnecessary delays in treatment.
Surgical Considerations for Atlantoaxial TB
Surgical intervention is recommended when TB leads to spinal instability or neurological impairment. In this case, posterior spinal fusion was performed initially, but further deterioration required transoral decompression surgery. Various surgical approaches, including anterior decompression and posterior stabilization, are available depending on the severity and location of the TB infection. Surgeons must weigh the risks of each method, ensuring that the spinal cord and surrounding neurovascular structures are preserved.
Long-Term Prognosis and Recovery
Following successful treatment, the patient experienced significant neurological improvement. Her condition stabilized after the completion of the anti-TB medication regimen, and follow-up imaging showed no recurrent abscess formation. However, given the aggressive nature of spinal TB, long-term monitoring is necessary to detect potential relapses.
Conclusions
This case highlights the complexities of diagnosing and managing atlantoaxial TB. The two-year delay in confirming TB underscores the challenges associated with detecting spinal infections without classical symptoms. Advanced imaging techniques, including MRI and CT scans, can provide early clues, but definitive diagnosis often requires multiple biopsies. Treatment involves a combination of prolonged anti-TB medication and surgical intervention when necessary. Physicians should maintain a high index of suspicion for spinal TB in patients with unexplained cervical pain and instability. The findings from this study provide valuable insights for clinicians managing similar cases, ultimately improving early detection and treatment outcomes.
The study findings were published in the peer-reviewed journal: Medicina.
https://www.mdpi.com/1648-9144/61/2/224
For the latest TB news, keep on logging to Thailand
Medical News.
Read Also:
https://www.thailandmedical.news/news/sunday-editorial-covid-19-could-possibly-be-contributing-directly-and-indirectly-to-the-rise-of-tuberculosis-infections
https://www.thailandmedical.news/news/tuberculosis-survivors-face-elevated-risk-of-heart-disease
https://www.thailandmedical.news/articles/tuberculosis-tb-news
Share
Tweet
Share
