Rescuing the falling head

摘要

Sir,A 28-year-old man presented with a progressive neck tilt, difficulty in opening mouth, and worsening spastic quadriparesis of about 2-months duration. About 2 years back, he was diagnosed with tuberculous spondylitis of the craniovertebral junction (CVJ). Unfortunately, a rigid immobilization of the neck could not be ensured during the course of subsequent antituberculous therapy. Fifteen days prior to the clinic visit, the patient had noticed a sudden clicking sound with sudden worsening of his neck tilt and neurological deficits [Figure la]. Computed tomography (CT) of cervical spine revealed a complex CVJ deformity, showing an osseous malunion of the occiput and the atlas, cranial migration of the odontoid process and atlanto axial dislocation with advanced lateral subluxation of the atlas over the axis. The tip of the odontoid appeared to have been resorbed [Figure lb-d]. The posterior arch of atlas, fused to the occiput, was identified as the main point of compression posteriorly. The compensatory hyperlordosis of the cervical spine and lateral neck tilt were probably limiting the mandibular excursions, which is the possible explanation for the restricted mouth opening. In addition, magnetic resonance imaging showed severe spinal cord compression at the CV junction. CT angiographic evaluation of neck vessels revealed a dominant left vertebral artery with a displaced course.