CV Junction Drug-Resistant Tuberculosis Presenting as Acquired Torticollis: A Rare Case Presentation

A twenty-eight year old male walked into neuro OPD with neck pain and stiffness, weakness of right upper arm after a minimal trauma to his neck. On examination his vitals were stable although a stridor was audible, and torticollis was noted with tenderness and stiffness of the neck. Further neurological examination showed UMN features on all four limbs with power of right upper limb of MRC grade 3. A sensory level of around C4 was noted with plantar extensors and without bladder involvement. An urgent CT cervical spine plain study was performed showing retropharyngeal collection with osteolytic destruction of C1 and C2 vertebra [Figure 1] causing airway narrowing and severe spinal stenosis. MRI cervical spine plain and contrast was performed showing a huge retropharyngeal abscess with anterior epidural extension causing severe cord compression [Figure 2]. In addition, there was high t2 signal changes in C1-C2 suggestive of marrow oedema and inflammation. The pus was drained urgently to relieve the airway compression which was sent for investigation which revealed CBNAAT positive for tuberculosis and rifampicin resistant was detected. Even after starting the necessary ATT regime, patient then showed further deterioration in the form of worsening of muscle power and respiratory involvement so patient was taken up for surgery where a transoral odontoidectomy was performed and occiput C2C3 fixation was planned. The patient became hemodynamically unstable during the surgery, so the posterior fusion procedure was postponed to a second setting and the patient was placed in traction.Figure 1: CT spine (bony window) sagittal and coronal cut section showing a huge retropharyngeal abscess causing airway obstruction along with osteolytic lesion and destruction of C1C2Figure 2: MRI contrast study of the cervical spine sagittal section showing retropharyngeal abscess with anterior epidural extension causing cord compressionTuberculosis of the CV junction although a rare presentation occurring only in 1-5% of spinal tuberculosis is a life-threatening condition.[1] An irreversible neurological deficit or death can occur because of mass effect or instability of the spine because of the infective inflammatory pathology. Surgical management of this condition has always been a controversy in the timing and the approach to be offered.[1] The “Middle Path Regimen” was proposed by Dr. Tuli in 1975 which is a combination of short-course chemotherapy and conservative management is effective.[2] Drug-resistant tuberculosis of the spine is widely reported and early detection by the help of molecular diagnostic studies has helped in improving the clinical outcome with the early initiation of the different regime.[3] Patient’s consent: Consent from the patient/guardian has been taken. The patient’s identity has been adequately anonymized. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.