Tubercular atlantoaxial dislocation in children: an institutional experience.

Object: In this paper the authors analyzed the clinical and imaging-documented profile of pediatric patients with tubercular atlantoaxial dislocation (AAD).

Methods: Seventeen children 16 years of age or younger with tubercular AAD were included in the study. Patients with reducible AAD underwent direct posterior stabilization. All patients were treated with a four-drug antituberculosis therapy (ATT) regimen (10-20 mg/kg/day rifampicin, 10-20 mg/kg/day isoniazid, and 15 mg/kg/day ethambutol in a single daily dose; and pyrazinamide 20-35 mg/kg/day in two divided doses) for 3 months. The pyrazinamide was then discontinued after 3 months and the ethambutol after 1 year. The rifampicin and isoniazid were continued for 18 months.

Results: Most of the patients had irreducible AAD. There was a high incidence of long tract signs, and the restriction of neck movements, as well as neck pain, was also very common. There was a significant delay in seeking neurosurgical consultation. Most patients were assigned poor preoperative grades, but they experienced excellent improvement postoperatively.

Conclusions: The presence of tubercular AAD in children can have subtle manifestations leading to delayed diagnosis. The successful management of tubercular AAD can be achieved after determining the extent of the disease process and the underlying instability. The goal of surgery is tissue diagnosis and relief of neural compression and stabilization. Medical treatment with ATT is an integral part of the treatment protocol.