Grand Rounds

Tuberculous Atlanto-axial dislocation – How to manage?

Suhani Jain1, Ira Shah2
1Grant Government Medical College, Sir JJ Group of Hospitals, Mumbai, India, 2Consultant in Pediatric Infectious Diseases, Levioza Health Care, Mumbai, India

Address for Correspondence: Suhani Jain, Flat number 402, Ramdeo Arise, Behind Hotel Airport Centre Pt, Wardha Road, Nagpur-440025. Email:

Keywords: Pediatric Tuberculosis, atlanto-axial dislocation, TB spondylitis

Clinical Problem:
An 8-year-old girl presented with pain and inability to extend her neck for three months. She had a history of occasional low-grade fever during this period, but she was afebrile at presentation. There had been no prior trauma or surgery. There was no history of contact with a patient suffering from tuberculosis (TB). On examination, weight was 24 kg(at 50th centile as per Indian Academy of Paediatrics (IAP) 2015 growth charts), height was 125 cms (at 50th centile as per IAP 2015 growth charts) and Body mass Index (BMI) was 15.4 kg/m2.(between 50th and overweight percentile as per IAP 2015 growth chart)
There was restriction in extension of the neck with pain but there was no swelling. Other general examination and systemic examination were normal. There was no neurological deficit. X-ray of the cervical spine showed dislocation of the atlanto-axial joint (Figure 1). MRI cervical spine showed a lytic lesion with associated granulation tissue in the left lateral mass of the atlas bone. This granulation tissue appeared to be extending into the atlanto-dental interspace. There was atlantoaxial dislocation and mild indentation of the cervicomedullary junction by the odontoid process and there was no evidence of cord edema or myelomalacia, thus suggestive of tuberculosis (TB). Mantoux test by 5 TU PPD-S was positive (10 mm). Chest X-ray was normal.

Figure 1. X-ray of the cervical spine showing dislocation of the atlanto-axial joint
Tuberculous Atlanto-axial dislocation – How to manage?

How to manage this patient further?

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