A 23-year-old female presented with a 4-week history of severe neck pain (VAS:10) and torticollis with a classic "Cock Robin" deformity. Laboratory studies demonstrated an increased erythrocyte sedimentation rate (ESR) of 42. The lateral cervical plain radiographs and computed tomography (CT) axial, 2D, and 3D reconstructed images showed C1-C2 AARF with destruction of the left lateral mass of the atlas [Figures 1-4]. The integrity of the vertebral artery at C1-C2 was also critically confirmed on the preoperative CT angiogram (CTA) [Figure 5].
As cervical traction failed to reduce the deformity, surgical intervention was warranted. Surgery required; the initial insertion of bilateral C2 pedicle screws, isolation of the V3 segment of the vertebral artery, removal of the destroyed left C1 lateral mass in a piecemeal fashion, and fusion (e.g., utilizing a tricortical iliac bone graft secured with left C1 laminar hook-C2 pedicle screw, and an additional right C1 lateral mass-C2 pedicle screw rod construct) [Figure 6]. Postoperatively, the patient's torticollis and intractable pain resolved. X-rays taken 1 week, and 3 months after surgery demonstrated adequate alignment of the instrumentation/ construct [Figure 7]. Three years later, the patient is asymptomatic [Figure 8].
The operative specimens demonstrated: a positive polymerase chain reaction (PCR) for TB, and the pathology was compatible with a granulomatous infection.
Four-drug therapy was warranted for TB; isoniazid (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg), and pyrazinamide (25 mg/kg). They were administered as a first-line of treatment for 4 months. This was followed by an additional 12 months of rifampicin and isoniazid.