A 66-year-old man had been diagnosed with infectious cervical tuberculosis on C1 and undergone posterior C1-2 screw-plate fixation at a hospital in India one year prior to his visit to our hospital. Although the surgery was successful and his neck pain had improved, his swallowing function had gradually worsened over the nine-month period after the initial surgery, along with loss of reduction. Due to progressive dysphagia and severe weight loss, he was referred to our hospital. His medical history included hypertension and mild diabetes mellitus (HbA1c 6.2% NGSP). He had been given antitubercular treatment since he was diagnosed with infectious cervical tuberculosis at the local hospital.
The patient's height was 165 cm, his weight was 52 kg (BMI 19), and he exhibited normal cognitive function. He had lost 25 kg over 7 months because of difficulty in swallowing, and a nasogastric (NG) tube was placed for tube feeding. Neurological examination of the patient revealed left dominant proximal arm muscle weakness with atrophy, dysesthesia in distal fingers, hyperreflexia throughout with bilateral extensor plantar reflex. Oral examination was remarkable for left tongue atrophy as well as left tongue deviation, which was consistent with unilateral HNP. Routine blood work showed slightly elevated level of C reactive protein (CRP), but the findings were otherwise normal.
Chest X-ray results showed no specific abnormality. Lateral cervical X-ray showed O-C2 angle of 17-degree kyphosis (Figure 1). Computed tomography (CT) showed an erosive lesion at dens and anterior arch of the atlas (Figure 2). Magnetic resonance imaging showed a space-occupying lesion in the retropharyngeal space, which presented with heterogeneous signals on both T1- and T2-weighted images (Figure 3). Further sequential review of previous imaging studies revealed that, contrary to the progression of O-C kyphosis, the lesion had been gradually decreasing in size.
In sum, the patient had two main problems: severe dysphagia and subsequent malnutrition and neck pain. Initially, we assumed that the dysphagia was primarily caused by oropharyngeal stenosis resulting from O-C kyphosis. However, since no findings of the intracranial pathology were observed and the patient exhibited a persistent unilateral HNP and severe swallowing dysfunction, we eventually hypothesized that the dysphagia would have been deteriorated even worse due to the limited tongue movement. In other words, both O-C kyphosis and HNP were related to dysphagia, and it was not possible to draw a clear line by which these two factors were divided regarding the etiology. No conservative treatments had improved these symptoms, and we therefore decided to perform a corrective surgery to restore the swallowing function and to relieve the neck pain.
Posterior O-C3 fusion surgery with iliac bone graft was performed without complications. The O-C kyphosis was corrected to 6-degree lordosis on O-C2 (Figure 4). Findings of the tissue biopsy from the retropharyngeal mass were negative for infectious etiology. The postoperative course was uneventful. His swallowing function concomitantly with his tongue movement improved in two weeks after the surgery. At the final follow-up visit at five months, bone union was observed, and swallowing function was confirmed without further deterioration.