A 23-year-old female patient presented in outpatient department with chief complaints of pain in neck, restricted neck movement, gait changes, and weakness in all the extremities for the past 3 months. She had no history of trauma, but the history of difficulty in speech and constitutional symptoms were present. The general physical examination was within normal limits. On clinical examination, cervical spine tenderness was present with paraspinal muscle spasm. There was no palpable swelling or sinus. Cervical lymph nodes were not palpably enlarged. The range of motion of neck was markedly reduced due to pain and spasm. Neurological examination revealed that a higher mental function and cranial nerves except hypoglossal nervewithin normal limits. The upper motor neuron signs were present in bilateral upper and lower limbs. Tonewas increased with clasp knife type of rigidity. Power was grossly 5/5 in all the limbs, with exaggerated deep tendon reflexes, and planters were upgoing.
On hematological investigation, erythrocyte sedimentation rate (ESR) was 90 mm, rest hematological, and biochemical examinations were normal. HIV, HBsAg, anti-HCV, X-ray chest, and ultrasonography abdomen were normal. The patient had X-ray of cervical spine showing increased soft-tissue shadow [Figure 1] andmagnetic resonance imaging (MRI) of occipitocervical junction and cervical spine. An MRI was suggestive of destruction of atlas and axis vertebra with an abscess in the prevertebral region and cord having a mild compression from anterior aspect [Figure 2].
By clinical-radiological correlation, the patient was diagnosedwithpott's spine of C1-C2. She was started on antituberculosis therapy (ATT) Category 1 (Rifampicin 450 mg, Ethambutol 1000 mg, INH 300 mg, and Pyrazinamide 1500 mg), advised complete bed rest and initially kept on head halter traction for 6 weeks, at 6 weeks of patient was given four postcollar, and was mobilized. Patient improved clinically with no worsening of symptoms, but she noticed tongue deviation and hypotrophy of the right side of the tongue.
She was followed up regularly in the outpatient department. Four postcollar was removed at 1 year, and ATT was given for 18 months. At followup of 4 years, flexion and extension X-ray of cervical spine shows no instability, on repeat MRI there are healed lesion of C1-C2 spine with no abscess [Figure 3].
Clinically, she has no neck pain, there is a terminal restriction of neck nodding movements, and on the protrusion of tongue there is deviation of tongue with hypotrophy on the right side [Figure 4]. She has some difficulty in speaking, apart from that patient is doing all her activities without any difficulty.