Journal of Clinical Neuroscience 19 (2012) 632

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Journal of Clinical Neuroscience

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Images in Neuroscience: Answer

Atypical atlanto-axial subluxation

Jamie A. Nicholson ⇑, Susan M. Liew
Department of Orthopaedic Surgery, The Alfred, 55 Commercial Road, Melbourne, Victoria 3004, Australia

1. Answer present (Fig. 2 Images in Neuroscience: Question). Septic arthritis of

B. Osteomyelitis.
2. Discussion
Atlanto-axial subluxation (AAS) is defined as excessive move-
ment between the atlas (C1) and axis (C2) due to bony or ligamen-
tous abnormality. The condition can be totally asymptomatic until
cord compression occurs. A distance of more than 3 mm in adults
from the posterior aspect of the anterior arch of C1 to the anterior
margin of the odontoid process is pathognomonic. Common causes
include: trauma, rheumatoid arthritis, malignancy, infection,
Down’s syndrome and ankylosing spondylitis.
Our patient presented in an unusual fashion. The presenting
history raised suspicion of a focal brain lesion given the previous
history of malignancy and lack of localising signs of cord compres-
sion on examination. A head CT scan revealed severe AAS (8 mm)
of unknown cause and duration. Imaging with MRI showed an
extensive T2 signal abnormality within the joint anteriorly and
surrounding the tip of the odontoid process that was highly sug-
gestive of osteomyelitis at the craniocervical junction and skull
base. Presumably the infective destruction of the supporting liga-
ments around the odontoid process resulted in AAS. Marked oede-
ma within the medulla and the cervical cord down to C3 was also
the C0-1 and C1-2 facet joints was also noted bilaterally with joint
effusions visible between C1 and C2 (Fig. 3 Images in Neuroscience:
Question). Further contrast imaging also showed basal meningitis
at the cerebellomedullary angle (Fig. 4 Images in Neuroscience:
Question).
The patient was placed in a Philadelphia collar that reduced the
anteroposterior displacement to 4 mm and was commenced on
empirical ceftazidine, vancomycin and metronidazole for pre-
sumed osteomyelitis. Further investigation via a trans-oral biopsy
of pre-vertebral soft tissue and polymerase chain reaction on lum-
bar puncture samples revealed Mycobacterium tuberculosis, Candida
parapsilosis and Candida tropicalis. A halo-thoracic brace was used
for cervical spine control at this stage and a regimen of tuberculo-
sis and fungal treatment began. The only predisposing factors that
were established were that of ethanol abuse, malnourishment, and
previous chemotherapy treatment. Surgical stabilisation is likely to
be required for definitive treatment at a suitable time.
Acknowledgements
We acknowledge the clinical expertise of P. Thompson (ENT
surgeon) and K. Cherry (ID physician) in their assistance with the
management of this patient.

DOI of question: 10.1016/j.jocn.2011.02.009

⇑ Corresponding author. Tel.: +61 3 9076 2000.
E-mail address: j.a.nicholson.05@aberdeen.ac.uk (J.A. Nicholson).

0967-5868/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocn.2011.02.012