Iatrogenic pyogenic osteomyelitis of C-1 and C-2 treated with transoral decompression and delayed posterior occipitocervical arthrodesis

Abstract

<jats:p>✓The authors describe a case of osteomyelitis of the craniocervical junction caused by iatrogenic infection of the spine during corticosteroid injection therapy. This 58-year-old diabetic man presented with acute exacerbation of neck pain that had began 4 months prior to admission. He did not experience the associated fever, chills, or sweats, but he did notice transient weakness in the right upper extremity. A computed tomography (CT) scan of the cervical spine demonstrated a destructive process involving the odontoid and the left occipitocervical and atlantoaxial joints that was not present on a CT obtained 2 months earlier, just before trigger-point and left-sided C1–2 facet joint corticosteroid injections. A diagnosis of staphylococcal osteomyelitis was made, and initial treatment with external immobilization and appropriate antibiotic therapy failed to control radiographically demonstrated and clinical progression. The patient was successfully treated using staged anterior decompression and posterior instrumented fusion with prolonged antibiotic therapy.</jats:p> <jats:p>To the authors' knowledge this case is the first reported instance of iatrogenic pyogenic osteomyelitis of the craniocervical junction successfully treated with anterior decompression and delayed posterior arthrodesis.</jats:p>

Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis

“…CSF fistula occurring in the setting of osteomyelitis is also quite atypical, but must be recognized in a timely manner—particularly in patients presenting with meningitis and/or immunosuppression. In this setting, Staphylococcus aureus is recognized as the most common causative microorganism 2 although infection with Streptococcus 9 and gram-negative organisms has been reported. As illustrated in this case series, notable risk factors for acute skull base osteomyelitis include diabetes mellitus, intravenous drug abuse, active immunosuppression, and hemodialysis.…”

“…Pyogenic osteomyelitis of the craniocervical junction is a rare event that has been infrequently described in the literature. 1 2 3 4 5 6 7 8 9 The clinical manifestations most often include neck pain, stiffness, swelling, and dysphagia, although this entity may also present with meningitis. Most commonly afflicted are elderly or immunocompromised patients harboring comorbidities such as diabetes or end-stage renal disease.…”

Transoral Mandibular Tongue-Splitting Approach in Upper Cervical Epidural Abscess: A Case Report and Review of the Literature

“…The incidence of spinal epidural abscesses has increased due to the increasing prevalence of immunocompromized status and the aging population 30,31) . Moreover, the main source of UCEA is contiguous spread, such as that in the case of otorhinolaryngologic disease and tooth extraction [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] . Thus, 7 there may be an increasing number of patients with UCEA requiring anterior debridement and 8 stabilization.…”

“…An upper cervical epidural abscess (UCEA) can cause fatal 6 respiratory failure and/or tetraplegia, and emergent surgical intervention is required in patients with 7 progressive limb paralysis 7) . Although the transoral approach is frequently used for the treatment of 8 UCEA [8][9][10][11][12][13][14][15][16][17] , it may be inappropriate if a wide operative field and anterior stabilization are required [18][19][20][21][22][23][24][25][26][27] . For such patients, the transoral mandibular tongue-splitting approach may be useful, but it has not been used for the treatment of UCEA due to its invasiveness and possible complications [18][19][20][21][22][23][24][25][26][27] .…”

Upper Cervical Spine Infection. Complication of Hypopharyngeal Injury

“…Multiple causes have been postulated, such as direct spine trauma [15], post-surgical manifestation [16], hematogenous seeding [17] or a direct infection from a paravertebral space [18]. Symptoms upon presentation are vague, until neurological deficits develop, usually due to the long time lag between the onset of infection and the diagnosis [19]. In contrast to the thoracic spine area, the cervical spine has less stability and a smaller diameter of the bone canal.…”