Posterior Decompression and Fusion for Cervical Spondylodiscitis due to Osteoradionecrosis after Head-and-Neck Cancer Radiotherapy: Two Case Reports.

Introduction: Cervical spondylodiscitis due to osteoradionecrosis (ORN) after head-and-neck cancer radiotherapy is a severe complication. However, there are few reports on the surgical treatment of this condition. Case Report: We report two cases of cervical spondylodiscitis due to ORN, which were successfully treated with posterior decompression and fusion. The first case was in a 73-year-old male patient with spondylodiscitis at C3-C5, due to ORN. A posterior fusion of the spine (C2-T1) was performed, and a biopsy was conducted at a site separate from the incision for fusion. The second case was in a 76-year-old female patient with spondylodiscitis due to C4-C7 ORN. Cervical posterior decompression and fusion (C2-Th2) were performed, and decompression (C5-6) was conducted through an incision separate from that for the fusion.An anterior approach was avoided in both cases because of radiation-induced tissue changes. For these two patients with cervical spondylodiscitis due to ORN, surgery resulted in an improvement of infection and neurological deficits by posterior spinal fusion, isolation from decompression or biopsy of the infected area, and antibiotic treatment. Conclusion: Posterior decompression and fusion are effective for spondylodiscitis in the cervical spine after head-and-neck radiotherapy, treating both infection and neurological deficits. Spinal fusion that avoids the level of the infected vertebral body and decompression from separate skin incision sites may prevent the spread of infection. An anterior approach should be avoided because the risk of esophageal perforation and posterior pharyngeal wall defects is high.

Spontaneous Cervical Spondylodiscitis With Retropharyngeal Abscess and Bacteremia: A Case Report.

Retropharyngeal abscess is a deep neck infection, rarely reported in adults. Nevertheless, when it occurs, it is mostly in immunocompromised patients and it can have life-threatening complications such as airway obstruction. On the other hand, more insidious complications can develop, such as mediastinitis, spinal osteomyelitis, and epidural abscess which represent an emergency medical condition when the patient develops neurologic symptoms. All must be diagnosed early and treated promptly. Spinal infection is an ancient disease, yet, morbidity remains significant despite developments in surgical and radiologic methods and the discovery of antibiotics. Management frequently involves a combination of these to achieve the best results.  The aim of this case report, as a research design, is to describe scientific observations that we encountered in a clinical setting, expand our knowledge, and highlight the role of the interprofessional team in evaluating and managing these conditions.

Cervical epidural abscess complicated by a pharyngoesophageal perforation after anterior cervical spine surgery for subaxial spondylodiscitis.

Background: The anterior approach to the cervical spine is safe and effective, but not without risks. The pharyngoesophageal perforation (PEP) is a rare but potentially life-threatening complication of this surgical route. A prompt diagnosis and adequate treatment are crucial for the prognosis; nevertheless, there is no unique consent about the best management. Case Description: A 47-year-old woman was referred to our neurosurgical unit for clinical and neuroradiological signs of multilevel cervical spine spondylodiscitis, which was conservatively treated with long-term antibiotic therapy and cervical immobilization after computed tomography-guided biopsy. Nine months later, when the infection was resolved, the patient underwent C3-C6 spinal fusion with anterior plate and screws through anterior approach to the cervical spine for degenerative vertebral changes causing severe myelopathy, and C5- C6 retrolisthesis with instability. Five days after surgical procedure, the patient developed a pharyngoesophageal-cutaneous fistula, detected through wound drainage, and confirmed by swallowing contrast study, without systemic signs of infection. The PEP was conservatively treated, with antibiotic therapy and parenteral nutrition, and it was monitored through seriate swallowing contrast and magnetic resonance studies up to the complete resolution. Conclusion: The PEP is a potentially fatal complication of the anterior cervical spine surgery. We suggest an accurate intraoperative control of the pharyngoesophageal's tract integrity at the end of the surgical procedure and a longtime follow-up, because the risk of occurrence is up to several years after surgery.

A Rare Case of Candida glabrata Cervical Spondylodiscitis.

Introduction: Invasive candidiasis can lead to numerous life-threatening sequelae. Candida glabrata is the second-most common causative species of invasive candidiasis. This species possesses a high risk for persistent infection and candidemia. An uncommon complication of invasive candidiasis is spondylodiscitis and can rarely affect the cervical spine. Case Presentation: The patient is a female in her late 50s with a complex medical history inclusive of chronic obstructive pulmonary disease, chronic pain, multiple abdominal surgeries, prolonged intensive care unit admission, and administration of total parenteral nutrition and broad-spectrum antibiotics who presented with complaints of worsening neck pain. She was last hospitalized 3 months prior and found to have C glabrata fungemia but was nonadherent to antifungal therapy.She was found to have advanced C5-6 spondylodiscitis and an epidural abscess. Her surgical cultures grew C glabrata. Despite surgical intervention and antimicrobial therapy, she clinically deteriorated and acquired septic shock with multiorgan failure. Conclusion: This is a rare case of cervical spondylodiscitis caused by a deep-seated C glabrata infection.

Fatal neck pain in a patient on maintenance hemodialysis.

Infectious spondylodiscitis (IS) is defined as the pathogenic invasion of the vertebrae and intervertebral disks. It is a serious condition that can lead to many complications such as chronic pain, permanent neurological deficits, and even death. Vertebral surgical procedures, invasive urinary tract manipulations, and central line-associated bloodstream infection are the primary methods by which microorganisms reach the vertebrae and intervertebral disks. Hemodialysis (HD) patients are regularly exposed to bloodstream infections due to long-term catheter utilization or repeated vascular puncturing in patients with arteriovenous fistula. Due to the high risk of blood stream infections, HD patients have a higher risk of developing IS. Despite advanced diagnostic methods, diagnosis of spondylodiscitis is often delayed due to insidious and nonspecific symptoms, allowing dissemination of the infection, which explains the high level of mortality due to spondylodiscitis in HD patients. The infectious process typically occurs in the thoracic or lumbar region, although cervical IS does occur. We herein report the case of a 67-year-old man on HD who developed infectious cervical spondylodiscitis. The diagnosis was established a few days after symptom onset, but the issue was unfortunately fatal despite a well-conducted antibiotic treatment.

Neck stiffness after transoral pharyngolaryngeal surgery for squamous cell carcinoma.

INTRODUCTION: Pyogenic spondylodiscitis is a rare, destructive intervertebral disc infection. CASE SUMMARY: We describe a case of C2-C3 pyogenic spondylodiscitis after transoral surgery of the posterior pharyngeal wall in a 64-year-old man with a history of oropharyngeal squamous cell carcinoma (SCC) treated by neck irradiation (45Gy). Ten years after initial treatment, he underwent total laryngectomy for laryngeal SCC, together with transoral resection of carcinoma in situ (CIS) of the posterior pharyngeal wall followed by BioDesign® tissue repair graft. Five months later, C2-C3 spondylodiscitis was diagnosed with the formation of a fistula between the posterior pharyngeal wall and the intervertebral disc. Antibiotic therapy was administered for a total duration of 3 months (multi-susceptible Escherichia coli). Eight months after the diagnosis of spondylodiscitis, the patient died from carotid artery rupture following another course of radiotherapy for lymph node recurrence. DISCUSSION: Larger-scale studies are necessary to evaluate the prevalence and risk factors of radiation-induced spondylodiscitis that currently remain poorly elucidated. The best treatment strategy (choice and duration of antibiotic therapy) and the optimal frequency of follow-up must be determined and the value of preventive measures (biomaterial, flap repair) needs to be evaluated.

Full Endoscopic Removal of Cervical Spinal Epidural Abscess: Case Report and Technical Note.

Spinal epidural abscess is a rare disease that is less likely to occur in the cervical region. When it occurs here, cervical spondylodiscitis can develop. Surgical treatment is recommended because of possible life-threatening septic and neurological complications. We present a case of an 81-year-old man who suffered from right side paralysis and was subsequently diagnosed with a C4 to C7 epidural abscess. We utilized full endoscopic surgery for patient management. The traditional surgical methods for treating cervical epidural abscesses may cause spinal instability. There has only been one previous case report on the endoscopic-assisted method. Minimal invasive surgery by a full endoscopic method can be done with a small incision and is associated with minimal blood loss and muscle damage. This is the first report on cervical epidural abscess drainage utilization a full endoscopic method. We recommend this alternative minimally invasive method to manage cervical epidural abscess.

Serratia marcescens as a cause of cervical myelopathy / Serratia marcescens como causa de mielopatia cervical / Serratia marcescens como causa de mielopatía cervical

ABSTRACT Introduction: The main causative agent of spinal infections is Mycobacterium Tuberculosis, followed by saprophytes of the skin. The most affected segment is the lumbar, followed by the thoracic. Objective: Case report. Results: A previously healthy 40-year-old man with posterior cervical pain and myelopathy was referred to our spine service for vertebral destruction syndrome in C3-C4 and altered carbohydrate metabolism. Microdiscectomy and abscess drainage were performed and a biopsy was taken for definitive diagnosis. Multiresistant Serratia Marcescens was isolated in the culture. Both the myelopathy and carbohydrate intolerance were resolved as the infection was resolved. Conclusion: The significance of this case lies in the infective presentation of the S. Marcescens in an immunocompetent person, since it is mainly an opportunistic microorganism, and in the atypical location. The most commonly isolated pathogen is Mycobacterium Tuberculosis, followed by Staphylococcus aureus. Identification of the causative agent is essential to the initiation of antibiotic therapy. Therefore, microbiological isolation plays a fundamental role in the treatment, recovery and quality of life of the patient. Level of evidence V; Case report.

RESUMO Introdução: O principal agente causador das infecções da coluna vertebral é o Mycobacterium tuberculosis, seguido pelos saprófitos da pele. O segmento mais afetado é o lombar, seguido pelo torácico. Objetivo: Relato de caso. Resultados: Um homem, anteriormente saudável, de 40 anos, com dor cervical posterior e mielopatia como principal sintomatologia, foi encaminhado ao nosso serviço de coluna vertebral com síndrome de destruição vertebral em C3-C4 e alteração do metabolismo de carboidratos. A microdiscectomia e a drenagem de abscessos foram realizadas e uma biópsia foi feita para diagnóstico definitivo. A Serratia marcescens multirresistente foi isolada na cultura. Tanto a mielopatia como a intolerância a carboidratos foram resolvidas, uma vez que a infecção foi tratada. Conclusão: A importância desse caso reside na apresentação infecciosa da S. marcescens em uma pessoa imunocompetente, uma vez que esse é principalmente um microrganismo oportunista e por sua localização atípica. O patógeno mais comumente isolado é o Mycobacterium tuberculosis, seguido pelo Staphylococcus aureus. A identificação do agente causador é essencial para início da terapia com antibióticos. Portanto, o isolamento microbiológico desempenha um papel fundamental no tratamento, recuperação e qualidade de vida do paciente. Nível de evidência: V; Relato de caso.

RESUMEN Introducción: El principal agente causal de las infecciones de columna es la Mycobacterium Tuberculosis seguido de los saprófitos de la piel y el principal segmento afectado es el lumbar, seguido del torácico. Objetivo: Reporte de caso. Resultados: Presentamos un masculino de 40 años previamente sano, referido al servicio de columna por síndrome de destrucción vertebral C3-C4, con dolor cervical posterior y mielopatía como principal sintomatología, y alteración del metabolismo de carbohidratos. Se realizó microdiscectomía y drenaje de absceso con toma de biopsia para diagnóstico definitivo. En el cultivo se aisló Serratia Marcescens, multirresistente. La mielopatía y la intolerancia a los carbohidratos se resolvieron una vez resuelta la infección. Conclusión: La importancia de este caso radica en la presentación infectante de la S. Marcescens en una persona inmunocompetente ya que esta es principalmente un microorganismo oportunista y por su localización atípica. El patógeno más comúnmente aislado es Mycobacterium Tuberculosis seguido de Staphylococcus aureus. La identificación del agente causal es fundamental para iniciar la terapéutica antibiótica. Por lo tanto, el aislamiento microbiológico tiene un papel fundamental en el tratamiento, la recuperación y calidad de vida del paciente. Nivel de evidencia V; Reporte de caso.

Treatment considerations for cervical and cervicothoracic spondylodiscitis associated with esophageal fistula due to cancer history or accidental injury: a 9-patient case series.

BACKGROUND: The combination of cervical spondylodiscitis and esophageal fistula is rare but life-threatening. Due to both the rarity of these conditions' coincidence and the complexity and heterogeneity of individual cases, there is no optimal treatment or management approach. The aims of this study are to obtain an overview of patients' outcomes and to discuss treatment options. METHOD: This study is a retrospective analysis of patients who presented with cervical spondylodiscitis and associated esophageal fistula between January 2010 and November 2018. We examined reports of 59 patients who suffered from cervical spondylodiscitis and included nine patients (15.25%) who had an esophageal fistula as the underlying cause. We assessed clinical findings, treatment, and outcome. RESULTS: Three of the nine patients were female, and the mean age of the sample was 64.56 years. Six of the patients had a history of esophagopharyngeal cancer and had undergone tumor resection followed by radiotherapy. Two of the remaining patients' fistulas were caused by an iatrogenic injury during cervical spine surgery and a swallowed toothpick; in the final case, the origin remained unclear. Five patients presented with tetraparesis or tetraplegia, and the other four patients were neurologically intact. In seven cases, dorsal instrumentation was initially performed. Three patients secondarily received a ventral approach for debridement, and one received explantation of the ventral implants. Two patients died during the hospital stay, and three were transferred to a palliative care unit. Thus, the spondylodiscitis and esophageal fistula were cured in only four patients. At discharge, two patients were neurologically intact, two others remained in tetraparesis. CONCLUSIONS: Cervical spondylodiscitis in association with an esophageal fistula carries high morbidity and high mortality. Because patients whose infections are not cured have high morbidity, we recommend using interdisciplinary and individual management, including definite surgical treatment of the discitis and fistula, in every case.

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group.

BACKGROUND: Cervical spondylodiscitis is a rare but severe complication of pharyngeal surgery. MATERIAL AND METHODS: This multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017. OBJECTIVES: To describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications. RESULTS: Seven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6days. The interval between surgery and spondylodiscitis diagnosis ranged from 20days to 4.5months, for a mean 2.1months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%). CONCLUSION: This French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.

Anterior cervical spine surgery for the treatment of subaxial cervical spondylodiscitis: a report of 30 consecutive patients.

OBJECTIVEInfection of the cervical spine is a rare disease but is associated with significant risk of neurological deterioration, morbidity, and a poor response to nonsurgical management. The ideal treatment for cervical spondylodiscitis (CSD) remains unclear.METHODSHospital records of patients who underwent acute surgical management for CSD were reviewed. Information about preoperative neurological status, surgical treatment, peri- and postoperative processes, antibiotic treatment, repeated procedure, and neurological status at follow-up examination were analyzed.RESULTSA total of 30 consecutive patients (17 male and 13 female) were included in this retrospective study. The mean age at procedures was 68.1 years (range 50-82 years), with mean of 6 coexisting comorbidities. Preoperatively neck pain was noted in 21 patients (70.0%), arm pain in 12 (40.0%), a paresis in 12 (40.0%), sensory deficit in 8 (26.7%), tetraparesis in 6 (20%), a septicemia in 4 (13.3%). Preoperative MRI scan revealed a CSD in one-level fusion in 21 patients (70.0%), in two-level fusions in 7 patients (23.3%), and in three-level fusions in 2 patients (6.7%). In 16 patients an antibiotic treatment was initiated prior to surgical treatment. Anterior cervical discectomy and fusion with cervical plating (ACDF+CP) was performed in 17 patients and anterior cervical corpectomy and fusion (ACCF) in 12 patients. Additional posterior decompression was performed in one case of ACDF+CP and additional posterior fixation in ten cases of ACCF procedures. Three patients died due to multiple organ failure (10%). Revision surgery was performed in 6 patients (20.7%) within the first 2 weeks postoperatively. All patients received antibiotic treatment for 6 weeks. At the first follow-up (mean 3 month) no recurrent infection was detected on blood workup and MRI scans. At final follow-up (mean 18 month), all patients reported improvement of neck pain, all but one patients were free of radicular pain and had no sensory deficits, and all patients showed improvement of motor strength. One patient with preoperative tetraparesis was able to ambulate.CONCLUSIONSCSD is a disease that is associated with severe neurological deterioration. Anterior cervical surgery with radical debridement and appropriate antibiotic treatment achieves complete healing. Anterior cervical plating with the use of polyetheretherketone cages has no negative effect of the healing process. Posterior fixation is recommended following ACCF procedures.

Cervical Spine Osteomyelitis: A Systematic Review of Instrumented Fusion in the Modern Era.

OBJECTIVE: For cases of cervical osteomyelitis that require surgery, concern has continued regarding instrumentation owing to the potential for bacterial seeding of the hardware. We performed a systematic review of the current data. METHODS: A search was performed using Medline, Embase, and Ovid for articles using the keywords "cervical osteomyelitis/spondylodiscitis" and "fusion" or "instrumentation" reported from 1980 to 2017. Prospective or retrospective studies describing ≥2 patients with cervical osteomyelitis were included in the analysis; non-English reports were excluded. Individual patients were excluded from the final analysis if they had previously undergone spinal instrumentation. RESULTS: A total of 239 patients from 24 studies met our criteria. Surgical approaches were classified as anterior-only, combined anteroposterior, and posterior-only for 64.8%, 31.9%, and 3.3% of the patients respectively. Of the patients treated using an anterior-only approach, 76.5% had received anterior plating and 85.3%, a cage or spacer implants. Of the patients who had undergone combined approaches, 85.1% underwent circumferential fixation and 14.9%, anterior debridement with posterior instrumentation. The follow-up period ranged from 6 weeks to 11 years (mean, 31.0 months). All the studies reporting the fusion rates, except for 1, reported a 100% fusion rate. The reported rates of pain improvement and neurologic recovery were favorable. The incidence of hardware failure and wound complications was 4.6% and 4.0%, respectively. CONCLUSIONS: Despite placing instrumentation during active infection, the rates of hardware failure and wound complications were comparable to those of elective cervical spine procedures. These results suggest that surgical intervention with instrumentation is a safe treatment option for patients with cervical spine osteomyelitis.

Cervical spondylodiscitis following an invasive procedure on the neopharynx after circumferential pharyngolaryngectomy: a retrospective case series.

PURPOSE: To highlight cervical spondylodiscitis as an infrequent complication following an invasive procedure on the neopharynx in patients previously treated with circumferential pharyngolaryngectomy with pectoralis major myocutaneous flap reconstruction. METHODS: Patients diagnosed with cervical spondylodiscitis after circumferential pharyngolaryngectomy between 2001 and 2013 were retrospectively studied using a questionnaire sent to the French head and neck tumour study group. Medical history; tumour management; clinical symptoms; biological, microbiological and imaging results; and management of the infection were collected for each patient. RESULTS: Six men aged 51-66 years were diagnosed with spondylodiscitis on average 5.6 years after circumferential pharyngolaryngectomy, and a mean 2 months following an invasive procedure on the neopharynx (oesophageal dilatation, phonatory prosthesis insertion). The patients presented with cervical pain and increased CRP level. MRI showed epidural abscess and communication between the pharynx and vertebral bodies in most cases. Microbiological samples yielded bacteria from the pharynx flora. Infection was managed using antibiotics adjusted according to the culture results and spinal immobilisation for duration of 6-12 weeks. No surgical treatment was required. During follow-up, no patient experienced recurrence or residual disability. CONCLUSIONS: Cervical spondylodiscitis is a rare but potentially severe complication following an invasive procedure on the neopharynx after circumferential pharyngolaryngectomy. Therefore, the onset of nonspecific symptoms should not be overlooked, and MRI must be performed if infection is suspected. Microbiological confirmation is critical in optimising treatment, which should be aggressive, even if overall prognosis seems to be good.

Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report.

INTRODUCTION: Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. MATERIALS AND METHODS: Case report and review of the literature. RESULTS: A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. CONCLUSION: Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner.

Espondilodiscitis cervical por Streptococcus agalactiae y síndrome de Parsonage-Turner secundario / Cervical spondylodiscitis caused by Streptococcus agalactiae and Parsonage-Turner syndrome

La espondilodiscitis por Streptococcus agalactiae es infrecuente, ya que éste es un microrganismo clásicamente patógeno en el periodo gestacional y perinatal. Sin embargo se está produciendo un aumento en la incidencia de infecciones invasivas en adultos inmunocompetentes. Asimismo, el síndrome de Parsonage-Turner o neuritis braquial aguda es una entidad clínica poco frecuente, caracterizada por dolor y debilidad muscular de la extremidad superior. Presentamos el caso de un varón de 50 años con bacteriemia por S. agalactiae, espondilodiscitis cervical y neuritis braquial secundaria y revisamos la literatura.

Spondylodiscitis caused by streptococcus agalactiae has been traditionally considered an infrequent disease since S. agalactiae is a pathogenic microorganism conventionally in gestational and perinatal period. However it is producing an increase in the incidence of invasive infections in immunocompetent adults. Also Parsonage-Turner syndrome or brachial radiculitis is a rare disorder and is characterized by pain followed by weakness in the distribution of the upper brachial plexus. We report one case and review the literature.