Working Diagnosis:
Cervical Osteomyelitis and discitis with epidural abscess and paraspinal abscess
Treatment:
Once the MRI resulted, she was admitted to the hospital. She underwent surgical debridement with cervical corpectomy of C6-C7 and arthrodesis with a titanium cage. She was started on vancomycin and zosyn until bone culture sensitivities resulted MSSA and was transitioned to cefazolin before discharge.
Outcome:
Blood cultures were negative. Echocardiogram did not show signs of endocarditis. She completed a 6 week course of antibiotics. She had to wear her neck brace for several months. Repeat Xray showed stable hardware. She underwent several months of physical therapy to manage her residual neck pain and radicular symptoms. After completing therapy, she returned to full activity about 1 year later. Her eczema and seborrheic dermatitis is still controlled with topical treatment.
Author's Comments:
Cervical vertebral osteomyelitis (VO) is uncommon with reported 2.4 cases per 100,000 population and 11% of all VO cases (lumbar VO, 58%, thoracic VO, 30%) (1,2). VO commonly occurs via hematogenous spread; one third of cases are associated with endocarditis (1-3). VO may not present with fever (reported incidence 35-60%) as people may be taking analgesics (1). Thus, there may be a delay in diagnosis up to 42-59 days in some studies (1). Many patients have underlying medical conditions like diabetes, heart disease, renal failure, cancer, immunosuppressive disorders, or history of IV drug use (1,2, 4-7). This patient may have been at risk due to her underlying skin condition, prior neck trauma, and brief prednisone usage (1,7).
Editor's Comments:
Vertebral osteomyelitis is a very uncommon diagnosis but one that should be considered for those patients that present with worsening neck pain and other red flags such as fever, radiating symptoms, and abnormal laboratory findings, especially if certain underlying medical conditions exist. Early MR imaging is essential to make this diagnosis and start appropriate treatment. Urgent surgery is often considered to help improve outcomes and avoid permanent neurologic sequelae amongst other causes of morbidity and mortality.
References:
1. Zimmerli W. Clinical practice. Vertebral osteomyelitis. N Engl J Med. 2010 Mar 18;362(11):1022-9. doi: 10.1056/NEJMcp0910753. PMID: 20237348
2. Tsai CE, Lee FT, Chang MC, Yu WK, Wang ST, Liu CL. Primary cervical osteomyelitis. J Chin Med Assoc. 2013 Nov;76(11):640-7. doi: 10.1016/j.jcma.2013.07.011. Epub 2013 Sep 8. PMID: 24025539.
3. Epstein N. Diagnosis, and Treatment of Cervical Epidural Abscess and/or Cervical Vertebral Osteomyelitis with or without Retropharyngeal Abscess; A Review. Surg Neurol Int. 2020 Jun 20;11:160. doi: 10.25259/SNI_294_2020. PMID: 32637213; PMCID: PMC7332491.
4. Fang WK, Chen SH, Huang DW, Huang KC. Post-traumatic osteomyelitis with spinal epidural abscess of cervical spine in a young man with no predisposing factor. J Chin Med Assoc. 2009 Apr;72(4):210-3. doi: 10.1016/S1726-4901(09)70057-7. PMID: 19372079.
5. Bartels JW, Brammer RE. Cervical osteomyelitis with prevertebral abscess formation. Otolaryngol Head Neck Surg. 1990 Feb;102(2):180-2. doi: 10.1177/019459989010200216. PMID: 2113245.
6. Scully RE, et al. Case records of the Massachusetts General Hospital (case 16-1992). New England Journal of Medicine. 1992.
7. Stander S. Atopic Dermatitis. N Engl J Med. 2021 Mar 25;384(12):1136-1143. doi: 10.1056/NEJMra2023911. PMID: 33761208.
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