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Case Report Cervical Discitis with Spinal Epidural Abscess After Percutaneous Nucleoplasty: a Case Report

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Case Report Cervical Discitis with Spinal Epidural Abscess After Percutaneous Nucleoplasty: a Case Report Int J Clin Exp Med 2016;9(11):22851-22855 www.ijcem.com /ISSN:1940-5901/IJCEM0034112 Case Report Cervical discitis with spinal epidural abscess after percutaneous nucleoplasty: a case report Ruofeng Yin1, Jeremiah Raphael Cohen2, Qingsan Zhu1, Leichao Zhang3, Rui Gu3, Hua Xin4 Departments of 1Orthopaedic Surgery, 3Pathology, 4Thoracic Surgery, China-Japan Union Hospital, Jilin University, Changchun, China; 2David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States of America Received June 20, 2016; Accepted August 15, 2016; Epub November 15, 2016; Published November 30, 2016 Abstract: Disc space infections are a rare complication that can potentially follow any invasive spinal procedure. Infections of the cervical region, such as epidural abscesses, are particularly rare and should be diagnosed and treated decisively. In this report, we study a 46-year-old male patient with severe neck pain radiating to his left upper extremity after percutaneous cervical Coblation® nucleoplasty, a previously undocumented complication. A thorough examination revealed osteomyelitis with an accompanying epidural abscess at the site of related disc. The patient experienced symptomatic relief immediately after emergency debridement and reconstruction of the related segment. Following the administration of culture-sensitive antibiotics and appropriate post-operative management, repeated imaging and physical exam revealed a satisfactory recovery. Taken together, cervical discitis is an infre- quent iatrogenic complication with potentially catastrophic sequelae. It is important for understanding potential risks, early diagnosis via physical exam and imaging, and prompt management with open surgical treatment and antibiotic therapy for successful management of this rare complication. Keywords: Spinal epidural abscess, percutaneous nucleoplasty, cervical discitis, coblation nucleoplasty Introduction Case report Disc space infection is a rare complication A 46-year-old male patient with a noncontribu- that can follow any invasive spinal procedure. It tory past medical history underwent percutane- is particularly rare in the cervical region and ous cervical Coblation® nucleoplasty due to was first described by Turnbull in 1953 [1]. An neck pain. Three days after the procedure, the epidural abscess in the disc space may elicit patient developed slowly increasingly neck pain severe neck pain and neurologic deficits. Post- with radiation to his left shoulder and hand by procedural discitis represents 30.1% of all seven days after. Cervical bracing was required cases of pyogenic discitis and has been linked to support the patient’s head and keep his neck to almost every open and minimally invasive in flexion to mitigate the pain. The patient did spinal procedure including less invasive pro- not develop fever or chills during this period. cedures such as discography [2-6]. Percutan- eous cervical nucleoplasty was first reported Physical examination showed numbness of the in 2005 [7], and has been widely used in left forearm and radial two and a half fingers. patients with symptomatic cervical herniated Muscle strength from bicep to flexor decrease disks [8, 9]. to IV (-), Visual Analogue Scale (VAS) was 10. Though we believed that the Coblation® tech- Laboratory examination revealed a white blood nique in the treatment of cervical disc disor- cell count of 18.7×109/L, and erythrocyte sedi- der is a safe, minimally-invasive procedure mentation rate (ESR) was elevated to 50 mm/h with less resulting patient discomfort [10], post (normal range at 0-20 mm/h), and C-Reactive operational complications are always possible protein (CRP) elevated to 94.4 mg/L (normal and should be watched for. range at <10 mg/L). Cervical discitis with spinal epidural abscess after percutaneous nucleoplasty After surgery, the patient’s symptoms of radi- ating neck pain immediately resolved. The VAS decreased to 3/10 and was proven to have originated from iliac bone harvesting surgical incision. Muscle strength was restored to V 24 hours post operatively. A follow-up MRI at 7 days showed resolution of the epidural collec- tion with no observable signal changes in the C5 and C6 vertebral bodies, and a return to a normal lordotic curvature (Figure 4). Discussion Post-operative infection following direct cervi- cal disc procedures is exceedingly rare [11, 12]. Normal intervertebral discs are largely avas- cular with nutrition supplied through the verte- bral end plates and annular fibrosus via diffu- sion from capillary plexuses [4, 13]. Additionally, the bone-disc interface is only partially perme- able to substrates. The avascular nature of the Figure 1. Segmental kyphotic position due to col- disc renders it vulnerable to iatrogenic innocu- lapse of C5-6 intervertebral disc. lation of bacteria during interventional proce- dures and makes it particularly difficult to treat Lateral neck X-ray showed a disc height loss at with antibiotics alone [4]. C5-6 and C6-7, with the whole cervical spine in an abnormal kyphotic position (Figure 1). A fol- Coblation is a new kind of radiofrequency sur- low-up cervical MRI showed signal changes gery that uses a low reaction temperature to indicating osteomyelitis in the C5 and C6 verte- limit the amount of heat delivered to surro- bral bodies with a C5-6 disc space infection unding structures, and was first adopted for and epidural collection (Figure 2). A CT scan of treating tonsillar hypertrophy [14]. In 2005, the same region revealed a wormy appearance Nardi et al. first reported a cervical nucleo- at the involved level (Figure 3). plasty with coblation [7]. Lower heat ensures a lower risk of neurological injuries, which makes Treatment coblation more popular in minimally invasive nucleoplasty [15, 16]. Immediately after the diagnosis was made, the patient was taken to the operating room and In the development of discitis, osteomyelitis at put under general anesthesia. An anterior cer- the involved segment can lead to increased vical intervertebral disc resection at C5-6 was pressure in the disc space. In some patients performed, during which a fistulous channel who undergo nucleoplasty, structural imper- extending from the disc space to spinal canal fections in the posterior disc or posterior longi- was discovered. A standardized anterior cervi- tudinal ligament can lead to pyogenic fluid cal decompression was then performed with drainage into the cervical canal and develop- removal and cleaning of the abscess collection. ment of an abscess. Afterwards, an anterior titanium cervical inter- nal fixation with an auto-iliac strut bone graft. Fever, pain overlying the site of compression, The wound was closed in layers and drained for and progressive neurologic deficits has been 48 hours. A rigid head-neck-chest bracing was characterized as the triad sequence of spinal prescribed for additional postoperative immo- epidural abscess clinical syndrome [17, 18]. bilization. A culture and sensitivity of the puru- Although our patient in this case did not lent material collected intra-operatively reve- become febrile, he did develop severe neck aled Staphylococcus epidermidis with sensi- pain and neurologic symptoms within 3 weeks tivity to ceftriaxone, which was then immedi- following nucleoplasty. We therefore suggest ately prescribed. that physicians should be aware of the possi- 22852 Int J Clin Exp Med 2016;9(11):22851-22855 Cervical discitis with spinal epidural abscess after percutaneous nucleoplasty Figure 2. Cervical MRI image. Left image: signal changes indicating osteomyelitis extend in the C5 and C6 vertebral bodies with a C5-6 disc space infection and epidural collection. Right image: epidural collection to the left side which was in accordance with physical examination findings. Figure 3. Wormy appearance at the involved level indicated osteotomy extension during debridement. 22853 Int J Clin Exp Med 2016;9(11):22851-22855 Cervical discitis with spinal epidural abscess after percutaneous nucleoplasty cally coincide with increased signal intensity within the bone marrow of the adjacent verte- bral bodies, and are thought to represent edematous changes secondary to an inflam- matory process such as osteomyelitis [21]. In this case, the abscess was located immedi- ately posterior to the affected disc at C5-6. As soon as the diagnosis of an epidural abs- cess is made, anterior discectomy with drain- age of the infected material should be per- formed as soon as possible. Conservative management may lead to irreversible neuro- logical deficiency or death and should be avoid- ed. During the discectomy and drainage pro- cedure, disc tissue and purulent secretions should be collected and sent for culture and sensitivity analysis. Radulovic et al. reported a cervical spinal epi- dural abscess after oesophagoscopy where the entire cervical epidural space was irrig- ated with saline solution delivered through an infant urinary catheter [12]. However, in our case, we opted to mitigate the risk of spinal cord injury and further bacterial inoculation by not irrigating the intra-spinal canal space. Following a complete debridement of the disc space, posterior longitudinal ligament, and dev- astated bony endplate, it is important to recon- struct the cervical spine alignment. Auto-graft bone is the most favorable grafting source. Figure 4. Follow-up MRI at 7 days showed resolution Internal or outer instrumentation is neces-sary of the epidural collection with no observable signal to ensure the periodical immobilization.
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