PURULENT OSTEOMYELITIS EPIDURAL ABSCESS
OF THE CERVICAL SPINE WITH
OPERATIVE TREATMENT BY MEANS OF DORSAL AND VENTRAL APPROACH
P. Gruff, B. Friedrich, H. G. Mertens and J. Bockhorn*
SUMMARY The present case concerns an acute purulent osteomyelitis with an epidural abscess, located particularly in the intervertebral foramen between C5 and C6, which led to infection by staphylococci of the adjacent vertebral arches and vertebral bodies. An obstruction of the CSF passage was discovered by myelography at the level between C5 and C6. The bony tissue changed by inflammation was removed as far as possible by laminectomy. After irrigation of the epidural space with antibiotics and after control of the severe inflammation, the vertebral bodies C6 and C7 which were destroyed by the spreading inflammatory granulations, could be removed by a ventral approach 4 weeks later. The defect was filled with spongiosa chips. After immobilisation in a plaster shell and Crutchfield extension for 8 weeks the patient was slowly mobilized. A fusion of the vertebral bodies C5 and C6, C6/C7 and C7/D1 was achieved. A dislocation of the cervical spine did not occur and the patient recovered completely except for a paresis of the right hand. Treatment of this very rare and severe case was only possible by a combined dorsal and ventral procedure on the cervical spine. INTRODUCTION I n f l a m m a t o r y lesions of the spine are to b e classified into two m a i n groups: p u r u l e n t a n d s u b a c u t e o r c h r o n i c g r a n u l a t i n g infections (VINCENT DUS, 1960). T h e e a r l y stage of the acute t y p e is c h a r a c t e r i z e d as a rule b y signs of a g e n e r a l infection f o l l o w e d by a s t a g e with pains, fixation of the spine a n d r a d i c u l a r s y m p t o m s ; in the l,ate stage, a c o m p r e s s i o n of the spinal c o r d with .transverse lesion will b e f o u n d (WEBER, 1955). Such diseases l o c a l i z e d in the cervical spinal a r e a are e x t r e m e l y rare (ALLBROOK, 1949; JAKOBY, 1952). E v e n m o r e r a r e ,are cases successfully treated. BARTEL, SCHIEFER, HEILBRONN a n d .rAHEL, 1972, r e p o r t e d a soldier suffering f r o m an infection of a cervical v e r t e b r a , c a u s e d b y a shell s p l i n t e r injury. T h e v e r t e b r a was r e m o v e d b y m e a n s of v e n t r a l a p p r o a c h and was r e p l a c e d b y a b o n e graft f r o m the iliac crest.
* From the Neurosurgical Clinic (Director: Prof. Dr. K. A. Bushe). the Surgical Clinic (Director: Prof. Dr. E. Kern). and the Neurological Clinic (Director: Prof. Dr. H. G. Mea'tens) of the University of Wiirzburg. Clin. Neurol. Neurosurg., Vol. 79~1
58 This paper concerns ,a 38 year old man, who was cured from an acute osteomyelitis with an extensive epidural abscess of .the lower cervical spine and with destruction of the 6th and 7t.h cervical vertebrae by a combined operative procedure using the dorsal and ventral approach.
CASE REPORT
A 38 year old man, healthy till then, fell sick in the summer of 1974: An abscess on the left wrist, oaused by a bee's sting, had been incised. Though the inflammation of the hand healed it moved later on up t,he arm to the elbow ,and further to the ,axilla and finally settled in the region of the cervical spine, causing the patient to suffer intolerable pains in the shoulder and arm. In the last week of 1974 in addition to the pains the patient developed high temperature, meningism and paresis of the shoulder and upper arm. X-rays of the cervical spine showed enlargement of the left intervertebra,1 foramen between C5 and C6, and increased density of the 5th and 6th cervical vertebrae (fig. 1 and 2). Pantopaque myelography confirmed an incomplete block at this level.
Fig. 1
Fig 2
On December 31, 1974, a laminectomy was carried out and an extensive epidural abscess was found. The middle of the abscess was localised in the left in tervertebral foramen between C5 and C6. The bony structures (vertebral arches, part of the spinous processes and the vertebral bodies) were also affected.
59 After removing all those bony structures affected by .the inflammatory process, as far as they could be reached by the dorsal approach, and curetting the left C5/C6 intervertebral foramen, the epidural space was drained and irrigated with antibiotics. Bacteriological examination of the purulent material revealed pathogenetic staphylococci. Following the operation the .temperature returned .to normal, the pains disappeared and the paresis improved. X-rays performed 4 weeks later showed an extensive destruction of the.bodies of C6 .and C7 (fig. 3).
Fig. 3
By means of a ventral approach the cervical vertebrae destroyed by granulating inflammatory changes were removed, and the defect filled with chips from the greater trochanter. Post-operatively the head and chest of the patient were incased in a plaster cast, the head was immobilized addkionally by slight traction wi~h Crutchfield calhpers for 8 weeks. As soon as X-rays had show;n the beginning of consolidation of the bony destruction the patient was mobilized. At this time the cervical spine was supported by a plaster collar. 12 weeks after the second operation the patient was discharged from ,hospital with a residual weakness of the right hand. The control X-rays of the cervical spine showed a good consolidation of the cervical vertebral bodies previously destructed by .the disease and a fusion between the 5th and the 6th and 6th and 7th cervical vertebrae and the 7th cervical and the first dorsal vertebrae (fig. 4 and 5).
60
Fig. 4
Fig. 5
DISCUSSION
As mentioned in the introduction, purulent osteomyelitis of the cervical spine is an extremely rare .disease. The present case of a serious purulent osteomyelitis of the cervical spine involving the vertebral arches, the intervertebral foramen C5/6 and destroyir~g the vertebral bodies of C6 .and C7 is extremely uncommon, not only because of the rarity from a statistical point of view but also the peculiar cause of the disease in this particular case. The patient reported tl~at an abscess of the ,hand had been cauterized. The inflammation did not heal, but moved up the arm to the neck. According to this description a lymphogenic dissemination must be assumed. Further cases, reported in the literature, deal with hematogenic infections (ALLBROOK, 1949; JAKOBY, 1952; MORIN, 1953; ABLIN and ERICKSON, 1958) BARTAL et al. reported on an infection, caused by direct trauma (also RIMALOVSKIand ARONSON, 1968). Despite the clinical picture of a very acute inflammation with widening of the intervertebral foramen (i.e. bony destruction), surgical treatment was necessary as the process had led to a spinal space occupying lesion (incomplete block on the Pantopaque myelogram). An operation was carried out at the risk of losing the stability of the cervical spine. After laminectomy of the lower cervical spine i,t was possible to control the highly inflammatory disease by removing the epidural abscess. The infection changed into a granulating chronic stage; the ventral approach to the cervical spine was necessary: the two lowest cervical vertebrae were exposed and had to be removed. The defect was filled with chips from the
61 greater trochamer. We hoped that bony .chips would h e n more easily than a large bone graft. After strict immobilisation for 8 weeks there was not only a healing, but even a bony fusion between the cervical bodies C5/6, C6/7 and the cervical vertebra C7 and the first dorsal vertebra (fig. 4 and 5). W e b e l i e v e t h a t it was i m p o r t a n t to p r o c e e d f r o m the d o r s a l and' v e n t r a l a p p r o a c h in o r d e r to a c h i e v e a successful o u t c o m e , a l t h o u g h it ,had to b e c a r r i e d o u t in two stages. P r o c e e d i n g in this w a y i,t was p o s s i b l e on ,the o n e h a n d to r e m o v e the i n f l a m m a t o r y o s t e o l y t i c ch,anges o n the v e r t e b r a l :arches as well as at the spinal processes, a n d e s p e c i a l l y in the i n t e r v e r t e b r a l f o r a m e n C5/6, a n d o n the o t h e r h a n d to r e a c h a n d to r e m o v e t h e tissue of the v e r t e b r a l b o d i e s C6 a n d C7, affected b y c h r o n i c g r a n u l a t i n g i n f l a m m a t i o n . A p a r t f r o m that the long a n d strict i m m o b i l i s a t i o n of t h e cervical spine by a pl,aster cast, the slight ,traction e x e r t e d b y m e a n s of C r u t c h f i e l d tongs, a n d high doses of antibiotics m u s t have p l a y e d an i m p o r t a n t role in t h e healing.
LITERATURE
ABLIN, G. and T. C. ERICKSON (1958). Osteomyelitis of cervical vertebrae (and quadriparesis) secondary to urinary tract infection. J. Neurosurg., 15, 455. ALLBROOK,D. B. (1949). Cervicodorsal osteomyelitis with extradural abscess. Lancet, 2, 1174. BARTEL, A. D., SCHIEFER, J., HEILBRONN, Y. D. and M. YAHEL (1972). Anterior interbody fusion for cervical osteomyelitis. J. Neurol. Neurosurg. Psych., 15, 133. JACOBY, w. (1952). Der akute spinale EpiduralabszeB bei bakterieller Allgemeininfektion. Zbl. Neurochir., 12, 265. MORIN, H. (1953). Les 6pidurites staphylococciques. Rev. neurol., 89, 110. RIMALOVSKI, A. B. and s. M. ARONSON (1968). Abscess of medulla oblongata associated with osteomyelitis of odontoid process. Case report. J. Neurosurg. 29, 97. SCHMALZ,A. (1925). Ober akute Pachymeningitis spinalis externa. Virchows Arch., 257, 521. SILLEVISSMITT, W. G. (1929). Sur l'absc~s spinal epidural. Rev. neurol., 2, 512. VINCENT DUS (1960). Spinal Peripachymeningitis (Epidural Abscess). J. Neurosurg., 17, 972. WEBER, W. (1955). Ober spinale Eiterungen und ihre Komplikationen (RilckenmarksabszeB). Zbl. Neurochir., 15, 226.
OF THE CERVICAL SPINE WITH
OPERATIVE TREATMENT BY MEANS OF DORSAL AND VENTRAL APPROACH
P. Gruff, B. Friedrich, H. G. Mertens and J. Bockhorn*
SUMMARY The present case concerns an acute purulent osteomyelitis with an epidural abscess, located particularly in the intervertebral foramen between C5 and C6, which led to infection by staphylococci of the adjacent vertebral arches and vertebral bodies. An obstruction of the CSF passage was discovered by myelography at the level between C5 and C6. The bony tissue changed by inflammation was removed as far as possible by laminectomy. After irrigation of the epidural space with antibiotics and after control of the severe inflammation, the vertebral bodies C6 and C7 which were destroyed by the spreading inflammatory granulations, could be removed by a ventral approach 4 weeks later. The defect was filled with spongiosa chips. After immobilisation in a plaster shell and Crutchfield extension for 8 weeks the patient was slowly mobilized. A fusion of the vertebral bodies C5 and C6, C6/C7 and C7/D1 was achieved. A dislocation of the cervical spine did not occur and the patient recovered completely except for a paresis of the right hand. Treatment of this very rare and severe case was only possible by a combined dorsal and ventral procedure on the cervical spine. INTRODUCTION I n f l a m m a t o r y lesions of the spine are to b e classified into two m a i n groups: p u r u l e n t a n d s u b a c u t e o r c h r o n i c g r a n u l a t i n g infections (VINCENT DUS, 1960). T h e e a r l y stage of the acute t y p e is c h a r a c t e r i z e d as a rule b y signs of a g e n e r a l infection f o l l o w e d by a s t a g e with pains, fixation of the spine a n d r a d i c u l a r s y m p t o m s ; in the l,ate stage, a c o m p r e s s i o n of the spinal c o r d with .transverse lesion will b e f o u n d (WEBER, 1955). Such diseases l o c a l i z e d in the cervical spinal a r e a are e x t r e m e l y rare (ALLBROOK, 1949; JAKOBY, 1952). E v e n m o r e r a r e ,are cases successfully treated. BARTEL, SCHIEFER, HEILBRONN a n d .rAHEL, 1972, r e p o r t e d a soldier suffering f r o m an infection of a cervical v e r t e b r a , c a u s e d b y a shell s p l i n t e r injury. T h e v e r t e b r a was r e m o v e d b y m e a n s of v e n t r a l a p p r o a c h and was r e p l a c e d b y a b o n e graft f r o m the iliac crest.
* From the Neurosurgical Clinic (Director: Prof. Dr. K. A. Bushe). the Surgical Clinic (Director: Prof. Dr. E. Kern). and the Neurological Clinic (Director: Prof. Dr. H. G. Mea'tens) of the University of Wiirzburg. Clin. Neurol. Neurosurg., Vol. 79~1
58 This paper concerns ,a 38 year old man, who was cured from an acute osteomyelitis with an extensive epidural abscess of .the lower cervical spine and with destruction of the 6th and 7t.h cervical vertebrae by a combined operative procedure using the dorsal and ventral approach.
CASE REPORT
A 38 year old man, healthy till then, fell sick in the summer of 1974: An abscess on the left wrist, oaused by a bee's sting, had been incised. Though the inflammation of the hand healed it moved later on up t,he arm to the elbow ,and further to the ,axilla and finally settled in the region of the cervical spine, causing the patient to suffer intolerable pains in the shoulder and arm. In the last week of 1974 in addition to the pains the patient developed high temperature, meningism and paresis of the shoulder and upper arm. X-rays of the cervical spine showed enlargement of the left intervertebra,1 foramen between C5 and C6, and increased density of the 5th and 6th cervical vertebrae (fig. 1 and 2). Pantopaque myelography confirmed an incomplete block at this level.
Fig. 1
Fig 2
On December 31, 1974, a laminectomy was carried out and an extensive epidural abscess was found. The middle of the abscess was localised in the left in tervertebral foramen between C5 and C6. The bony structures (vertebral arches, part of the spinous processes and the vertebral bodies) were also affected.
59 After removing all those bony structures affected by .the inflammatory process, as far as they could be reached by the dorsal approach, and curetting the left C5/C6 intervertebral foramen, the epidural space was drained and irrigated with antibiotics. Bacteriological examination of the purulent material revealed pathogenetic staphylococci. Following the operation the .temperature returned .to normal, the pains disappeared and the paresis improved. X-rays performed 4 weeks later showed an extensive destruction of the.bodies of C6 .and C7 (fig. 3).
Fig. 3
By means of a ventral approach the cervical vertebrae destroyed by granulating inflammatory changes were removed, and the defect filled with chips from the greater trochanter. Post-operatively the head and chest of the patient were incased in a plaster cast, the head was immobilized addkionally by slight traction wi~h Crutchfield calhpers for 8 weeks. As soon as X-rays had show;n the beginning of consolidation of the bony destruction the patient was mobilized. At this time the cervical spine was supported by a plaster collar. 12 weeks after the second operation the patient was discharged from ,hospital with a residual weakness of the right hand. The control X-rays of the cervical spine showed a good consolidation of the cervical vertebral bodies previously destructed by .the disease and a fusion between the 5th and the 6th and 6th and 7th cervical vertebrae and the 7th cervical and the first dorsal vertebrae (fig. 4 and 5).
60
Fig. 4
Fig. 5
DISCUSSION
As mentioned in the introduction, purulent osteomyelitis of the cervical spine is an extremely rare .disease. The present case of a serious purulent osteomyelitis of the cervical spine involving the vertebral arches, the intervertebral foramen C5/6 and destroyir~g the vertebral bodies of C6 .and C7 is extremely uncommon, not only because of the rarity from a statistical point of view but also the peculiar cause of the disease in this particular case. The patient reported tl~at an abscess of the ,hand had been cauterized. The inflammation did not heal, but moved up the arm to the neck. According to this description a lymphogenic dissemination must be assumed. Further cases, reported in the literature, deal with hematogenic infections (ALLBROOK, 1949; JAKOBY, 1952; MORIN, 1953; ABLIN and ERICKSON, 1958) BARTAL et al. reported on an infection, caused by direct trauma (also RIMALOVSKIand ARONSON, 1968). Despite the clinical picture of a very acute inflammation with widening of the intervertebral foramen (i.e. bony destruction), surgical treatment was necessary as the process had led to a spinal space occupying lesion (incomplete block on the Pantopaque myelogram). An operation was carried out at the risk of losing the stability of the cervical spine. After laminectomy of the lower cervical spine i,t was possible to control the highly inflammatory disease by removing the epidural abscess. The infection changed into a granulating chronic stage; the ventral approach to the cervical spine was necessary: the two lowest cervical vertebrae were exposed and had to be removed. The defect was filled with chips from the
61 greater trochamer. We hoped that bony .chips would h e n more easily than a large bone graft. After strict immobilisation for 8 weeks there was not only a healing, but even a bony fusion between the cervical bodies C5/6, C6/7 and the cervical vertebra C7 and the first dorsal vertebra (fig. 4 and 5). W e b e l i e v e t h a t it was i m p o r t a n t to p r o c e e d f r o m the d o r s a l and' v e n t r a l a p p r o a c h in o r d e r to a c h i e v e a successful o u t c o m e , a l t h o u g h it ,had to b e c a r r i e d o u t in two stages. P r o c e e d i n g in this w a y i,t was p o s s i b l e on ,the o n e h a n d to r e m o v e the i n f l a m m a t o r y o s t e o l y t i c ch,anges o n the v e r t e b r a l :arches as well as at the spinal processes, a n d e s p e c i a l l y in the i n t e r v e r t e b r a l f o r a m e n C5/6, a n d o n the o t h e r h a n d to r e a c h a n d to r e m o v e t h e tissue of the v e r t e b r a l b o d i e s C6 a n d C7, affected b y c h r o n i c g r a n u l a t i n g i n f l a m m a t i o n . A p a r t f r o m that the long a n d strict i m m o b i l i s a t i o n of t h e cervical spine by a pl,aster cast, the slight ,traction e x e r t e d b y m e a n s of C r u t c h f i e l d tongs, a n d high doses of antibiotics m u s t have p l a y e d an i m p o r t a n t role in t h e healing.
LITERATURE
ABLIN, G. and T. C. ERICKSON (1958). Osteomyelitis of cervical vertebrae (and quadriparesis) secondary to urinary tract infection. J. Neurosurg., 15, 455. ALLBROOK,D. B. (1949). Cervicodorsal osteomyelitis with extradural abscess. Lancet, 2, 1174. BARTEL, A. D., SCHIEFER, J., HEILBRONN, Y. D. and M. YAHEL (1972). Anterior interbody fusion for cervical osteomyelitis. J. Neurol. Neurosurg. Psych., 15, 133. JACOBY, w. (1952). Der akute spinale EpiduralabszeB bei bakterieller Allgemeininfektion. Zbl. Neurochir., 12, 265. MORIN, H. (1953). Les 6pidurites staphylococciques. Rev. neurol., 89, 110. RIMALOVSKI, A. B. and s. M. ARONSON (1968). Abscess of medulla oblongata associated with osteomyelitis of odontoid process. Case report. J. Neurosurg. 29, 97. SCHMALZ,A. (1925). Ober akute Pachymeningitis spinalis externa. Virchows Arch., 257, 521. SILLEVISSMITT, W. G. (1929). Sur l'absc~s spinal epidural. Rev. neurol., 2, 512. VINCENT DUS (1960). Spinal Peripachymeningitis (Epidural Abscess). J. Neurosurg., 17, 972. WEBER, W. (1955). Ober spinale Eiterungen und ihre Komplikationen (RilckenmarksabszeB). Zbl. Neurochir., 15, 226.
