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Cervical Myelopathy with Osteomyelitis or Something Else?

History

The patient is a 70-year-old male with a history of cervical pain. Neck pain has increased the last two months. He is an active golfer and complains of hand grip weakness which affects his swing and putting skills. The patient reports no difficulty swallowing, no fevers or chills. There is no history of trauma.

Examination

The patient presents with slight pitched forward cervical alignment. Hand grip weakness is noted. Lower body strength is good. Lab results showed elevated C-reactive protein, white blood cell count, and erythrocyte sedimentation rate.

Images

X-rays, CT, whole body scan, and MRI were performed.

Cervical lateral x-rayFigure 1A. Cervical lateral x-ray

 

cervical posterior anterior x-rayFigure 1B. Cervical posterior anterior x-ray

 

Cervical sagittal CTFigure 2. Cervical sagittal CT

 

Whole body scanFigure 3. Whole body scan

Cervical sagittal MRIs (Figs. 4A-4C) reveal marrow signal changes involving C5-C6.

Cervical sagittal MRI; marrow signal changes involve C5-C6Figure 4A

Cervical sagittal MRI; marrow signal changes involve C5-C6Figure 4B

Cervical sagittal MRI; marrow signal changes involve C5-C6Figure 4C

Cervical axial MRI; C5-C6Figure 4D. Cervical axial MRI; C5-C6 disc level

Diagnosis

Cervical myelopathy and diagnostic considerations that include discitis/osteomyelitis or tumor

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Selected Treatment

An open biopsy revealed infection, the integrity of the C5-C6 vertebral bodies was severely compromised by the osteomyelitis, a C4-C7 debridement and reconstruction using iliac crest strut and cervical spine locking plate was performed.

The patient was fitted with a rigid cervical collar, which was worn postoperatively for 8 weeks. He was started on antibiotics for staph aureus osteomyelitis.

Outcome

The patient recovered with no neurological deficits or neck pain. His hand grip weakness resolved and he returned to golf. His cervical lateral and posterior anterior x-rays at 12 months postop (Figs. 5A, 5B) demonstrate a good outcome.

Postoperative cervical lateral x-ray; C4-C7 plate and fusionFigure 5A

Postoperative cervical anterior posterior x-ray; C4-C7 plate and fusionFigure 5B

Spontaneous osteomyelitis has been described in the elderly even with no other risk factors. (1) In many cases a source is never identified. (2)

The MRI diagnosis correctly stated the differential diagnoses. However, tumors rarely involve the disc space. In this case, the primary site of infection appears to be the disc space with secondary spread into the surrounding vertebral bodies.

Some may argue that this could be followed nonoperatively. However, the focal kyphosis on plain films is likely to progress, especially given the extensive bony involvement. It should be noted that while most patients go on to autofuse, the deformity and neurologic compression here should be surgically addressed.

Graft selection is the biggest area of uncertainty. A large case series demonstrated no difference in infection rates between allograft and autograft in virgin cases. (3) Likewise, in patients with known osteomyelitis, no appreciable difference was found. (4) Three small case series even describe the use of BMP in the surgical treatment of infectious lesions with no untoward complications. (5, 6, 7) The inflammatory response created by BMP in this setting may even be therapeutic, although given the high rate of fusion these patients have, it is difficult to justify the higher cost.

References:
1. Cahill DW, Love LC, Rechtine GR. Pyogenic osteomyelitis of the spine in the elderly. J Neurosurg. 1991 Jun;74(6):878-86.

2. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis. 1979 Sep-Oct;1(5):754-76.

3. Mikhael MM, Huddleston PM, Nassr A. Postoperative culture positive surgical site infections after the use of irradiated allograft, nonirradiated allograft, or autograft for spinal fusion. Spine (Phila Pa 1976). 2009 Oct 15;34(22):2466-8.

4. Lu DC, Wang V, Chou D. The use of allograft or autograft and expandable titanium cages for the treatment of vertebral osteomyelitis. Neurosurgery. 2009 Jan;64(1):122-9; discussion 129-30.

5. O'Shaughnessy BA, Kuklo TR, Ondra SL. Surgical treatment of vertebral osteomyelitis with recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976). 2008 Mar 1;33(5):E132-9.

6. Aryan HE, Lu DC, Acosta FL Jr, Ames CP. Corpectomy followed by the placement of instrumentation with titanium cages and recombinant human bone morphogenetic protein-2 for vertebral osteomyelitis. J Neurosurg Spine. 2007 Jan;6(1):23-30.

7. Allen RT, Lee YP, Stimson E, Garfin SR. Bone morphogenetic protein-2 (BMP-2) in the treatment of pyogenic vertebral osteomyelitis. Spine (Phila Pa 1976). 2007 Dec 15;32(26):2996-3006.

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