Cervical osteomyelitis in the setting of multiple comorbidities: a complex anatomical approach. Illustrative case

Abstract

BACKGROUND

Vertebral osteomyelitis (VO), also known as spinal osteomyelitis or spondylodiscitis, is a rather rare yet serious disease comprising 3%–5% of all osteomyelitis cases, with only 3%–6% of this subset affecting the cervical spine. Risk factors include an advanced age, diabetes, immunosuppression, and intravenous (IV) drug use. The incidence of VO has increased over recent decades, with high-risk patients experiencing higher mortality rates. Treatment guidelines for VO are not standardized and rely on physician preference, often starting with IV antibiotics and progressing to surgery, if necessary.

OBSERVATIONS

A 54-year-old female with tracheostomy-dependent obesity hypoventilation syndrome, hypertension, and morbid obesity presented with upper back pain after a fall. Imaging revealed early C6–7 discitis osteomyelitis, which was initially managed conservatively with IV antibiotics. Her condition worsened, leading to anterior corpectomy of C6–7, followed by posterior cervical fusion from C5 to T2 in the sitting position. This approach was chosen due to the patient’s complex anatomy and tracheostomy.

LESSONS

This case underscores the need for unique surgical approaches in high-risk patients with complex anatomy. It highlights the importance of interdisciplinary care when managing VO, especially in patients with multiple comorbidities. Given the increasing rates of morbid obesity, this case provides valuable insights for neurosurgical decision-making in similar future cases.

https://thejns.org/doi/10.3171/CASE24448

Vertebral osteomyelitis (VO), otherwise referred to as “spinal osteomyelitis” or “spondylodiscitis,” is a rare but serious and potentially life-threatening disease that can develop because of surgical site infection, spinal trauma, or hematological spread.¹ Osteomyelitis that affects the spine accounts for approximately 3%–5% of all osteomyelitis cases,² while only 3%–6% of those cases affect the cervical vertebrae.³ The incidence of VO has increased from 2.9 per 100,000 persons to 4.8–7.4 per 100,000 persons over the past 2.5 decades.^{2, 4} Risk factors include an advanced age, diabetes, chronic corticosteroid use, immunosuppression, cancer, malnutrition, and intravenous (IV) drug use.¹ The annual mortality rate ranges from 1.7% to 2.2% in the United States,² with high-risk patients (older males with increasing comorbidity scores) experiencing higher mortality than low-risk patient populations.¹

Although treatment guidelines for VO do exist, they have not been standardized and rely primarily on physician preference.⁵ Initial management is conservative in the absence of neurological deficit or severe deformity at presentation and should consist of an IV antibiotic regimen. Surgical intervention is warranted with new neurological deficits, significant disc space or vertebral body collapse, kyphotic deformity formation, or epidural abscess causing neural compression.⁵ In the cervical spine, surgical management usually consists of anterior debridement and fusion of the involved vertebrae or discs, most often an anterior corpectomy.⁶ When multiple consecutive levels are involved or severe deformities are present, the anterior approach is followed by a separate posterior stabilization procedure via posterior cervical fusion,^{6, 7} known as a front-back or 360° approach. A general rule of thumb is that when two or more consecutive cervical vertebrae are affected, a 360° surgical approach is performed to confer stability and alignment.

Posterior cervical fusion is a procedure routinely performed with the patient prone; however, a subset of patients warrants surgery in a sitting position if there is a risk of airway obstruction in the prone position or if body habitus obstructs exposure.⁸ While the sitting position has been associated with an increased risk of venous air embolism development, previous studies have found that the sitting position offers a safety profile and outcomes similar to those in the prone position.^{8, 9} The sitting position also confers enhanced control of an unstable spine, especially in morbidly obese patients and those with ankylosing spondylosis.⁸

This report presents the case of a patient with C6–7 discitis/osteomyelitis in the setting of tracheostomy-dependent obesity hypoventilation syndrome, treated with anterior corpectomy followed by posterior cervical fusion in the sitting position. The case highlights the challenges of managing cervical osteomyelitis in high-risk patients, surgical decision-making, and interdisciplinary care required for optimal treatment of the condition in those with multiple comorbidities.

Illustrative Case

A 54-year-old female presented to the hospital with the chief complaint of upper back pain following a fall. Her complex medical history included tracheostomy-dependent obesity hypoventilation syndrome, essential hypertension, and class 3 morbid obesity.

Initial computed tomography (CT) of her cervical spine (Fig. 1) demonstrated the early stages of discitis/osteomyelitis at C6–7 with collapse of the disc space and erosion of the end plates. Initially, conservative management with IV antibiotics was chosen, as the patient did not have significant deformity or neurological compromise.

FIG. 1.

MRI of the cervical spine at presentation.

During her hospitalization, the patient exhibited significant deterioration of her condition both clinically and radiographically. On day 7, she began to experience intermittent shocking sensations and numbness in her arms and legs, particularly prominent in her left upper extremity in a C7 distribution. By the 12th day, she reported worsening pain, hyperesthesia, and allodynia throughout her body with distinct severity in her left upper extremity. At this point, repeat magnetic resonance imaging (MRI) of the cervical spine (Fig. 2) was performed. The decision was made to proceed with cervical decompression and fusion due to cervical cord compression with worsening vertebral body destruction and significant kyphotic deformity.

FIG. 2.

Repeat sagittal MRI of the cervical spine prior to surgery demonstrates an increased size of the epidural abscess from C4 to T1 with worsening cervical cord compression, kyphosis, and vertebral body destruction.

On day 19 of her hospitalization, the patient underwent an anterior corpectomy of C6 and C7. Her tracheostomy added complexity to this portion of the case (Fig. 3). The tubing was taped off and draped out of the surgical field. Her chin was taped to the head of the bed with her neck in extension. The neck incision was planned at the level of C6–7 but slightly more lateral than usual to avoid the tracheostomy site. Initial neck dissection was performed in a standard fashion. The esophagus appeared intact without involvement of the infection. The vertebral bodies were mostly disintegrated and removed with a combination of drill and suction. The posterior longitudinal ligament was taken down, and the abscess was irrigated copiously until the surgeons were confident that the cord was well decompressed. A titanium cage filled with allograft was inserted and secured with a plate. Given the high degree of instability, the patient’s deformity self-corrected during positioning, and no additional traction or manipulation was required during the procedure.

FIG. 3.

Photographs obtained during anterior approach debridement and C6–7 corpectomy, showing the tracheotomy tube in place.

The following day, posterior cervical fusion from C5 to T2 was performed with the goal of augmenting stability. Performing this portion of the procedure with the patient in the sitting position allowed for easier exposure of the anatomy by utilizing gravity for the downward retraction of redundant tissue of the neck and shoulders. It also allowed blood to clear more easily from the surgical field. The patient was placed in a true seated position with her head in a Mayfield head holder (Fig. 4). A C-arm was then turned sideways and positioned to obtain lateral radiographs. The neck was prepped and draped in the usual sterile fashion. A midline posterior neck dissection was then performed to expose the C5 to T2 vertebrae. Instrumentation was placed under the guidance of lateral fluoroscopy.

FIG. 4.

A C5–T2 posterior cervical fusion in the sitting position.

The patient underwent posterior instrumentation at one level above and two levels below the corpectomy cage with additional fixation at C6. The 360° approach is associated with higher fusion rates, allowing for shorter constructs. Given this patient’s complex medical history, the risk of venous air embolism in the seated position, and the danger of developing an additional soft tissue infection, a shorter construct was desired to reduce operative time. In the sitting position, the lateral mass screws required a steep cranial-caudal angulation; thus, the surgeon’s hand was dropped toward the floor with the screw trajectory pointing to the ceiling, whereas pedicle screws were placed in a trajectory nearly parallel to the floor. Instrumentation was placed under the guidance of lateral fluoroscopy. Considering the limitations of bone grafting in the sitting position, the brand of synthetic bone graft used in this case had a putty-like consistency, which allowed it to stick within the patient’s facet joints and lateral masses after packing without falling out.

The patient had immediate improvement in her paresthesia and allodynia postoperatively. Her postoperative course included consultation with the otolaryngology team to assess her tracheal condition. There was a high likelihood of revision of the tracheal procedure based on the otolaryngology team’s recommendation. Throughout her hospitalization, the patient remained on IV antibiotics (daptomycin and cefepime) with a planned end date set for 2 months out from her original presentation, per the guidance of infectious disease specialists. Despite these treatments, tissue cultures were negative for the presence of organisms, further complicating the diagnostic picture. Two weeks following surgery, she was discharged to a long-term acute care facility for rehabilitation. At the 3-month follow-up, she was ambulatory with 5/5 strength in her proximal bilateral upper extremities and 4/5 strength bilaterally in her hands. Postoperative CT at 1 year (Fig. 5) demonstrated adequate alignment and clear fusion of posterior elements with hardware intact.

FIG. 5.

One-year follow-up CT of the cervical spine demonstrates good bony and hardware alignment with evidence of solid fusion through the posterior elements from C5 to T2. Corpectomy was performed at C6–7, lateral mass screws were placed at C5–6, and pedicle screws were placed at T1–2.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

The primary observation of this report is that the complex anatomy of the patient, specifically a large body habitus in the setting of morbid obesity, required a combination of unique approaches that many neurosurgeons do not often encounter. Specifically, this is the first cited cervical osteomyelitis case utilizing anterior corpectomy and debridement with tracheostomy-dependent obesity hypoventilation syndrome, followed by a posterior cervical fusion in the sitting position.

Lessons

This case highlights the unique surgical approach warranted in the face of complex anatomy compounded with multiple comorbidities in a patient presenting with degenerating cervical osteomyelitis. The case is relevant in that VO comprises a rare subset of osteomyelitis patients in general and has an even scarcer incidence in the cervical spine, at 3%–6% of cited cases.³ A notable limitation of this paper is the case in a single patient. Yet given the rarity of this condition along with the patient’s characteristics, we believe that it is instrumental in instructing neurosurgical patient-care decision-making for high-risk patients. Furthermore, although guidelines for the treatment of VO exist, they are not standardized and are often institutional or provider driven.⁵ The complex anatomy in the face of a large body habitus is especially pertinent due to increasing rates of morbid obesity across the United States, with an age-adjusted prevalence of 9.2% in 2017–2018.¹⁰

The patient has voiced continuous appreciation for the care she received from our team. While acknowledging that this was a difficult barrier to overcome in her life, she has expressed satisfaction with the overall outcome and continues to work hard in rehabilitation.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Leoni, Derouen, Wilson. Acquisition of data: Leoni, Wilson. Analysis and interpretation of data: Leoni. Drafting the article: Leoni, Veillon-Bradshaw, Derouen, Shoap. Critically revising the article: Leoni, Veillon-Bradshaw, Derouen, Shoap. Reviewed submitted version of manuscript: Leoni, Veillon-Bradshaw, Shoap. Approved the final version of the manuscript on behalf of all authors: Leoni. Study supervision: Wilson, Shoap.

Correspondence

Jack A. Leoni: Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA. jleoni@lsuhsc.edu.