Diagnosis and Management of Adult Pyogenic Osteomyelitis of the Cervical Spine

Frank L. Acosta Jr., MD; Cynthia T. Chin, MD; Alfredo Quiñones-Hinojosa, MD; Christopher P. Ames, MD; Philip R. Weinstein, MD; Dean Chou, MD

Disclosures

Neurosurg Focus. 2004;17(6) 

In This Article

Abstract and Introduction

Abstract

Establishing the diagnosis of cervical osteomyelitis in a timely fashion is critical to prevent catastrophic neurological injury. In the modern imaging era, magnetic resonance imaging in particular has facilitated the diagnosis of cervical osteomyelitis, even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, disagreement remains regarding appropriate surgical treatment. The role of instrumentation and type of graft material after cervical decompression remain controversial. The authors describe the epidemiological features, pathogenesis, and diagnostic evaluation, and the surgical and nonsurgical interventions that can be used to treat osteomyelitis of the cervical spine. They also review the current debate about the role of instrumentation in preventing spinal deformity after surgical decompression for cervical osteomyelitis. Based on this review, the authors conclude that nonsurgical therapy is appropriate if neurological signs or symptoms, instability, deformity, or spinal cord compression are absent. Surgical decompression, debridement, stabilization, and deformity correction are the goals once the decision to perform surgery has been made. The roles of autogenous graft, instrumentation, and allograft have not been clearly delineated with Class I data, but the authors believe that spinal stability and decompression override creating an environment that can be completely sterilized by antibiotic drugs.

Introduction

According to Dimar, et al.,[15] Hippocrates was the first to describe osteomyelitis of the spine in 400 BCE. In 1864, as discussed in Wiltse,[67] Boudof described draining an abscess of the cervical spine via an anterior approach. In the same historical review, Wiltse reported Wright's account of draining a tuberculous abscess through the pharynx in 1930. Although the advent of antibiotic therapy enabled early stages of vertebral osteomyelitis to be managed with out surgery, more advanced disease with spinal in stability, cord compression, and neurological deficits required surgical decompression and stabilization.[7,54] Nonetheless, anterior approaches to the cervical spine were seldom used until Robinson and Smith[50] described a technique for anterior cervical disc removal and fusion in 1955. Current surgical treatment options include anterior or posterior decompression with or without fusion, and with or without instrumentation.[16,24,35,36,39,40] The fact that there exist several alternative surgical approaches highlights the lack of a consensus on the optimal operative treatment for cervical vertebral osteomyelitis.

The large diameter of the cervical spinal cord relative to the spinal canal and the significant range of motion of the cervical spine make cervical osteomyelitis a unique entity. A small epidural infection can cause a neurological deficit. Bone destruction and ligamentous laxity can manifest as severe instability, deformity, or a neurological deficit.[13] Establishing the diagnosis of cervical osteomyelitis in a timely fashion is critical to prevent catastrophic neurological injury.[15,41] In the modern imaging era, MR imaging in particular has facilitated the diagnosis of cervical osteomyelitis even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, there remains disagreement regarding appropriate surgical treatment. The role of instrumentation and type of graft material after cervical decompression remain controversial. We describe the epidemiological features, pathogenesis, diagnostic evaluation, and surgical and nonsurgical interventions that can be used to treat osteomyelitis of the cervical spine. We also review the current debate about the role of instrumentation in preventing spinal deformity after surgical decompression for cervical osteomyelitis.

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