Injury, Int. J. Care Injured 46 (2015) 1684–1688
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report Anna Voelker *, Nicolas H. von der Hoeh, Jens Gulow, Christoph-Eckhard Heyde Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 16 May 2015
Introduction: Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. Materials and methods: Case report and review of the literature. Results: A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. Conclusion: Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Cervical spondylodiscitis Stab wound to the neck Inflammation cervical spine Cervical epidural abscess
Introduction Cervical spondylodiscitis is a rare medical condition that requires prompt medical treatment. Due to the unique anatomy of the cervical spine, namely, the proximity of the neural structures to the ligaments and vertebral bones and the larger diameter of the spinal cord, neurological deficits can develop faster and exhibit more dramatic consequences. Radical surgical therapy that includes abscess drainage, the collection of tissue culture samples,
* Corresponding author at: Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany. Tel.: +49 3419723000; fax: +49 3419723009. E-mail addresses: [email protected] (A. Voelker), [email protected] (N.H. von der Hoeh), [email protected] (J. Gulow), [email protected] (C.-E. Heyde). http://dx.doi.org/10.1016/j.injury.2015.05.043 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
the decompression of neural structures and stabilization of the spine followed by antibiotic therapy are necessary to prevent severe neurological symptoms and sepsis [1,2]. The underlying causes of cervical spondylodiscitis include the hematogenous spreading of bacteria, retropharyngeal abscesses [3,4], iatrogenic infections [5,6] and complications caused by swallowing foreign bodies [7,8]. Patients with penetrating neck injuries (PNIs) are rarely seen in the emergency room. Typically, PNIs include stab wounds, gunshot wounds or other accidental causes and are the result of violent attacks, accidents or self-inflicted injuries [9,10]. PNIs can be divided into subgroups based on the type of injury (vascular or aerodigestive) or according to their location within three anatomical zones of the neck (zone I: from the clavicles/ sternum to the cricoid cartilage; zone II: from the cricoid cartilage to the angle of the mandible; and zone III: superior to the angle of mandible to the base of the skull). Depending on the anatomical
[(Fig._2)TD$IG]
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1685
zone of the injury and the condition of the patient (hemodynamically stable or unstable), various primary diagnostic work-ups are recommended, which range from mandatory neck exploration to computed tomographic angiography, bronchoscopy, esophagoscopy and serial examinations [11]. Treatments for PNI are individual and include surgical therapy, radiological therapy with stenting and conservative therapy [12]. We present a case report of cervical spondylodiscitis secondary to a stab wound injury of the neck. Materials and methods A 54-year-old male patient was brought to our orthopaedic surgery clinic with cervical spondylodiscitis of the C3/4 segment with paravertebral and epidural abscesses. The medical history indicated that the patient had been involved in a fight 5 weeks prior. After the assault, he had been taken to the emergency room, where multiple superficial wounds and hematomas all over his body were detected during the clinical examination. Furthermore, a one-centimetre-long cut on the left lateral side of the neck was discovered. The range of motion of the cervical spine was reduced due to pain. The initial CT-scan of the head and the midface ruled out intracranial injuries and revealed a fracture of the left zygomatic bone. Multiple air bubbles along the stab canal on the left side behind the sternocleidomastoid muscle were revealed (Fig. 1). Vessel injuries and injuries to other neck organs, as well as fractures of the cervical spine, were ruled out. Sonography of the abdomen failed to reveal free fluid or any indication of lesions in the parenchymatous organs. The lateral neck wound was thoroughly cleaned, and prophylactic antibiotic therapy with cefuroxime was started. A tetanus vaccine was administered. The fracture of the zygomatic bone was treated non-operatively. After 8 days, the wound healing was normal, and the patient was discharged from the hospital. Four weeks later, the patient presented with increasing neck pain and reduced general health to our outpatient clinic. An X-ray of the cervical spine showed a wider prevertebral soft tissue shadow (Fig. 2). Because of elevated inflammatory blood parameters (C-reactive protein (CRP), 91.7 mg/l; leukocytes (LZ),
[(Fig._1)TD$IG]
Fig. 2. X-ray of the cervical spine with wider prevertebral soft tissue shadow (red line, 1.6 mm) at the time of increasing neck pain 5 weeks after the stab wound to the neck. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
13.8 109/l) and a suspicion of spondylodiscitis, an MRI of the cervical spine was performed. The observed inflammatory changes involved the third and fourth vertebrae, as well as the intervertebral disc. Additionally, an epidural abscess that caused spinal stenosis and retropharyngeal inflammatory changes was observed (Fig. 3). Surgical treatment with debridement of the inflamed soft tissue, removal of the infected intervertebral disc with replacement through a bone graft from the iliac crest, easing of the epidural abscess, decompression of the spinal canal and plate osteosynthesis from C3 to C4 were performed (Figs. 4 and 5). Intraoperatively, the stab canal remained present, ending on the level of C3/4. That area was also debrided and syringed. Tissue probes were collected from all infectious sites for microbiological and pathological testing. All probes were negative for pathogens. The pathological report described chronic phlegmonous inflammation of the tissue. Calculated antibiotic therapy was started with clindamycin and rifampicin intravenously for seven days, followed by oral administration of clindamycin for an additional 7 weeks.
Results
Fig. 1. Native CT-scan of the neck shows the violation of the platysma with multiple air bubbles along the stab canal on the left side behind the sternocleidomastoid muscle.
The inflammatory laboratory parameters subsided after the radical surgical treatment and had returned to normal at the end of antibiotic treatment (CRP, 1.98 mg/l; LZ, 7.1 109/l). Three months after surgical intervention, follow-up X-rays and MRI and CT-scans of the cervical spine were carried out. The MRI revealed normal findings without ongoing inflammatory processes. The X-rays and CT scan indicated the osseous consolidation of the C3/4 segment (Fig. 6). Clinically, the patient was free from pain
[(Fig._3)TD$IG]
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Fig. 3. MRI of the cervical spine (A, T2 sequence) with inflammatory processes in the third and fourth vertebral bodies, prevertebral and epidural abscess; Image B (TIRM sequence) shows a transverse cut through the fourth vertebra body with compression of the spinal cord due to epidural abscess (narrow arrows) and a large prevertebral inflammatory process (wide arrows).
[(Fig._4)TD$IG]
Fig. 4. Intraoperative picture of the debrided intervertebral disc of the C3/4 segment (A). Postoperative picture of the debrided wound canal on the left side of the neck (B).
and presented a good functional outcome in terms of range of motion of the neck. Discussion Cervical spondylodiscitis is a rare and serious illness that can arise from various causes, such as pyogenic infections, iatrogenic infections and complications after swallowing foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. It is difficult to treat patients with penetrating neck injuries (induced by stab wounds, gunshot wounds or by accidents) in the emergency department. In general there are two different paths for diagnostics and treatment, depending on the cardiopulmonary condition of the patient. In a patient who presents in an unstable haemodynamic condition, prompt surgical neck exploration is necessary. The optimal surgical approach depends on the anatomical zone of the injury. Most injuries can be reached through an anterior sternocleidomastoid incision. Sometimes, a median sternotomy,
supraclavicular incision, transverse cervical collar incision or manipulations of the mandible are necessary to reach vessel injury [11]. For patients in a stable condition with a suspected vessel injury, computed tomographic angiography (CTA) is recommended to detect the direct and indirect signs of vessel injury. A CT-scan could decrease the likelihood of a negative neck exploration [13,14]. Nevertheless, Gonzalez et al. [15] showed in a prospective study that not all vessel injuries and esophageal injuries due to penetrating zone II injuries could be detected using a dynamic CT-scan or esophagography. In our case, the patient was in a stable cardiopulmonary condition when he was brought to the emergency room after the assault. During the initial examination a penetrating neck injury in zone II was found. The injury was dorsal to the sternocleidomastoid muscle and caused by a knife. Because of additional bruises on the face, the patient received a CT-scan of the head, forehead and neck. Determining the depth of a stab wound can be difficult. In the emergency room a blunt probing could be done but has a higher risk of additional tissue injuries.
[(Fig._5)TD$IG]
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Fig. 5. Control X-ray of the cervical spine after surgery with good positioning of the plate and screws along with the bone graft from the iliac crest between the vertebral bodies of C3 and C4.
[(Fig._6)TD$IG]
Fig. 6. Follow-up CT-scan (A) with correct positioning of the plate and bony fusion of the C3/4 segment; control MRI of the cervical spine with no signs of an ongoing inflammatory process (B, T2 sequence).
Osborn et al. found that computer tomographic angiography can be a helpful diagnostic tool to rule out major injuries in stable patients with penetrating neck wounds that penetrate the platysma. They demonstrated in a study of 120 patients with penetrating neck injuries that computer tomographic angiography can reduce the number of surgical neck explorations, resulting in shorter hospital stays for patients [16]. Contaminated wounds require a thorough lavage and debridement before suturing. Alternatively a loose adaptation can be considered. In either case prophylactic antibiotic therapy should be administered. The CT of our patient showed signs of a lesion to the platysma (Fig. 1). Retrospectively the primary wound treatment without thorough local exploration and irrigation was insufficient. However, the patient was treated with antibiotics until complete wound healing was achieved. No clinical signs of an ongoing infection were observed at this time.
In general, severe neck pain and poor physical condition are red flags indicating that spondylodiscitis should be suspected. A detailed medical history must be taken, and prompt assays of inflammatory laboratory parameters and an X-ray of the cervical spine are mandatory. Elevated inflammatory laboratory parameters indicate the urgent need for an MRI [1]. During the patient’s second visit to the clinic and under the clinical suspicion of an inflammatory process of the cervical spine, an MRI was performed. The radiological findings confirmed the diagnosis of spondylodiscitis involving the third and fourth vertebral bodies. Spinal stenosis caused by an epidural abscess was also observed. There are no reports in literature about the time between a PNI and the onset of symptoms associated with discitis. For spondylodiscitis after surgical procedures an interval up to 30 days and longer is reported [17].
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Various authors have reported that epidural abscesses are often observed in cervical spondylodiscitis [1,18] and that narrowing of the spinal cord can cause severe and rapidly worsening neurological symptoms. For cervical spondylodiscitis, surgical treatment is the mainstay of therapy and should include radical debridement with discectomy, decompression of the spinal canal with abscess evacuation as necessary and autologous bone grafting and stabilization [2]. Postoperative antibiotic therapy over the course of 6–8 weeks is recommended [2]. Our patient recovered well after surgical treatment. His neck pain decreased, and his inflammatory laboratory parameters were normal after 3 months. Implant-associated infections of the spine have only been reported in single case reports [19]. However, implantation of larger cages and plates after corporectomy do not lead to more persistent infections of the involved segments of the spine [20]. In the present case, we used a bone graft from the iliac crest after debridement and discectomy and then performed an additional segmental fixation using a ventral plate. Mondorf et al. and Walter et al. reported separately that using Polyether ether ketone (PEEK) cages as disc replacements is possible and can be applied as an alternative treatment for cervical spondylodiscitis [18]. When treating deep penetrating neck wounds, it is necessary to first exclude vascular, nerve or other neck organ injuries. In a stable patient, a conservative diagnostic procedure using computed tomographic angiography is preferred to surgical exploration. In patients with severe neck pain and elevated inflammatory laboratory parameters, cervical spondylodiscitis must be ruled out with an MRI. Our case showed that it is mandatory to obtain a detailed medical history of the patient before choosing further diagnostic and treatment procedures. We suggest performing careful but radical surgical wound debridement to avoid complications after penetrating neck wounds. Authors’ contribution AV: conception, design and writing the manuscript; vdH: analysis and interpretation of data and data collection; GJ: data collection and conception; HCE: critical revision of the manuscript and supervision. All authors read and approved the final manuscript. Conflict of interest The authors declare that they have no conflict of interest and sources of financial support to the publication of this article.
References [1] Shousha M, Boehm H. Surgical treatment of cervical spondylodiscitis: a review of 30 consecutive patients. Spine 2012;37(1):E30–6. [2] Heyde CE, Boehm H, El Saghir H, Tschoke SK, Kayser R. Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up. Eur Spine J 2006;15(9):1380–7. [3] Charfeddine I, Hammami B, Charfeddine F, Chakroun A, Ghorbel A. Cervical spondylodiskitis revealed by retropharyngeal abscess. Rev Laryngol Otol Rhinol 2009;130(3):185–8. Spondylodiscite cervicale revelee par un abces retropharynge. [4] Avcu S, Unal O, Turan A, Kiris M, Yuca K. Retropharyngeal abscess presenting with acute respiratory distress in a case of cervical spondylodiscitis. B-ENT 2010;6(1):63–5. [5] Radulovic D, Vujotic L. Cervical spinal epidural abscess after oesophagoscopy. Eur Spine J 2013;22(Suppl. 3):S369–72. [6] Korovessis P, Repantis T, Vitsas V, Vardakastanis K. Cervical spondylodiscitis associated with oesophageal perforation: a rare complication after anterior cervical fusion. Eur J Orthop Surg Traumatol 2013;23(Suppl. 2):159–63. [7] Wadie GM, Konefal SH, Dias MA, McLaughlin MR. Cervical spondylodiscitis from an ingested pin: a case report. J Pediatr Surg 2005;40(3):593–6. [8] Tan A, Wolfram S, Birmingham M, Dayes N, Garrow E, Zehtabchi S. Neck pain and stiffness in a toddler with history of button battery ingestion. J Emerg Med 2011;41(2):157–60. [9] Pakarinen TK, Leppaniemi A, Sihvo E, Hiltunen KM, Salo J. Management of cervical stab wounds in low volume trauma centres: systematic physical examination and low threshold for adjunctive studies, or surgical exploration. Injury 2006;37(5):440–7. [10] Siau RT, Moore A, Ahmed T, Lee MS, Tostevin P. Management of penetrating neck injuries at a London trauma centre. Eur Arch Otorhinolaryngol 2013;270(7):2123–8. [11] Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al. Western trauma association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg 2013;75(6):936–40. [12] Van Waes OJ, Cheriex KC, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg 2012;99(Suppl. 1):149–54. [13] Gracias VH, Reilly PM, Philpott J, Klein WP, Lee SY, Singer M, et al. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study. Arch Surg 2001;136(11):1231–5. [14] Offiah C, Hall E. Imaging assessment of penetrating injury of the neck and face Insights into imaging 2012;3(5):419–31. [15] Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003;54(1):61–4 [discussion 4–5]. [16] Osborn TM, Bell RB, Qaisi W, Long WB. Computed tomographic angiography as an aid to clinical decision making in the selective management of penetrating injuries to the neck: a reduction in the need for operative exploration. J Trauma 2008;64(6):1466–71. [17] Dall BE, Rowe DE, Odette WG, Batts DH. Postoperative discitis. Diagnosis and management. Clin Orthop Relat Res 1987;(224):138–46. [18] Mondorf Y, Gaab MR, Oertel JM. PEEK cage cervical ventral fusion in spondylodiscitis. Acta Neurochir 2009;151(11):1537–41. [19] Korovessis P, Repantis T, Iliopoulos P, Hadjipavlou A. Beneficial influence of titanium mesh cage on infection healing and spinal reconstruction in hematogenous septic spondylitis: a retrospective analysis of surgical outcome of twenty-five consecutive cases and review of literature. Spine 2008;33(21):E759–67. [20] Liljenqvist U, Lerner T, Bullmann V, Hackenberg L, Halm H, Winkelmann W. Titanium cages in the surgical treatment of severe vertebral osteomyelitis. Eur Spine J 2003;12(6):606–12.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report Anna Voelker *, Nicolas H. von der Hoeh, Jens Gulow, Christoph-Eckhard Heyde Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 16 May 2015
Introduction: Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. Materials and methods: Case report and review of the literature. Results: A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. Conclusion: Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Cervical spondylodiscitis Stab wound to the neck Inflammation cervical spine Cervical epidural abscess
Introduction Cervical spondylodiscitis is a rare medical condition that requires prompt medical treatment. Due to the unique anatomy of the cervical spine, namely, the proximity of the neural structures to the ligaments and vertebral bones and the larger diameter of the spinal cord, neurological deficits can develop faster and exhibit more dramatic consequences. Radical surgical therapy that includes abscess drainage, the collection of tissue culture samples,
* Corresponding author at: Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany. Tel.: +49 3419723000; fax: +49 3419723009. E-mail addresses: [email protected] (A. Voelker), [email protected] (N.H. von der Hoeh), [email protected] (J. Gulow), [email protected] (C.-E. Heyde). http://dx.doi.org/10.1016/j.injury.2015.05.043 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
the decompression of neural structures and stabilization of the spine followed by antibiotic therapy are necessary to prevent severe neurological symptoms and sepsis [1,2]. The underlying causes of cervical spondylodiscitis include the hematogenous spreading of bacteria, retropharyngeal abscesses [3,4], iatrogenic infections [5,6] and complications caused by swallowing foreign bodies [7,8]. Patients with penetrating neck injuries (PNIs) are rarely seen in the emergency room. Typically, PNIs include stab wounds, gunshot wounds or other accidental causes and are the result of violent attacks, accidents or self-inflicted injuries [9,10]. PNIs can be divided into subgroups based on the type of injury (vascular or aerodigestive) or according to their location within three anatomical zones of the neck (zone I: from the clavicles/ sternum to the cricoid cartilage; zone II: from the cricoid cartilage to the angle of the mandible; and zone III: superior to the angle of mandible to the base of the skull). Depending on the anatomical
[(Fig._2)TD$IG]
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zone of the injury and the condition of the patient (hemodynamically stable or unstable), various primary diagnostic work-ups are recommended, which range from mandatory neck exploration to computed tomographic angiography, bronchoscopy, esophagoscopy and serial examinations [11]. Treatments for PNI are individual and include surgical therapy, radiological therapy with stenting and conservative therapy [12]. We present a case report of cervical spondylodiscitis secondary to a stab wound injury of the neck. Materials and methods A 54-year-old male patient was brought to our orthopaedic surgery clinic with cervical spondylodiscitis of the C3/4 segment with paravertebral and epidural abscesses. The medical history indicated that the patient had been involved in a fight 5 weeks prior. After the assault, he had been taken to the emergency room, where multiple superficial wounds and hematomas all over his body were detected during the clinical examination. Furthermore, a one-centimetre-long cut on the left lateral side of the neck was discovered. The range of motion of the cervical spine was reduced due to pain. The initial CT-scan of the head and the midface ruled out intracranial injuries and revealed a fracture of the left zygomatic bone. Multiple air bubbles along the stab canal on the left side behind the sternocleidomastoid muscle were revealed (Fig. 1). Vessel injuries and injuries to other neck organs, as well as fractures of the cervical spine, were ruled out. Sonography of the abdomen failed to reveal free fluid or any indication of lesions in the parenchymatous organs. The lateral neck wound was thoroughly cleaned, and prophylactic antibiotic therapy with cefuroxime was started. A tetanus vaccine was administered. The fracture of the zygomatic bone was treated non-operatively. After 8 days, the wound healing was normal, and the patient was discharged from the hospital. Four weeks later, the patient presented with increasing neck pain and reduced general health to our outpatient clinic. An X-ray of the cervical spine showed a wider prevertebral soft tissue shadow (Fig. 2). Because of elevated inflammatory blood parameters (C-reactive protein (CRP), 91.7 mg/l; leukocytes (LZ),
[(Fig._1)TD$IG]
Fig. 2. X-ray of the cervical spine with wider prevertebral soft tissue shadow (red line, 1.6 mm) at the time of increasing neck pain 5 weeks after the stab wound to the neck. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
13.8 109/l) and a suspicion of spondylodiscitis, an MRI of the cervical spine was performed. The observed inflammatory changes involved the third and fourth vertebrae, as well as the intervertebral disc. Additionally, an epidural abscess that caused spinal stenosis and retropharyngeal inflammatory changes was observed (Fig. 3). Surgical treatment with debridement of the inflamed soft tissue, removal of the infected intervertebral disc with replacement through a bone graft from the iliac crest, easing of the epidural abscess, decompression of the spinal canal and plate osteosynthesis from C3 to C4 were performed (Figs. 4 and 5). Intraoperatively, the stab canal remained present, ending on the level of C3/4. That area was also debrided and syringed. Tissue probes were collected from all infectious sites for microbiological and pathological testing. All probes were negative for pathogens. The pathological report described chronic phlegmonous inflammation of the tissue. Calculated antibiotic therapy was started with clindamycin and rifampicin intravenously for seven days, followed by oral administration of clindamycin for an additional 7 weeks.
Results
Fig. 1. Native CT-scan of the neck shows the violation of the platysma with multiple air bubbles along the stab canal on the left side behind the sternocleidomastoid muscle.
The inflammatory laboratory parameters subsided after the radical surgical treatment and had returned to normal at the end of antibiotic treatment (CRP, 1.98 mg/l; LZ, 7.1 109/l). Three months after surgical intervention, follow-up X-rays and MRI and CT-scans of the cervical spine were carried out. The MRI revealed normal findings without ongoing inflammatory processes. The X-rays and CT scan indicated the osseous consolidation of the C3/4 segment (Fig. 6). Clinically, the patient was free from pain
[(Fig._3)TD$IG]
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Fig. 3. MRI of the cervical spine (A, T2 sequence) with inflammatory processes in the third and fourth vertebral bodies, prevertebral and epidural abscess; Image B (TIRM sequence) shows a transverse cut through the fourth vertebra body with compression of the spinal cord due to epidural abscess (narrow arrows) and a large prevertebral inflammatory process (wide arrows).
[(Fig._4)TD$IG]
Fig. 4. Intraoperative picture of the debrided intervertebral disc of the C3/4 segment (A). Postoperative picture of the debrided wound canal on the left side of the neck (B).
and presented a good functional outcome in terms of range of motion of the neck. Discussion Cervical spondylodiscitis is a rare and serious illness that can arise from various causes, such as pyogenic infections, iatrogenic infections and complications after swallowing foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. It is difficult to treat patients with penetrating neck injuries (induced by stab wounds, gunshot wounds or by accidents) in the emergency department. In general there are two different paths for diagnostics and treatment, depending on the cardiopulmonary condition of the patient. In a patient who presents in an unstable haemodynamic condition, prompt surgical neck exploration is necessary. The optimal surgical approach depends on the anatomical zone of the injury. Most injuries can be reached through an anterior sternocleidomastoid incision. Sometimes, a median sternotomy,
supraclavicular incision, transverse cervical collar incision or manipulations of the mandible are necessary to reach vessel injury [11]. For patients in a stable condition with a suspected vessel injury, computed tomographic angiography (CTA) is recommended to detect the direct and indirect signs of vessel injury. A CT-scan could decrease the likelihood of a negative neck exploration [13,14]. Nevertheless, Gonzalez et al. [15] showed in a prospective study that not all vessel injuries and esophageal injuries due to penetrating zone II injuries could be detected using a dynamic CT-scan or esophagography. In our case, the patient was in a stable cardiopulmonary condition when he was brought to the emergency room after the assault. During the initial examination a penetrating neck injury in zone II was found. The injury was dorsal to the sternocleidomastoid muscle and caused by a knife. Because of additional bruises on the face, the patient received a CT-scan of the head, forehead and neck. Determining the depth of a stab wound can be difficult. In the emergency room a blunt probing could be done but has a higher risk of additional tissue injuries.
[(Fig._5)TD$IG]
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Fig. 5. Control X-ray of the cervical spine after surgery with good positioning of the plate and screws along with the bone graft from the iliac crest between the vertebral bodies of C3 and C4.
[(Fig._6)TD$IG]
Fig. 6. Follow-up CT-scan (A) with correct positioning of the plate and bony fusion of the C3/4 segment; control MRI of the cervical spine with no signs of an ongoing inflammatory process (B, T2 sequence).
Osborn et al. found that computer tomographic angiography can be a helpful diagnostic tool to rule out major injuries in stable patients with penetrating neck wounds that penetrate the platysma. They demonstrated in a study of 120 patients with penetrating neck injuries that computer tomographic angiography can reduce the number of surgical neck explorations, resulting in shorter hospital stays for patients [16]. Contaminated wounds require a thorough lavage and debridement before suturing. Alternatively a loose adaptation can be considered. In either case prophylactic antibiotic therapy should be administered. The CT of our patient showed signs of a lesion to the platysma (Fig. 1). Retrospectively the primary wound treatment without thorough local exploration and irrigation was insufficient. However, the patient was treated with antibiotics until complete wound healing was achieved. No clinical signs of an ongoing infection were observed at this time.
In general, severe neck pain and poor physical condition are red flags indicating that spondylodiscitis should be suspected. A detailed medical history must be taken, and prompt assays of inflammatory laboratory parameters and an X-ray of the cervical spine are mandatory. Elevated inflammatory laboratory parameters indicate the urgent need for an MRI [1]. During the patient’s second visit to the clinic and under the clinical suspicion of an inflammatory process of the cervical spine, an MRI was performed. The radiological findings confirmed the diagnosis of spondylodiscitis involving the third and fourth vertebral bodies. Spinal stenosis caused by an epidural abscess was also observed. There are no reports in literature about the time between a PNI and the onset of symptoms associated with discitis. For spondylodiscitis after surgical procedures an interval up to 30 days and longer is reported [17].
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Various authors have reported that epidural abscesses are often observed in cervical spondylodiscitis [1,18] and that narrowing of the spinal cord can cause severe and rapidly worsening neurological symptoms. For cervical spondylodiscitis, surgical treatment is the mainstay of therapy and should include radical debridement with discectomy, decompression of the spinal canal with abscess evacuation as necessary and autologous bone grafting and stabilization [2]. Postoperative antibiotic therapy over the course of 6–8 weeks is recommended [2]. Our patient recovered well after surgical treatment. His neck pain decreased, and his inflammatory laboratory parameters were normal after 3 months. Implant-associated infections of the spine have only been reported in single case reports [19]. However, implantation of larger cages and plates after corporectomy do not lead to more persistent infections of the involved segments of the spine [20]. In the present case, we used a bone graft from the iliac crest after debridement and discectomy and then performed an additional segmental fixation using a ventral plate. Mondorf et al. and Walter et al. reported separately that using Polyether ether ketone (PEEK) cages as disc replacements is possible and can be applied as an alternative treatment for cervical spondylodiscitis [18]. When treating deep penetrating neck wounds, it is necessary to first exclude vascular, nerve or other neck organ injuries. In a stable patient, a conservative diagnostic procedure using computed tomographic angiography is preferred to surgical exploration. In patients with severe neck pain and elevated inflammatory laboratory parameters, cervical spondylodiscitis must be ruled out with an MRI. Our case showed that it is mandatory to obtain a detailed medical history of the patient before choosing further diagnostic and treatment procedures. We suggest performing careful but radical surgical wound debridement to avoid complications after penetrating neck wounds. Authors’ contribution AV: conception, design and writing the manuscript; vdH: analysis and interpretation of data and data collection; GJ: data collection and conception; HCE: critical revision of the manuscript and supervision. All authors read and approved the final manuscript. Conflict of interest The authors declare that they have no conflict of interest and sources of financial support to the publication of this article.
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