Home Print this page Email this page
Users Online: 181
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 4  |  Page : 263-266

Cervical spondylodiscitis presenting with dysphagia and dysphonia


Department of Orthopaedics, KSHEMA Nitte University, Deralakatte, Mangalore, Karnataka, India

Date of Web Publication16-Oct-2014

Correspondence Address:
Siddharth M Shetty
Department of Orthopaedics, KSHEMA Nitte University, Deralakatte, Mangalore - 575 018, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.143069

Rights and Permissions
  Abstract 

Infections of the deep spaces of the neck, like the prevertebral abscess, can present with catastrophic consequences due to compromise of air and food passages. The most common causes of the prevertebral abscess in orthopedic practice are tuberculosis of spine, retropharyngeal abscess, infections secondary to foreign body impalement and injury. Early recognition of these conditions is necessary to avert fatal complications. We report a case of a 50-year-old gentleman who presented with symptoms of dysphagia and dysphonia with altered sensorium of 4 days duration. He was diagnosed with septicemia, diabetic ketoacidosis, and an upper motor neuron type of quadriparesis. There was diffuse swelling over the anterior aspect of the neck with magnetic resonance imaging study suggesting a prevertebral abscess with septic discitis of cervical 5 and 6 vertebras. The case is presented along with the literature review discussed as an unusual cause of septic discitis due to Klebsiella manifesting as dysphonia and dysphagia.

Keywords: Dysphagia, dysphonia, Klebsiella pneumonia, prevertebral abscess, septic discitis


How to cite this article:
Shetty SM, Mohan K, Dilip K S, Shetty JB. Cervical spondylodiscitis presenting with dysphagia and dysphonia. Int J Health Allied Sci 2014;3:263-6

How to cite this URL:
Shetty SM, Mohan K, Dilip K S, Shetty JB. Cervical spondylodiscitis presenting with dysphagia and dysphonia. Int J Health Allied Sci [serial online] 2014 [cited 2019 Sep 21];3:263-6. Available from: http://www.ijhas.in/text.asp?2014/3/4/263/143069


  Introduction Top


A retropharyngeal abscess is an infection of deep space of the neck presenting as swelling in front of the neck with features of dyspnea or dysphagia. This abscess is a rarity in adults and usually occurs following local trauma due to foreign body ingestion, instrumental procedures such as laryngoscopy, endotracheal intubation, feeding tube placement or secondary to pyogenic spondylitis or tuberculosis of the spine. [1],[2] This condition requires early recognition and immediate intervention by surgical drainage. [1],[2] The case being presented is septic discitis of the cervical spine of the 5, 6 intervertebral disc in an immunocompromised individual attributed due to diabetes mellitus, who presented with septicemia, dysphagia, and dysphonia due to a prevertebral collection, which is a rarity in orthopedic practice.


  Case report Top


A 50-year-old male presented to the emergency department with difficulty in swallowing, hoarseness of voice, and altered sensorium for 4 days. There was no history of vomiting, neck pain, weakness of limbs, loss of weight, or cough. Patient on arrival was drowsy and febrile with a diffuse swelling of about 5 cm × 4 cm noted over the right side of the neck. He had tachypnea, with tachycardia and features suggestive of meningitis and neurological examination revealing an upper motor neuron type of quadriparesis.

The total blood cell count was 19,800 cells/cumm with neutrophil predominance and erythrocyte sedimentation rate was 115 mm at end of 1 h. The blood sugar was 475 mg/dl and other blood parameters were normal. The cervical spine radiograph showed uniform reduction in the cervical spine 5-6 intervertebral disc space with paradiscal destruction of 5 and 6 cervical vertebral bodies and soft tissue shadow in prevertebral area indenting the air passage with spondylosis and loss of lordosis [Figure 1] and [Figure 2].
Figure 1: Preoperative X-ray lateral view showing reduction of C5-C6 disc space with vertebral destruction with prevertebral soft tissue shadow displacing and compressing the airway

Click here to view
Figure 2: Preoperative X-ray anterior-posterior view

Click here to view


Magnetic resonance imaging (MRI) cervical spine showed fluid intensity signals in prevertebral region extending into retropharyngeal space and right carotid space, displacing medially the vocal cords with compression of pharynx along with collapse of cervical spine 5 and 6 vertebral bodies and reduction of intervertebral disc space [Figure 3],[Figure 4],[Figure 5] and [Figure 6].
Figure 3: Magnetic resonance imaging sagittal section with prevertebral collection and vertebral and disc destruction and spinal cord compression

Click here to view
Figure 4: Magnetic resonance imaging coronal section with prevertebral collection and soft tissue extension on either side of the midline

Click here to view
Figure 5: Magnetic resonance imaging axial section with prevertebral collection and spinal cord compression

Click here to view
Figure 6: Magnetic resonance imaging axial section with prevertebral collection and spinal cord compression

Click here to view


Patient underwent an emergency surgical drainage of abscess, debridement, and discectomy of 5-6 cervical intervertebral disc under general anesthesia through a left para-central anterior approach. The wounds were closed over a suction drain of 14 French with a Philadelphia collar immobilization of the neck. Intensive monitoring in the isolation unit was continued in the postoperative period without invasive ventilation for 12 h. Ryles tube feeding was begun after 12 h and was continually nursed in a propped-up position [Figure 7] and [Figure 8].
Figure 7: Immediate postoperative X-ray lateral view

Click here to view
Figure 8: Immediate postoperative X-ray anterior-posterior view

Click here to view


Glycemic control was achieved by insulin administration. Fever settled to the baseline within 24 h after surgery and continued to remain at baseline.

The pus specimen was negative for Acid fast bacilli, Gram-stain showed numerous polymorphonuclear cells, few Gram-negative bacilli, and suggestive of a Klebsiella species. Histopathology study showed disc tissue and bony spicules with sparse lymphocytic infiltrate. Intravenous antibiotics cefuroxime sodium was administered for 1 week and followed with oral medications for 10 days along with an oral formulation of rifampicin (600 mg) once a day for 3 weeks. Drain was removed at 5 days and sutures were removed on the 12 th day.

The cervical spine was immobilized in a Philadelphia collar, and an early rehabilitation was begun. After 2 days in the intensive care unit, he was shifted to the ward. He was initially fed through a Ryles tube which was removed after 2 days. The symptoms of dysphonia and dysphagia improved by 3 weeks.

The patient was discharged at 2 weeks and was followed up at 3 weeks, 6 weeks, and 3 months. In about 6 weeks, there was significant neurological improvement and the upper motor neuron lesion signs disappeared and motor power had shown complete recovery.

The cervical immobilization was continued till 3 months, and he was on regular follow-up for 6 months [Figure 9] and [Figure 10].
Figure 9: X-ray lateral view at 6 months shows collapse at C5-C6 level with increased gap at the interspinous C5-C6 region with calcification of the interspinous ligament area

Click here to view
Figure 10: X-ray anterior-posterior view of the C spine at 6 months

Click here to view



  Discussion Top


Cervical spondylodiscitis is a rarity, and its occurrence is attributed to various factors which directly or indirectly may have a bearing e.g.: Intravenous cannulation, spinal surgery, genitourinary tract infection or instrumentation, chronic obstructive lung disease, dialysis, immunodeficiency disorders, steroid therapy, diabetes mellitus, alcoholism, and drug addiction. [1],[2] Our case had presented to us with uncontrolled diabetes mellitus.

Early diagnosis is paramount to prevent disastrous consequences and irreversible neurological deficits. [3] The noninvasive imaging method of choice for evaluating infectious spondylodiscitis is MRI study with contrast. [3] In the present case, MRI study of cervical spine showed fluid intensity signals in prevertebral region extending into retropharyngeal space and right carotid space, displacing medially the vocal cords with compression of pharynx along with collapse of cervical spine 5 and 6 vertebral body, reduction intervertebral disc space. The patient was advised to undergo an anterior decompression, corpectomy, and discectomy with autologous bone grafting and fusion with titanium cervical plating of the cervical 5 and 6 spine.

On the exposure, there was frank green colored foul smelling pus at the level of the lesion that was drained and the necrotic tissue of the vertebral body and disc material was removed. In view of noting frank pus at the site, bone grafting and anterior cervical plating were not proceeded with and the procedure was completed with debridement and discectomy. Cases have been described were autologous grafting with instrumentation were performed for a septic cause but our decision was against it. [1]

The isolation of Gram-negative bacilli, Klebsiella pneumonia at the site is a rarity for septic discitis. [2],[4],[5],[6] The blood culture was negative, in the literature, 30% of septic discitis are negative for blood. Histopathology study suggested a septic focus.

It is prudent to treat the patient with appropriate intravenous and oral antibiotics after surgical decompression. Our postoperative protocol for antibiotics was to administer a broad spectrum 3 rd generation IV cephalosporin with oral rifampicin 600 mg once a day for 3 weeks. His symptoms of dyspnea and dysphagia subsided in 3 weeks, and the neurological status recovered by end of 6 weeks with normalization of total white blood cell count and good glycemic control, along with normalization of erythrocyte sedimentation rate and C-reactive protein values. Serial radiographs at 6 weeks and 6 months showed sclerosis of the vertebral bodies with evidence of anterior interbody bony fusion with widening of the posterior interspinous gap and calcific shadows in the interspinous area and no instability at the cervical spine level.

Spontaneous spondylodiscitis and cervical epidural abscess caused by K. pneumonia are extremely rare, neurological deficits associated with dysphagia and dysphonia can be successfully treated with aggressive decompression with abscess drainage in addition to appropriate antibiotic treatment. [2],[3],[7]


  Acknowledgments Top


Department of Pathology and Microbiology, KSHEMA Nitte University, Deralakatte, Mangalore 575 018, Karnataka, India. Department of Radiology, KSHEMA Nitte University, Deralakatte, Mangalore 575 018, Karnataka, India. Colleagues and PG Residents, Department of Orthopedics, KSHEMA Nitte University, Deralakatte, Mangalore 575 018, Karnataka, India.

 
  References Top

1.
Del Curling O Jr, Gower DJ, McWhorter JM. Changing concepts in spinal epidural abscess: A report of 29 cases. Neurosurgery 1990;27:185-92.  Back to cited text no. 1
    
2.
Kim MS, Cho DC, Sung JK. Spontaneous cervical spondylodiscitis and epidural abscess caused by Klebsiella pneumonia-Single stage operation with decompressive corpectomy and autologous bone fusion. Korean J Spine 2008;5:237-40.  Back to cited text no. 2
    
3.
Hlavin ML, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: A ten-year perspective. Neurosurgery 1990;27:177-84.  Back to cited text no. 3
    
4.
Honan M, White GW, Eisenberg GM. Spontaneous infectious discitis in adults. Am J Med 1996;100:85-9.  Back to cited text no. 4
    
5.
Kangwanprasert M, Young RS. Case report: Spinal epidural abscess from Klebsiella pneumoniae. Hawaii Med J 2005;64:216-7.  Back to cited text no. 5
    
6.
Kouroussis C, Georgoulias V, Souglakos J, Simvoulakis E, Karabekios S, Samonis G. Spontaneous spondylodiscitis caused by Klebsiella pneumoniae. Infection 1999;27:368-9.  Back to cited text no. 6
    
7.
Singh J, Velankar H, Shinde D, Chordia N, Budhwani S. Retropharyngeal cold abscess without Pott′s spine. S Afr J Surg 2012;50:137-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case report
Discussion
Acknowledgments
References
Article Figures

 Article Access Statistics
    Viewed2605    
    Printed12    
    Emailed0    
    PDF Downloaded155    
    Comments [Add]    

Recommend this journal