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Late prevertebral abscess with sinus following anterior cervical corpectomy and fusion.

Bhise SD, Mathesul AA, Deokate P, Chandanwale AS, Bartakke GD - Asian J Neurosurg (2015 Jul-Sep)

Bottom Line: This procedure is highly successful and associated with fewer complications.Late infection as a complication of anterior cervical spine surgeries is rare and is associated with esophageal perforation, implant migration, seeding of the deep prevertebral space with oropharyngeal flora, or from surgical site/bacteremia or with Zenker's diverticulum.Exploring both triangles of the neck using radical neck dissection approach was essential for complete excision of sinus track, removal of screw and debridement.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, B J Govt Medical College and Sassoon General Hospitals, Pune, Maharashtra, India.

ABSTRACT
Anterior cervical discectomy/corpectomy and fusion is performed in degenerative, traumatic and neoplastic etiologies of the cervical spine. This procedure is highly successful and associated with fewer complications. The rates of early and late postoperative infection have been reported to be between 0.1% and 1.6%, the late infections are being very rare. We report a rare case of a 30-year-old HIV negative, non-diabetic male who developed a late prevertebral cervical abscess with discharging sinus over posterior triangle of neck 3 years after an anterior cervical C6 corpectomy with fibular grafting and buttress screw fixation performed elsewhere for traumatic fracture C6 vertebra. The abscess was drained using radical neck dissection approach with complete excision of sinus track and removal of the infected implant. On culture, the organism was found to be beta-hemolytic streptococci, for which appropriate antibiotics were administered postoperatively. The sinus tract completely healed in 3 months time. Late infection as a complication of anterior cervical spine surgeries is rare and is associated with esophageal perforation, implant migration, seeding of the deep prevertebral space with oropharyngeal flora, or from surgical site/bacteremia or with Zenker's diverticulum. Few cases have been reported till date, but none have presented with a sinus tract. We present a case of delayed prevertebral abscess after cervical spine instrumentation that followed abnormal path causing sinus track to be developed in the site (the posterior triangle of the neck) other than previous incision site. Exploring both triangles of the neck using radical neck dissection approach was essential for complete excision of sinus track, removal of screw and debridement.

No MeSH data available.


Related in: MedlinePlus

Healed wound and sinus
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Figure 6: Healed wound and sinus

Mentions: He had no complaints of neurological weakness, dysphagia, abnormal neck swelling, loss of appetite, loss of weight and any past history of tuberculosis or tuberculosis contact. A differential diagnosis of tuberculosis infection was made as a posterior triangle of the neck is the most common site for a cold abscess in the neck, also India being a tuberculous endemic country.[12] Hematological investigations showed raised erythrocyte sedimentation rate (ESR) 45, C-reactive protein (CRP) positive and HIV negative. He was investigated with the plain radiograph of the cervical spine, sinogram for the sinus, and computerized tomography (CT) of the neck. Radiographs showed an unusual single screw fixation with evidence of fusion without any vertebral destruction or lysis which was confirmed with CT scan [Figures 1–3]. The images showed prominent screw head anterior to the bodies supposedly irritating the esophagus, however, esophageal endoscopy was normal. Magnetic resonance imaging was not done as the patient had a metallic implant. Sinogram showed a prevertebral collection near the vicinity of the screw draining in the right posterior neck triangle through sinus track mostly posterior to vessels and sternocleidomastoid. Chest radiographs were normal, and there was no evidence of matted lymphadenopathy elsewhere. The pus culture report from the sinus discharge was negative. After discussing the case with an ear, nose and throat (ENT) surgeon, a decision for surgical debridement and implant removal was taken. Radical neck dissection approach (Crile's approach) was taken as this facilitates in addressing the problems of both the posterior triangle as well as the vertebral bodies.[13] Subplatysmal flaps were raised. Sternocleidomastoid was separated from the carotid sheath. The carotid sheath was separated from trachea esophageal complex. Inferior thyroid artery was ligated. Prevertebral fascia and muscles were dissected, and the screw was identified and removed. Sinus track was identified and dissected along with a pad of fat in the posterior triangle of the neck behind the sternocleidomastoid and prevertebral muscle and excised up to the vertebral origin. Sinus track was completely epithelized till the vertebra. There was no esophageal perforation. There was bony union, no loose sequestrum or vertebral osteomyelitis. The screw was removed [Figure 4]. The surgical bed was thoroughly debrided and washed with saline, the specimen was sent for high power field, culture sensitivity for bacteria and acid fast bacilli, Zeihl–Neilson staining and histopathology for tuberculosis. The wound was loosely closed in layers over negative suction drain [Figure 5]. Postoperative patient was on Ryle's tube for 5 days and intravenous antibiotics (cefuroxime 1.5 g twice daily for 5 days with amikacin 500 mg twice daily for 5 days) was given. The culture report showed beta-hemolytic streptococci sensitive to linezolid, rest all reports were negative. These were given intravenous for 2 weeks and then oral for next 3 weeks. Sinus track was healed completely in 3 months time [Figure 6].


Late prevertebral abscess with sinus following anterior cervical corpectomy and fusion.

Bhise SD, Mathesul AA, Deokate P, Chandanwale AS, Bartakke GD - Asian J Neurosurg (2015 Jul-Sep)

Healed wound and sinus
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4553753&req=5

Figure 6: Healed wound and sinus
Mentions: He had no complaints of neurological weakness, dysphagia, abnormal neck swelling, loss of appetite, loss of weight and any past history of tuberculosis or tuberculosis contact. A differential diagnosis of tuberculosis infection was made as a posterior triangle of the neck is the most common site for a cold abscess in the neck, also India being a tuberculous endemic country.[12] Hematological investigations showed raised erythrocyte sedimentation rate (ESR) 45, C-reactive protein (CRP) positive and HIV negative. He was investigated with the plain radiograph of the cervical spine, sinogram for the sinus, and computerized tomography (CT) of the neck. Radiographs showed an unusual single screw fixation with evidence of fusion without any vertebral destruction or lysis which was confirmed with CT scan [Figures 1–3]. The images showed prominent screw head anterior to the bodies supposedly irritating the esophagus, however, esophageal endoscopy was normal. Magnetic resonance imaging was not done as the patient had a metallic implant. Sinogram showed a prevertebral collection near the vicinity of the screw draining in the right posterior neck triangle through sinus track mostly posterior to vessels and sternocleidomastoid. Chest radiographs were normal, and there was no evidence of matted lymphadenopathy elsewhere. The pus culture report from the sinus discharge was negative. After discussing the case with an ear, nose and throat (ENT) surgeon, a decision for surgical debridement and implant removal was taken. Radical neck dissection approach (Crile's approach) was taken as this facilitates in addressing the problems of both the posterior triangle as well as the vertebral bodies.[13] Subplatysmal flaps were raised. Sternocleidomastoid was separated from the carotid sheath. The carotid sheath was separated from trachea esophageal complex. Inferior thyroid artery was ligated. Prevertebral fascia and muscles were dissected, and the screw was identified and removed. Sinus track was identified and dissected along with a pad of fat in the posterior triangle of the neck behind the sternocleidomastoid and prevertebral muscle and excised up to the vertebral origin. Sinus track was completely epithelized till the vertebra. There was no esophageal perforation. There was bony union, no loose sequestrum or vertebral osteomyelitis. The screw was removed [Figure 4]. The surgical bed was thoroughly debrided and washed with saline, the specimen was sent for high power field, culture sensitivity for bacteria and acid fast bacilli, Zeihl–Neilson staining and histopathology for tuberculosis. The wound was loosely closed in layers over negative suction drain [Figure 5]. Postoperative patient was on Ryle's tube for 5 days and intravenous antibiotics (cefuroxime 1.5 g twice daily for 5 days with amikacin 500 mg twice daily for 5 days) was given. The culture report showed beta-hemolytic streptococci sensitive to linezolid, rest all reports were negative. These were given intravenous for 2 weeks and then oral for next 3 weeks. Sinus track was healed completely in 3 months time [Figure 6].

Bottom Line: This procedure is highly successful and associated with fewer complications.Late infection as a complication of anterior cervical spine surgeries is rare and is associated with esophageal perforation, implant migration, seeding of the deep prevertebral space with oropharyngeal flora, or from surgical site/bacteremia or with Zenker's diverticulum.Exploring both triangles of the neck using radical neck dissection approach was essential for complete excision of sinus track, removal of screw and debridement.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, B J Govt Medical College and Sassoon General Hospitals, Pune, Maharashtra, India.

ABSTRACT
Anterior cervical discectomy/corpectomy and fusion is performed in degenerative, traumatic and neoplastic etiologies of the cervical spine. This procedure is highly successful and associated with fewer complications. The rates of early and late postoperative infection have been reported to be between 0.1% and 1.6%, the late infections are being very rare. We report a rare case of a 30-year-old HIV negative, non-diabetic male who developed a late prevertebral cervical abscess with discharging sinus over posterior triangle of neck 3 years after an anterior cervical C6 corpectomy with fibular grafting and buttress screw fixation performed elsewhere for traumatic fracture C6 vertebra. The abscess was drained using radical neck dissection approach with complete excision of sinus track and removal of the infected implant. On culture, the organism was found to be beta-hemolytic streptococci, for which appropriate antibiotics were administered postoperatively. The sinus tract completely healed in 3 months time. Late infection as a complication of anterior cervical spine surgeries is rare and is associated with esophageal perforation, implant migration, seeding of the deep prevertebral space with oropharyngeal flora, or from surgical site/bacteremia or with Zenker's diverticulum. Few cases have been reported till date, but none have presented with a sinus tract. We present a case of delayed prevertebral abscess after cervical spine instrumentation that followed abnormal path causing sinus track to be developed in the site (the posterior triangle of the neck) other than previous incision site. Exploring both triangles of the neck using radical neck dissection approach was essential for complete excision of sinus track, removal of screw and debridement.

No MeSH data available.


Related in: MedlinePlus