Severe muscle spasm of the neck secondary to osteomyelitis of the atlantoaxial joint.

Upper cervical osteomyelitis accounts for 3 to 10% of all cases of vertebral osteomyelitis. (1) Remote infections anywhere in the body may seed the cervical spine or occipital condyles. Other important risk factors for upper cervical osteomyelitis include intravenous drug abuse, diabetes mellitus, dental infections, human immunodeficiency virus infection with immunosuppression, alcoholism, liver disease, renal insufficiency, and heart disease. (1-4)

We evaluated a 14-year-old boy with progressive suboccipital pain, severe neck muscle spasm, and a low-grade fever. He had a strong history of occipital trauma, sustained while performing karate several weeks before the onset of his symptoms. Computed tomography (CT) (figure 1) and magnetic resonance imaging (MRI) (figure 2) demonstrated findings consistent with a focal osteomyelitis in the right atlantoaxial joint. This diagnosis was confirmed at surgical debridement. He had no neurologic deficit.

[FIGURE 1-2 OMITTED]

The bloodstream is the most common route by which bacterial infection spreads to the upper cervical spine and occipital condyles. Upper cervical osteomyelitis with occipital involvement may be caused by the spread of an adjacent nidus of infection following an invasive diagnostic or therapeutic procedure, such as a tracheotomy, pharyngeal surgery, or tonsillectomy. (2) (3) Occasionally, trauma can precipitate a bone infection; this theoretically could have occurred in our patient. (1-3)

The two most common organisms in upper cervical and occipital osteomyelitis are Staphylococcus aureus (40 to 80% of cases) and Streptococcus spp (8 to 12%.). (1-4) In addition, gram-negative bacteria such as Escherichia coli and diphtheroids have become more prevalent. Pseudomonal infection is frequently seen in IV drug abusers. Salmonella and Proteus spp are associated with gastrointestinal and genitourinary sources of infection. Polymicrobial sources are found in 20% of all cases of upper cervical osteomyelitis. (1) Anaerobic etiologies are rare.

Upper cervical occipital osteomyelitis can be managed conservatively or surgically. Nonsurgical management by external immobilization or halo fixation along with an aggressive regimen of IV and oral antibiotics is indicated for those patients with no neurologic deficits, epidural abscesses, or significant spinal deformities. (4) Surgical options include (1) debridement of the infected tissue, (2) drainage of an epidural abscess to reduce or prevent neurologic dysfunction, and (3) spinal surgical fixation to correct a spinal deformity or neurologic deficit secondary to compromise of the spinal cord or neural foramina. (4-6)

References

[1.] Acosta FL Jr., Chin CT, Quinones-Hinojosa A, et al. Diagnosis and management of adult pyogenic osteomyelitis of the cervical spine. Neurosurg Focus 2004; 17(6):E2.

[2.] Young WF, Weaver M. Isolated pyogenic osteomyelitis of the odontoid process. Scand J Infect Dis 1999;31 (5):512-15.

[3.] Zigler JE, Bohlman HH, Robinson RA, et al. Pyogenic osteomyelitis of the occiput, the atlas, and the axis. A report of five cases. J Bone Joint Surg Am 1987;69(7): 1069-73.

[4.] Barnes B, Alexander JT, Branch CL Jr. Cervical osteomyelitis: A brief review. Neurosurg Focus 2004;17(6):E11.

[5.] Noguchi S, Yanaka K, Yamada Y, Nose T. Diagnostic pitfalls in osteomyelitis of the odontoid process: Case report. Surg Neurol 2000;53(6):578-9.

[6.] Haridas A, Walsh DC, Mowle DH. Polymicrobial osteomyelitis of the odontoid process with epidural abscess: Case report and review of literature. Skull Base 2003; 13(2): 107-11.

From the Department of Radiology, Tulane University Medical Center, New Orleans.