Cervical facet joint infection and associated epidural abscess with Streptococcus intermedius from a dental infection origin: a case report and review.
Cervical spine infection in the setting of dental procedures or oral infections has been described in the literature, but only three other reports have involved the facet joints. We present a case of a cervical facet joint infection with epidural abscess secondary to a dental infection in a diabetic orthopaedic surgeon. We also review the literature to describe the clinical, radiographic, and pathologic features of facet joint infections. We performed a thorough search of PubMed/MEDLINE for the terms "facet joint infection" and "cervical," and "spine infection" and "dental." We reviewed abstracts of all articles for relevance and additional studies were identified by reviewing the references listed in these articles.
History and Examination
A 65-year-old, right hand dominant, male orthopaedic surgeon with a past medical history of type 2 diabetes mellitus (non-insulin dependent, managed with lifestyle modification), hypertension, and hyperlipidemia complained of right sided neck pain, swelling, and erythema on August 2, 2012.
One month prior, he had broken a crown over his right mandibular premolar, tooth 31, which was never treated, and was still a source of pain. The patient had isolated oral pain since that time, but on July 30, three days prior to presentation, his neck symptoms began. By July 31, he began noticing weakness at his right upper extremity, particularly, weakness with right shoulder abduction and right elbow flexion. The pain also began migrating to his right shoulder and upper arm and his neck range of motion became progressively more restricted. He denied any sensory loss or paresthesias. He complained of a holocephalic headache but denied any nausea or vomiting. Over the same time course, he was having subjective fevers at home. He had tried Percocet and Flexeril without relief. He denied any bowel or bladder incontinence. Despite decreased oral intake, his glucose levels had been poorly controlled for the 2 days prior to presentation. He denied any history of intravenous drug use.
The patient initially had presented to an outside institution's emergency room earlier on August 2. There, his white blood cell count (WBC) was found to be 25,000 B/L and was subsequently given one dose of intravenous antibiotics. A magnetic resonance imaging study (MRI) of the cervical spine without contrast showed right C4-C5 facet inflammatory arthropathy and a small epidural abscess with paracervical soft tissue edema and inflammation. He was transferred to our institution for planned biopsy of the lesion by the interventional radiology (IR) team.
On presentation to our emergency room, the patient's vital signs were as follows: temperature was 101[degrees] F (38.3[degrees] C), pulse was 116 beats/min, blood pressure was 130/60 mmHg, respiration was 18 breaths/min, and pulse oximetry was 98% on room air. The patient had poor dentition with tooth 31 broken at the gingival margin. The heart had a regular rate and rhythm without murmurs, and the lungs were clear.
Cranial nerves were intact. The right side of his neck was erythematous and mildly tender to palpation. His neck range of motion was 30[degrees] in flexion, 15[degrees] in extension, 20[degrees] in right sided rotation, and 15[degrees] with left sided rotation. Cervical motion was painful in all directions but particularly with rotation. Right deltoid strength was 2/5, right biceps 4/5, and right triceps was 4/5. Sensation was diminished along the right lateral brachium. There was an absent right biceps deep tendon reflex. Otherwise, strength, sensation, and reflexes were intact and within normal range in the upper and lower extremities.
At our emergency room, the WBC count was 18,100 B/L (84% neutrophils). Inflammatory markers were elevated with an erythrocyte sedimentation rate (ESR) of 110 mm/h (0 to 10 mm/h) and C-reactive protein (CRP) of 377 mg/L (0 to 9 mg/L). MRI of the cervical spine at our institution on August 3 revealed mild interval worsening compared to the prior MRI. Specifically, it demonstrated a moderate joint effusion in the C4-C5 right facet joint with adjacent subchondral erosive change along the opposing surfaces of the joint and a small epidural fluid collection with mild mass effect on the spinal cord at the same level (Fig. 1).
The patient was admitted for planned IR biopsy of the C4-C5 facet joint. Antibiotics were held pending cultures. Under computed tomography (CT) guided imaging, biopsy of the C4-C5 facet joint was performed on August 3 (Fig. 2). Purulent fluid in a quantity of 1 mL was aspirated, and widening and destruction of the right C4-C5 facet joint was noted. The patient was then started on intravenous Vancomycin and Ceftriaxone. Two days later, the cultures from the biopsy were finalized revealing growth of Streptococcus intermedius. Antibiotics were changed to ampicillin and sulbactam. On August 6, the patient was seen by the oral and maxillofacial surgery team who extracted teeth #15 and #31 and cultured the space. Cultures finalized as group F streptococcus.
Operation and Pathological Findings
Although pain improved after the cervical biopsy and antibiotics, the patient's right upper extremity weakness persisted and irrigation and debridement of C4-C5 and C4-C5 laminoforaminotomy were indicationg, which he underwent on August 7.
OR cultures were negative, and the patient was discharged on August 10 on intravenous penicillin G every 4 hours for 6 weeks. On October 10, his WBC count was 10,100 B/L, ESR was 21 mm/h, and CRP was greater than 5 mg/L. By 4 months, his neck pain and upper extremity weakness had completely resolved. Right deltoid and biceps strength was 5/5, and he had full neck range of motion. At 24 month follow-up, these results were maintained.
Our literature search identified 18 cases of spine infections attributed to dental origin, but of these, only two cases of cervical facet joint infections, and no others infected with Streptococcus intermedius (Table 1). The other cases of cervical facet joint infections were positive for Staphylococcus aureus. There are two potential modes of dissemination of a dental infection to the cervical spine: lymphatic or hematogenous. When the presentation is insidious, the mode may be lymphatic spread, but when it is more acute, the mode is more likely via hematogenous spread. Such hematogenous spread may be explained by drainage through the venous network of the oral cavity, which communicates with the intracranial venous plexuses, which in turn, communicate with the vertebral venous plexuses. Regarding lymphatic spread, both the upper and lower teeth drain through the submandibular nodes to the deep cervical nodes (the jugulodigrastric nodes). These, in turn, drain to the prevertebral nodes some of which lie in the alar space immediately in front of pre-vertebral fascia, thus allowing potential communication with the spine. (6-8)
In this case, Streptococcus intermedius was identified as the offending pathogen at the cervical spine. Streptococcus intermedius forms part of the normal flora of the mouth and gastrointestinal tract and is the most commonly isolated bacteria from dental plaque. (9,10) It has frequently been reported to cause purulent infections, and Whitworth found that it most commonly infected the central nervous system. (11,12) Alternatively, Group F Streptococcus was identified from the dental abscess culture. Although initially regarded as the same species, Group F Streptococcus and Streptococcus intermedius have more recently been recognized as discrete pathogens, yet still closely related. (13) While identification of the exact same bacterial species from the dental abscess culture would have more definitely linked the cervical facet infection with the dental abscess, identification of a pathogen, which is consistently identified in the oral flora, rather than elsewhere, corroborates the theory of dental seeding.
Stetcher and coworkers (1) found that in 38% to 58% of patients diagnosed with facet joint septic arthritis, one or more predisposing factor was found. Most commonly, these included concomitant infection and immunosuppression (most notably diabetes mellitus, liver disease, transplant patients, long-term corticosteroid use, and malignancy). (1,2,5) Other risk factors for the development of a septic facetjoint include older age, alcoholism, injection at facet joint, epidural anesthesia, and IV drug use. Underlying joint disease has been reported in almost 50% of cases of septic arthritis. (1,8)
Although cervical localization of spinal infection is uncommon, it often involves a spinal epidural abscess (SEA) associated with a high risk of morbidity and mortality. (4,14,15) Cervical facet infections, as opposed to those in the lumbar region, have a similarly high association with SEA. Mufolleto and colleagues (5) presented two cases of a hematogenous pyogenic cervical facet infection, and both cases were complicated by the development of an SEA.
The development of an SEA heralds an even more rapid progression of symptoms and can thus be distinguished from a facet infection. Neck pain usually develops within 24 to 72 hours. (16-20) Typically, patients with an SEA present with persistent neck pain and stiffness, fever, and neurological impairment, including radicular signs, motor weakness, numbness, impaired bowel and bladder control, and ultimately paralysis. (18,21,22)
Part of the early work-up of spine infections is blood tests. ESR and CRP are usually elevated, (4,14,18) with markers elevated up to 82% of the time. (4) However, infection may exist with normal inflammatory markers as well. (17) Similarly, the WBC is usually elevated (18) but often is not (14) with some reports claiming that WBC is only elevated 43% of time. (4) For cases of facet infection, blood cultures are positive between 50% to 80% of the time. (2,22,24) Cultures of joint aspirate have been shown to have less than (90) % sensitivity. (22,24)
Mufulleto and associates (5) presented a series of two cases of cervical facet infection, and both cases were found to be caused by S. aureus. S. aureus has been reported in several studies to be the most common pathogen in septic arthritis of the spine. (22,25-27) Our case was one of a facet infection seeded from a dental source. In these instances, the pathogens are more varied. Streptococcus milleri, the species of which S. intermedius, the pathogen identified in our case, is a member, is the most common cause of brain abscesses and has propensity to cause abscesses at many other sites in body. (28,29) It has been found in two other cases of spine infection from a dental origin, both in the form of an epidural abscess, but neither occurring in the setting of a facet joint infection. One case presented at the thoracolumbar junction (29) and the second case at the subaxial cervical spine. (20)
In addition to blood work, imaging is paramount in cases of potential spine infection. Early on, plain films may be normal or show evidence of osteomyelitis. (18) CT scans will show erosive joint changes before plain x-ray films. (5) However, MRI is considered the imaging modality of choice to visualize inflammatory processes of spine. (18) MRI is both sensitive and specific in diagnosing facet joint infection as early as 2 days after symptom onset. (5,30,31) MRI may show facet joint erosion and swelling as well as paraspinal muscle edema. Gadolinium-enhanced images define the presence of associated epidural granulation tissue or epidural or paraspinal muscle abscess formation, (32) which has been reported in as many as (81) % of facet infections. (1,2)
If a microbe can be detected and the patient is neurologically intact, some providers may elect for nonoperative management. (14) However, prompt treatment is necessary before neurological deterioration begins, and many are more aggressive with surgical intervention to prevent initiation or progression of neurological compromise. The goal of surgery is to decrease if not eradicate the bacterial burden with techniques, including laminectomies and corpectomies. Secondarily, surgery must try to preserve spinal stability often threatened by infection. Instability may be defined as vertebral body height less than 50% or spinal angulation greater than 20[degrees]. (14) In our case, although there was bony erosion as a consequence of the septic arthritis, greater than 50% of the facet was preserved (and there was no vertebral height loss or angulation), and fusion was not necessary.
Muzii and coworkers (14) described a minimally invasive approach for treatment of cervical spinal epidural abscesses, although none of their patients had a facet joint infection. In their series of eight patients, all underwent microsurgery via an anterior approach; a single-level discectomy with curettage of the disc plates was performed at the level of the discitis followed by incision of the posterior longitudinal ligament for abscess drainage. A 1.5 mm catheter was inserted into the anterior epidural space and used to perform lavage to remove pus located cranially and caudally to the disc space followed by lavage with rifamycin and chloramphenicol.
Once treatment is initiated, progression or remission of disease may be monitored with serial ESR/CRP levels. In all cases, intravenous antibiotic therapy should be employed for at least 6 weeks.
Cervical facet infections may be complicated by chronic pain, bony destruction and instability, spondylodiscitis, endocarditis, meningitis, and even death. (1,22-24) Even after successful eradication of disease, patients may be left with neurological compromise. No long-term follow-up or reports specifically aimed at addressing the recovery following infection were found, so an accurate prognosis for recovery is not available at this time. Further study to characterize outcomes following cervical spine infection may be beneficial.
We present a case of a cervical facet joint infection of presumed dental origin with Streptococcus intermedius as the pathogen. Although spine infections of dental origin often present with pain within 24 hours of a dental procedure, in our case, no procedure was performed, but the broken crown seems to have become infected around the time the neck pain began. Laminoformanitomy of C4-C5 was performed as the patient developed neurological findings. By 4 months postoperatively, the patient's symptoms had completely resolved, and the results were maintained.
None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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Ian David Kaye, M.D., and Themistocles S. Protopsaltis, M.D., Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York.
Correspondence: I. David Kaye, M.D., Hospital for Joint Diseases, 301 East 17th Street, Room 1402, New York, New York 10010; email@example.com.
Caption: Figure 1 A, T2 axial image demonstrating inflammation at right facet joint of C4-C5 (white arrow). B, T2 sagittal image demonstrating a small epidural abscess from C3-C6.
Caption: Figure 2 A, CT scan (soft tissue window) at time of IR biopsy, demonstrating right C4-5 facet fluid collection and bony erosion. B, CT scan (bone window) 3 days after IR biopsy, showing decreased fluid at the right C4-C5 facet with continued bony erosion.
Table 1 Cases of Spinal Infections of Presumed Dental Origin Case Age Sex Infection Walters, et al. (16) 18 Male Epidural abscess and osteomyelitis Walters, et al. (16) 23 Female Epidural abscess and osteomyelitis Pinckeney, et al. (18) 11 Male Osteomyelitis Pinckeney, et al. (18) 13 Male Osteomyelitis Fiegenbanm, et al. (17) 17 Female Discitis Fiegenbanm, et al. (17) 38 Female Discitis Goolamali, et al. (21) 63 Male Discitis and subsequent paravertebral abscess (also developed mitral valve endocarditis) Muzii, et al. (14) 63 Male Epidural abscess and spondylodiscitis Muzii, et al. (14) 63 Male Epidural abscess and spondylodiscitis Muzii, et al. (14) 27 Male Epidural abscess and C4 spondylodiscitis Muzii, et al. (14) 38 Male Anterior epidural abscess and spondylodiscitis Henton, et al. (19) 12 Female Epidural abscess and discitis Larkin, et al. (33) 65 Male Metastatic paraspinal abscess Gelfand, et al. (29) 63 Female Epidural abscess Dhariwal, et al. (20) 20 Female Epidural abscess Jones, et el. (22) 60 Male Facet joint infection Stetcher, et al. (1) 57 Male Facet joint septic arthritis and epidural abscess Michel-Batot, et al. (23) 69 Male Left facet joint infection (complicated by endocarditis) Case Level Organism Walters, et al. (16) C3-C5 Pseudomonas aeruginosa Walters, et al. (16) C4-C5 Pseudomonas aeruginosa Pinckeney, et al. (18) C3-C6 Pseudomonas aeruginosa Pinckeney, et al. (18) C3-C6 none Fiegenbanm, et al. (17) C5-C6 Enterobacter Fiegenbanm, et al. (17) C3-C4 Enterobacter Goolamali, et al. (21) L4-L5 Fusobacteriimi nucleatum Muzii, et al. (14) C5-C6 Streptococcus intermedins Muzii, et al. (14) C5-C6 Staphylococcus epidetmidis and Mycobacterium tuberculosis Muzii, et al. (14) C3-C5 Streptococcus sanguis, Mycobacterium tuberculosis Muzii, et al. (14) C5-C6 Streptococcus viridans Henton, et al. (19) C4-C5 None identified Larkin, et al. (33) T8-T9 Streptococcus salivarius, mutans, and mitis Gelfand, et al. (29) T9-L1 Steptococcus milleri Dhariwal, et al. (20) C3-C6 Streptococcus milleri Jones, et el. (22) C1-C2 Staphylococcus aureus Stetcher, et al. (1) C5-C6 Staphylococcus aureus Michel-Batot, et al. (23) L3-L4 Streptococcus viridans Case Patient Elistory Walters, et al. (16) None Walters, et al. (16) None Pinckeney, et al. (18) None Pinckeney, et al. (18) None Fiegenbanm, et al. (17) None Fiegenbanm, et al. (17) None Goolamali, et al. (21) Gout, osteoarthritis Muzii, et al. (14) Dental caries Muzii, et al. (14) Sarcoidosis, periodontal infection Muzii, et al. (14) Hepatitis C, drug abuse, tubercular orchiepididymitis, dental infection Muzii, et al. (14) Hepatitis C, drug abuse, periodontitis Henton, et al. (19) None Larkin, et al. (33) None Gelfand, et al. (29) None Dhariwal, et al. (20) None Jones, et el. (22) Multiple dental caries, chronic obstructive pulmonary disease, CHF, OSA Stetcher, et al. (1) Type 2 diabetes mellitus Michel-Batot, et al. (23) N/A Case Treatment Walters, et al. (16) Irrigation and debridement, C4 corpectomy, C3-C5 fusion, intravenous antibiotics Walters, et al. (16) Irrigation and debridement, C4 corpectomy, intravenous antibiotics Pinckeney, et al. (18) Body cast with halo traction for 3 months and intravenous antibiotics for 3 weeks Pinckeney, et al. (18) Body cast and halo traction for 2 months and intravenous antibiotics for 3 weeks Fiegenbanm, et al. (17) Intravenous antibiotics Fiegenbanm, et al. (17) Intravenous antibiotics Goolamali, et al. (21) L5 laminectomy, irrigation and debridement of L4-S1 epidural space, intravenous antibiotics Muzii, et al. (14) Microsurgical anterior C5-C6 discectomy, irrigation and debridement, intravenous antibiotics Muzii, et al. (14) Microsurgical anterior C5-C6 discectomy, irrigation and debridement, intravenous antibiotics Muzii, et al. (14) Microsurgical anterior C4-C5 discectomy, irrigation and debridement, intravenous antibiotics Muzii, et al. (14) Microsurgical anterior C5-C6 discectomy, irrigation and debridement, intravenous antibiotics Henton, et al. (19) Intravenous antibiotics Larkin, et al. (33) Irrigation and debridement followed by repeat irrigation and debridement and laminectomy and decompression, intravenous antibiotics Gelfand, et al. (29) T9-L1 laminectomy and irrigation and debridement, intravenous antibiotics Dhariwal, et al. (20) C1-C3 hemi-laminectomy, 5 months later, C4-C6 laminectomy and corpectomy with iliac bone crest and buttress plate Jones, et el. (22) Intravenous antibiotics Stetcher, et al. (1) Intravenous antibiotics Michel-Batot, et al. (23) Intravenous antibiotics, bracing Case Sequelae Walters, et al. (16) None Walters, et al. (16) None Pinckeney, et al. (18) Neck stiffness at 3 months Pinckeney, et al. (18) At 2 years x-ray showed C3-6 fusion Fiegenbanm, et al. (17) 6 weeks: x-ray showed collapse of the disc space and a slight anterior dislocation of C6 vertebra; 4.5 months: no change, clinically asymptomatic Fiegenbanm, et al. (17) No neuro impairment at 5 months; mild anterior subluxation of C4 on C3 Goolamali, et al. (21) None Muzii, et al. (14) Mild paraparesis at 40 months followup Muzii, et al. (14) None at 38 months follow- up Muzii, et al. (14) None at 30 months follow- up Muzii, et al. (14) None at 24 months Henton, et al. (19) None at 6 months follow- up Larkin, et al. (33) Paraplegia Gelfand, et al. (29) Paraplegic, wheelchair bound, urinary incontinence but able to control defecation Dhariwal, et al. (20) 23 months later, died of frontal intracranial hemorrhage thought to be related to infection Jones, et el. (22) None Stetcher, et al. (1) None Michel-Batot, et al. (23) None Table 2 Risk Factors for Development of Facet Joint Septic Arthritis Immunosuppression Diabetes mellitus Chronic liver disease Organ transplant recipient Chronic steroid use Malignancy End stage renal disease Iatrogenic Facet joint injection Epidural anesthesia Environmental Intravenous drug use Alcoholism Older age Miscellaneous Underlying joint disease Trauma
Please note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Kaye, Ian David; Protopsaltis, Themistocles S.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Article Type:||Clinical report|
|Date:||Jul 1, 2016|
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