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Cervical facet joint infection and associated epidural abscess with Streptococcus intermedius from a dental infection origin: a case report and review.

Pyogenic facet infections comprise between 1% to 20% of all spine infections, (1-4) but the majority of cases reported (86% to 97%) are isolated to the lumbar spine. (1,5) Although cervical facet joint infection is the least common site for pyogenic infection in the axial skeleton, several studies have helped elucidate a typical presentation. These infections present at an average age of 55 to 59 years. (1) When such infections occur in the cervical spine, patients may present with or without fever and often have unilateral neck pain with possible radiation to the ipsilateral shoulder, often worsened with neck motion. Radicular symptoms may be present as well. (5) As opposed to the more common cervical spondylodiscitis, facet joint septic arthritis often presents with unilateral symptoms with a more rapid progression of symptoms (4 weeks versus 2 to 3 months). (1,5)

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.

Case Report

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.

Hospital Course

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.

Postoperative Course

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.

Disclosure Statement

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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(32.) Fujiwara A, Tamai K, Yamato M, et al. Septic arthritis of a lumbar facet joint: report of a case with early MRI findings. J Spinal Disord. 1998;11:452-3.

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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;

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

Walters, et al. (16)        23    Female   Epidural abscess and

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

Muzii, et al. (14)          63    Male     Epidural abscess and

Muzii, et al. (14)          27    Male     Epidural abscess and C4

Muzii, et al. (14)          38    Male     Anterior epidural abscess
                                           and spondylodiscitis

Henton, et al. (19)         12    Female   Epidural abscess and

Larkin, et al. (33)         65    Male     Metastatic paraspinal

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

Michel-Batot, et al. (23)   69    Male     Left facet joint
                                           infection (complicated by

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

Muzii, et al. (14)          C3-C5   Streptococcus sanguis,

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

Muzii, et al. (14)          Hepatitis C, drug abuse,
                            orchiepididymitis, dental

Muzii, et al. (14)          Hepatitis C, drug abuse,

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,

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

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

Muzii, et al. (14)          Microsurgical anterior
                            C5-C6 discectomy,
                            irrigation and
                            debridement, intravenous

Muzii, et al. (14)          Microsurgical anterior
                            C4-C5 discectomy,
                            irrigation and
                            debridement, intravenous

Muzii, et al. (14)          Microsurgical anterior
                            C5-C6 discectomy,
                            irrigation and
                            debridement, intravenous

Henton, et al. (19)         Intravenous antibiotics

Larkin, et al. (33)         Irrigation and
                            debridement followed by
                            repeat irrigation and
                            debridement and
                            laminectomy and
                            intravenous antibiotics

Gelfand, et al. (29)        T9-L1 laminectomy and
                            irrigation and
                            debridement, intravenous

Dhariwal, et al. (20)       C1-C3 hemi-laminectomy, 5
                            months later, C4-C6
                            laminectomy and
                            corpectomy with iliac
                            bone crest and buttress

Jones, et el. (22)          Intravenous antibiotics

Stetcher, et al. (1)        Intravenous antibiotics

Michel-Batot, et al. (23)   Intravenous antibiotics,

Case                        Sequelae

Walters, et al. (16)        None

Walters, et al. (16)        None

Pinckeney, et al. (18)      Neck stiffness at 3

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

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-

Muzii, et al. (14)          None at 30 months follow-

Muzii, et al. (14)          None at 24 months

Henton, et al. (19)         None at 6 months follow-

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
                    End stage renal disease

Iatrogenic          Facet joint injection
                    Epidural anesthesia

Environmental       Intravenous drug use
                    Older age

Miscellaneous       Underlying joint disease


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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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