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Acute quadriplegia following a minimal injury in the posterior pharyngeal wall by a fishbone

2017; Wiley; Volume: 23; Issue: 7 Linguagem: Inglês

10.1111/cns.12704

1755-5949

Shui‐Hong Zheng, Yang Li, She‐Qing Zhang,

Amoebic Infections and Treatments

Spinal epidural abscess is a potentially disastrous condition in neurological clinical practice, because the diagnosis is often missed or mistaken for another disease. Infection of epidural space has many a route. An injury to the back, often trivial at the time, furunculus in the skin, or wound infection, even lumbar puncture, may seed bacteria in the epidural or subdural space, even vertebral body.1 In the latter case, the infection gives rise to osteomyelitis with extension of the purulent process to the epidural space; occasionally, the infected disk may spread to the epidural space. Staphylococcus aureus is the most frequent etiological agent, followed in frequency by streptococci, Gram-negative bacilli, and anaerobic organisms.2 Although spinal epidural abscess often occurs in immunodeficient patients, or in those with long-term immunodepressant drugs such as rituximab, infliximab, and methotrexate therapy,3, 4 previously healthy people are also reported to be infected with spinal epidural abscess.5, 6 In a rare case, cellulitis anterior to the cervical vertebra may spread and infect the vertebral body and disk, then penetrating into the epidural space, and finally causing acute epidural abscess. Recently, we have seen such a patient, who unfortunately suffered quadriplegia several days after a minimal injury by a fishbone. A 74-year-old man was admitted to the Department of Orthopaedics, complaining of an 8-day history of constant, dull pain in the waist and back. At first, the pain was limited in the waist, so he did not take it seriously. One day later, he felt the severe pain in the shoulders and found the difficulty in raising the arms after getting up in the morning. Four days later, the pain in the nucha, back, and waist became more intolerable and he went to see an orthopaedist. However, routine physical examinations showed normal, and the computerized tomography of the lumbar spinal column revealed only slight intervertebral disk protrusion. On the eighth day, he was admitted into the Department of Orthopaedics. At that time, the patient was alert and his temperature was 36.6°C. Physical examinations by the orthopaedist demonstrated pressure pain and percussive pain in the lumbar and cervical spinous processes, and associated radiation to the right shoulder and arm. The muscle power of the four limbs was normal. His deep and superficial sensations were normal; and the knee and ankle reflexes were within the normal range. The plantar reflexes were flexor. Laboratory investigations revealed normal in liver and kidney functions. The ECG and the troponin measurement were unremarkable. His peripheral blood examination showed normal haemoglobulin and platelets, but the white blood cells were elevated (17.27×109/L) with predominant neutrophils (84%). The erythrocyte sedimentation rate was 36 mm/h; and the C reaction protein (CRP) was 94 mg/L (normal range 0-8.2 mg/L). The AIDS and syphilis antibodies were negative. The chest CT scan was almost normal except for slight emphysema and scattered noduli. On the first day after admission, the patient was prescribed some pain-relieving drugs such as celecoxib, but the pain in the neck and back was not attenuated. On the second day, the cervical vertebrae MRI showed protruded intervertebral disks between C3/C4, C4/C5, C5/C6, and C6/C7 vertebral bodies; and the soft tissue anterior to the cervical vertebra was also found swollen (Figure 1, left). Unfortunately, the phenomenon could not be explained reasonably. Then, he was added dexamethasone sodium phosphate and mannitol, but the pain still existed. On the third day, the pain in the nucha and back worsened progressively, which made him unable to rise from the bed. Additionally, he also developed respiratory symptoms such as cough and sputum. In the night, he could not go into sleep; he even developed visual hallucinations and delirium, so diazepam and olanzapine were prescribed. On the fourth day, his temperature rose to 38.8°C, and blood extracted for bacterial culture. In the afternoon that day, he found his limbs unmovable. The muscle power of the left limbs was 2/5 grades and that of the right limbs was 1/5 grades. The bilateral plantar reflexes were doubtfully extensor. The neurologist was called for consultation. The central nervous system infection or Guillain-Barre syndrome was considered. And 4 g of ceftriaxone was intravenously injected daily. On the fifth day, his temperature rose to 39°C. Lumbar puncture showed slightly yellow cerebral spinal fluid (CSF) with nuclear cells of 126×106/L (normal range 0-5×106/L), among which were 32% mononuclear cell and 68% morphonuclear cell; CSF protein was 1.755 g/L, and glucose was 2.77 mmol/L. The muscle power fluctuated during the day. By the evening, the muscle power of the four limbs decreased to 0/5 grades, and the pain-temperature sensation and the vibration-joint position sensation disappeared below the thoracic segments. The peripheral white blood cell increased to 25.37×109/L, with 93% neutrophils. The neck MRI was performed again, and the soft tissue anterior to the cervical vertebrae was swollen more severely than that seen 3 days before (Figure 1). At that time, prevertebral abscess was considered, and emergent operation was ordered. On operation, it was found that an abscess anterior to the second and fifth vertebral bodies had been formed, and the intervertebral disk between the fourth and the fifth bodies was destructed, and the fourth vertebral body was necrotized. About 25 mL of purulent fluid had been drained from the abscess; then, the fourth vertebral body was removed and the cervical column was strengthened. Staphylococcus aureus was found by blood culture. When we investigated into the source of the infection, the family members reported that the patient had been stuck by a fishbone in the throat 5 days before the onset. The patient himself pulled out the bone but did not take it seriously. After operation, the combination of vancomycin and ceftriaxone was prescribed for an enough period. Unfortunately, the patient suffered permanent quadriplegia. To our knowledge, this is a rare and interesting case, in which epidural spinal abscess occurs after an injury by a fishbone. Because an injury stuck by a fishbone is frequently seen by ear-nose-throat (ENT) surgeons, it is especially worthy of emphasizing the likelihood of developing complications. In this case, the injury of posterior pharyngeal wall by the fishbone may cause the focal infection, which led to the formation of an abscess between the posterior pharyngeal wall and the vertebral bodies of cervical 2-5 segments (Figure 1). The pathogenesis of paralysis caused by spinal epidural abscess has long been thought to be attributed to compression effect; however, Shah et al.7 have recently found that spinal cord arterial and/or venous ischemia and thrombophlebitis might contributed much in humans. In our case, the inherent protruded disks may also promote the spinal cord ischemia in the purulent process of vertebrae. In view of the disastrous result of this case, the following points should be learned. Neurological or orthopaedic doctors should always remember the possibility of spinal epidural abscess when patients complain of neck, back, or lumbar pain (variable according to the site of infection), especially when accompanied with fever and elevated peripheral white blood cells. In our case, the first MRI of the cervical spine had convincingly revealed the swollen soft tissue anterior to the vertebral bodies of C2-C5 (Figure 1, left); however, the orthopaedist cannot explain the relationship between cervical pain and the swollen tissue. At that time, the symptoms of spinal cord compression had not developed; so it was the most suitable time for performing the decompression to save the spinal cord. Doctors may sometimes prescribe some pain-relieving drugs, even dexamethasone, as in our case and that reported by McDonald et al.6 This therapy may cause the spread of infection, so it is forbidden if the white blood cells are elevated. Antibiotics treatment alone is sometimes beneficial if the abscess does not inflict the spinal cord.5 Once the paraplegia or quadriplegia develops, the prognosis is often poor, with Curry et al.8 reporting that only 38% of patients experience improved neurological function after treatment. Spinal column MRI should be performed as early as possible if a patient complains of neck or back pain accompanied with elevated white blood cells, ESR, or CRP. Sometimes, sequential MRI is necessary. Once the abscess around the column is convicted by MRI or CT, emergent decompression must be considered to avoid subsequent spinal cord complications. This work was supported by STCSM funds (No 17ZR1438700).