ANTERIOR AND POSTERIOR FUSION OF CERVICAL SPINE IN OSTEOMYELITIC PROCESS OF SEVERAL VERTEBRAL BODIES: A CASE REPORT

A 52-year old male patient was initially examined because of short-term bronchopneumonia by the primary healthcare physician who prescribed antibiotic therapy that calmed the cough and lowered the temperature. In the following period, the patient started to complain of periodic febrile and subfebrile episodes. One month after the first symptoms of bronchopneumonia, the patient experienced pain in the neck and numbness in his right hand. After approximately ten days, the patient began to experience weakness in both legs and in the right hand. During the examination at the Clinic for Infectious Diseases, severe spastic paraparesis developed. MRI and MSCT scans showed compression of the medulla at the C5 and C6 level, with signs of destruction of the C5 and C6 corpuses. The progression of the neurological deficit necessitated complete removal of corpuses C5 and C6 and partial removal of corpus C7 which were then replaced by inserting an artificia limplant made of acrylate. Anterior stabilization was performed, followed by the posterior cervicothoracic stabilization. After the intervention, there was an improvement in the neurological deficit. Neurological restitution was achieved one month after surgery. Regular X-ray and MSCT check-ups were performed after 3 and 6 months, as well as after one year. The finding showed good decompression and stabilization. The patient was stable and with no neurological deficits. Acute osteomyelitic processes of the spine, accompanied by the development of neurological deficits, require urgent surgical procedures and spine reconstruction by using allotransplants and 3D fixation, in combination with intensive antibiotic therapy admi- nistered during a long period of time. Acta Medica Medianae 2016;55(2):50-56.


Introduction
Non-specific inflammatory processes of the vertebral corpuses incurred by hematogenous or lymphatic dissemination of infectious agents do not represent a common pathological entity. Their frequency ranges from 3-5% of all the cases of osteomyelitis, with an incidence of 2.4/100.000 (1). Non-specific inflammatory changes of the vertebrae are commonly found in the lumbar and lumbosacral spine, and usually are the conse-quence of pre-existing inflammatory changes in the retroperitoneal space. In some cases, osteomyelitis may develop after cervical injuries, but even then hematogenous or lymphatic dissemination are the underlying factor (2,3).
Unlike inflammatory changes in the lumbar spine, non-specific inflammatory changes in the vertebral corpuses of the cervical spine are very rare and as such associated with severe neurological deficits and mortality ranging between 0-11% (4). Moreover, they require very complex approach to treatment.

Material
Because of an extremely rare presence of non-specific inflammatory changes in the vertebral corpuses of the cervical spine, we will present a case of osteolytic inflammatory processes in segments C5, C6 and C7. The course of the disease, localization with a specific clinical presentation, and the complexity and adequacy of an appropriate thewww.medfak.ni.ac.rs/amm Figura 1: MRI finding: Destruction of C5 and C6, with the compression of the spinal canal rapeutic procedure make this case interesting, with a possibility of providing proper recommendations towards making necessary diagnostic and terapeutic approaches for the detection and treatment of other patients with similar issues (5,6).
The symptoms in a 52-year old male first occurred as a short-term bronchopneumonia. The patient was initially examined by the primary healthcare physician, who prescribed antibiotic therapy that calmed the cough and lowered the temperature. In the following period, however, the patient started to complain of periodic febrile and subfebrile episodes, which were successfully treated with antipyretics and antirheumatics. One month after the first symptoms of bronchopneumonia, the patient experienced pain in the neck, and after ten days also in his right hand. At this point, the pain was partially managed by introducing antirheumatic and corticosteroid therapy. The patient was referred to a neurologist who requested a cervical spine X-ray and EMG. The radiograph revealed an illumination in the region of the C5 corpus. Because of recurrent febrile episodes during the same period, with the temperature rising over 38.5 degrees, the patient was examined by an infectious disease specialist at the Clinic of Infectious Diseases. Chest X-ray, bloodculture and urinoculture were taken as part of the diagnostic procedure. The findings did not indicate the cause of febrile episodes. During the examination at the Clinic of Infectious Diseases, severe weakness in the legs and development of severe paraparesis with the pre-existing weakness in the patient's right hand were reported. The ne-urosurgeon indicated MRI of the cervical spine, which pointed to the presence of an expanding change in the spinal canal, epidurally at the level of the C5, C6 and C7 corpuses, and their destruction ( Figure 1). The patient was transferred to the Clinic of Neurosurgery because of the development of severe quadriparesis.

Methodology and treatment plan
The treatment plan consisted of several stages: •Additional diagnostic observations were necessary in order to make the final decision on further treatment (7). MSCT of the cervical spine, performed in order to define the expanding change, pointed to the existence of osteolytic changes in the C5, C6 and C7 corpuses, of osteomyelitic by type ( Figure 2). Evoked potentials showed conduction interferences. The complete biohumoral status indicated the presence of chronic inflammatory process, with high levels of CRP (224 mg/l) and procalcitonin (18 µg/ml), regardless of the lower WBC count (18.0x10^0/lit) •Highly potent empiric antibiotic therapy was included (Meropenem and Vancomycin) (8).
•Emergency surgery was done as a result of the development of severe neurological deficit.
Surgical treatment of the acute osteomyelitic focus in the cervical spine is associated with several very important surgical problems: •Addressing the issue of adequate decompression of the spinal cord and removing the corpuses affected by osteomyelitis and suppuration from the spinal canal. •The need for replacing the removed, inflamed bone tissue with appropriate material that would not be subject to colonization and progression of the process (9, 10).
•The need for performing high quality and complete stabilization and reconstruction of the cervical spine (11, 12).
It was decided to completely remove all the affected corpuses and surrounding tissue via anterior surgical approach, to clean the spinal canal and remove compression on the spinal cord (8). Complete removal of corpuses C5 and C6 and partial removal of corpus C7 were done. The corpuses were then replaced by inserting an artificialimplant made of acrylate and moulded so as to fit the required size and curvature of the space obtainned after the removal of the corpuses, and fixation was done using the front titanium plate (13) (Figure 3). Next, the posterior stabilization including transarticular stabilization of C4, C5 and C6, and transpeduncular stabilization of C7 and Th1 were done in order to achieve adequate stability and reconstruction of the physiological lordosis of the spine (Figure 4).
The removed material was sent for antimicrobial susceptibility testing. The finding pointed to streptococcal infection. The intensive therapy with Meropenem and Vancomycin was continued (14) and laboratory findings were regularly moni-tored (SE, blood count, CRP). Immediately after the surgery and during the postoperative follow-up, the patient was involved in the rehabilitation procedures. After three weeks, the signs of inflammation began to subside.

Results
After the signs of inflammation became less intense, the patient was transferred to the Clinic of Physical Medicine and Rehabilitation. During the rehabilitation, one month after the surgical treatment, he regained movement in his legs and the motor functions were restored. Complete recovery was achieved two months after the surgery.
Control MSCT scan performed three months after the surgical treatment showed good stability and functionality of the cervical spine ( Figure 5). Control X-ray of the cervical spine and MSCT per- formed after 6 months showed successful decompression and stabilization.

Discussion and Conclusion
Inflammatory processes of the spine are often clinically latent, until neurological disorders occur as a result of inflammatory or ischemic compression (15,16).
Clinical manifestations can often begin with painful conditions, as a result of disturbances in the osteoligamentous structures, before compression on the nerve elements occurs. In addition, the existence of signs of inflammatory changes in the biohumoral status (17) with the presence of non-specific subfebrile episodes may suggest the need for a diagnostic consideration of the corresponding regions of the spine, for the purpose of differential diagnostic elimination of dangerous and complex osteomyelitic processes. Early diagnosis of inflammatory changes in the spine may enable the processes to be remedied only by means of intensive medicamentous therapy (18), without the need for surgical treatment, which is very complex.
In the case of process development and of severe neurological deficits,which are the consequence of compression on the nerve elements, it is necessary to introduce aggressive antibiotic treatment and prepare the patient for emergency surgery (19) where, in spite of a well-planned surgical intervention, there is always a risk of serious postoperative complica-tions (20,21).There are different modalities of surgical ap-proach (22, -24); however, the surgical inter-vention must always be radical, with complete eradication of the osteomyelitic process and the use of complete surgical stabilization of the spine, as the basic prerequisite for further recovery and positive results of the rehabilitation procedures (25 -28).