A 57-year-old man presented to the emergency room with neck
back pain for about 2 months, unresponsive to nonsteroidal antiinflammatory
drugs and progressive course of upper and lower
extremity weakness with no sphincter dysfunction. The patient had
no predisposing risk factors such as recent spinal surgery, trauma,
instrumentation, distal site of infection, immunosuppression,
diabetes. He was apyrexial. Physical examination showed marked
mid neck tenderness, no palpable masses were felt, no lymph
nodes were felt. Neurological examination of his extremities,
spasticity was positive, and power was decreased 3/5 in both lower
extremities, 2/5 in both upper extremities. Bilateral Babinski signs
were present and deep tendon reflexes were increased.
Full blood count and biochemistry showed white blood cell
count (WBC) 10,269/L (neutrophils 71.3%; lymphocytes 21.8%;
monocytes 2.2%; WBC 4.4 to 11.3/L); C-reactive protein 13.86
mg/dL (0.1 to 6 mg/dL). Magnetic Resonance imaging of the
cervical spine showed the collapsed body of C4 with epidural
abscess formation, complicating with spinal cord compression.
He underwent urgent anterior cervical decompression and
evacuation of anterior epidural abscess with fusion. The material
underwent histologic examination and aerobic, anaerobic, fungal,
mycobacterial cultures. A tuberculous granuloma was detected on
histology. Ziehl-Neelsen stain confirmed the diagnosis. Cultures
also detected Staphylococcus aureus. Treatment was started with
rifampin (600 mg), Isoniazid (300 mg), ethambutol (25 mg/kg),
pyrazinamide (25 mg/kg), and levofloxacin 750 mg for two months.
This was followed by seven months of isoniazid and rifampin. The
patient was referred to rehabilitation. One year later, the patient is
able to walk independently, and the back pain is gone.
Figure 1: T2-weighted axial MRI showing an intraductal cystic lesion lateralized to the left and protruding in the adjacent
neuro foramina. Squeezing the cervical spinal cord
Spondylodiscitis can be etiologically classified as pyogenic,
granulomatous (tuberculosis, brucellosis, or fungal infection), or
parasitic. Pyogenic spondylodiscitis commonly affects the lumbar
column and more rarely affects the thoracic and the cervical column
[1,2] (Figure 1). S. aureus is the predominant pathogen in pyogenic
spondylodiscitis, followed in older people by enterobacteria, mainly Escherichia coli, Proteus, Klebsiella, and Enterobacter
[2-4]. Mycobacterium tuberculosis is the most common cause
of spondylodiscitis worldwide. Tuberculosis affects mostly the
thoracic spine and involves two or more vertebral segments. The
main contamination routes are hematogenous spread, external
inoculation, or involvement from adjacent tissue [5]. Isolation
of pyogenic bacteria from an abscess may guide the clinician to
disregard the possibility of spine tuberculosis. It is recommended,
therefore, to made mycobacterial culture and histopathological
examination for all suspicious cases even when there is positive
culture of pyogenic bacteria.