Spondylodiscitis after Cervical Nucleoplasty without Any Abnormal Laboratory Findings
A 33-year-old male (height 172.3 cm and weight 61.5 kg) visited our pain clinic due to neck pain radiating to both shoulders, which started 3 years ago. He complained of tingling sensations of the bilateral hand along with shoulder pain, and difficulty in neck flexion. Upon physical examination, the results of the Jackson compression test and the Spurling's test did not appear positive. On the cervical MRI, C5/6 and C6/7 intervertebral disc protrusions were found and chronic right C6 radiculopathy was found on the electromyography. This patient had already received an epidural steroid injection and decompressive neuroplasty using a Racz's catheter at a local hospital. However, the symptoms were not relieved. Therefore, we decided to perform cervical nucleoplasty at the C5/6 and C6/7 intervertebral discs. On the pre-procedural laboratory tests, there were no abnormalities in the CBC, ESR, and blood chemistry test (). In addition, there were no general underlying diseases. Nucleoplasty was performed on the C5/6 and C6/7 intervertebral discs without any perioperative events. Under a supine position, skin preparation was performed with betadine soap and 2% chlorhexidine-70% isoprophyl alcohol solution, and a sterile surgical drape was applied. The nucleoplasty procedure was performed in the same manner as reported previously []. After the internal carotid was laterally displaced, a 19 gauge 3 inch introducer needle was introduced till the anterolateral annulus fibrosus. After the needle was advanced deeper, the position of the needle was adjusted to reach the target site of the herniated disc under a C-arm guide. When the needle reached the proper target site, the stylet of the introducer needle was withdrawn, and the Perc™ DC spine Wand™ (ArthroCare Co., Sunnyvale, CA, USA) was replaced and fastened to the needle hub. Next, the Perc™ DC spine Wand™ was connected to the Arthrocare system 2,000®. After confirming that there was no cervical root stimulation, Coblation® was then carried out by rotating the flange 180° for 20 seconds. After this, the wand was retracted 1-2 mm under C-arm guidance and the same procedure was repeated 3 times. This procedure was repeated at each disc level (). During the hospital stay, the body temperature was 36.7-36.9℃ and there were no signs or symptoms of acute complications. Prophylactic antibiotic therapy with intravenous cefazoline 1 g was administered prior to nucleoplasty. An additional amount of intravenous cefazolin was administered three times a day and a routine prophylaxis for 2 more days during the hospital stay. Additional oral cefradine was prescribed 1,000 mg/day for 1 week after the patient's discharge. After 8 days, the patient revisited our outpatient clinic for routine postoperative checkup, but there were no improvements in the patient's symptoms. In addition, there were no symptoms or signs of infection including fever or chills, and the laboratory findings, such as the CBC and ESR, were in the normal range. After 2 months, during his second postoperative visit to our clinic, the patient complained of right shoulder pain and worsening neck pain during flexion. He also complained of feelings of weakness in both arms, but his motor functions were intact when a physical examination was performed. In addition, new physical signs developed; the Jackson compression test and Spurling's test were positive, with radiating pain in both shoulders. There was tenderness on the right cervical facet joint, but no tenderness was observed on the left side. The CBC and CRP were normal. The body temperature was normal, and there was no sensation of chills. In order to evaluate the focus of the pain, a cervical MRI was performed, and the findings were compatible with spondylodiscitis at the C6/7 intervertebral disc and the vertebral body (). The patient was referred to the neurosurgery department immediately, and intravenous antibiotics therapy was planned. However, with the patient's will, he was transferred to another hospital for long-term antibiotics therapy. After 6 weeks of antibiotics treatment, the patient's symptoms were relieved markedly.