Cervical epidural abscess and osteomyelitis of C-5 vertebra following percutaneous transluminal coronary angioplasty

Cervical epidural abscess and osteomyelitis is a rare condition. Cardiac catheterization can result in a life threatening complication like cervical epidural abscess and osteomyelitis. Prevention is the key. Early diagnosis and prompt intervention are the cornerstones of management. SICOT Online Report E051 Accepted December 17th, 2003 2 Introduction Epidural abscess and osteomyelitis following interventional cardiac procedures is extremely rare. Speed of diagnosis and intervention are of paramount importance to prevent neurological complications. Case report: A 48 year old male presented to Accident and Emergency department with complaint of gradually worsening neck pain and stiffness over duration of one month. There was no history of trauma related with the symptoms. The patient gave a history of swinging temperature associated with rigors two days prior to presentation. On questioning the patient said he was on holiday in Cyprus four weeks before presenting to us. During the holiday he had myocardial infarction. He was on intensive care and was treated initially with thrombolysis and temporary pacing followed twenty-four hours later by angioplasty, resulting in 70% recanalization of coronary vessels. He made a complete recovery thereafter. Towards the end of his stay he had high swinging temperature and rigors associated with neck pain and stiffness. His neck pain and stiffness persisted at discharge, two weeks after admission. Back from his holiday, because of persistent neck pain he saw his family doctor who prescribed painkillers and physiotherapy. During this period his neck pain and stiffness became worse with associated fever on and off, before presenting to us in the Emergency department. Patient was not a smoker, alcoholic, nor on any drugs. On Physical examination the patient had a temperature of 38o c. Blood pressure was 128/80 mm Hg. There was spasm over the entire Cspine area particularly over the lower cervical spine. Neck movements were restricted. Neurologically, power in the upper limbs was grade 4/5 in all the muscle groups on both the sides. The sensory system and examination of SICOT Online Report E051 Accepted December 17th, 2003 3 Reflexes were found to be normal. The lower limb neurology was normal. There was no bowel or bladder involvement. The laboratory profile showed the following picture: FBC: Haemoglobin 12.4 gm/dl, WBC: total count 14×10, C-reactive protein: 56, ESR: 39 mm first hour. Blood cultures and midstream urine specimens were sent. Plain radiographs showed the following picture (fig 1). Prompt MRI scan (fig 2) was requested and it showed a high signal at the C5-C6 level. There was thickening and elevation of the posterior ligament over the adjacent two vertebral levels. There is also radio-dense opacity of the C-5 vertebra. Diagnosis of C5-C6 discitis with C-5 vertebral osteomyelitis and epidural abscess at C5-C6 level was made.