Percutaneous cervical nucleoplasty (PCN) has proven to be a safe and effective technique for the management of the cervical herniated or bulging discs. The incidence of cervical spondylodicitis (CSD) after PCN is rare. Case 1: A 53-year-old male patient was admitted with right arm motor weakness, severe posterior neck pain. He diagnosed with a C5-6 bulging disc and underwent a PCN two months prior to admission to our hospital. Laboratory tests revealed WBC counts and CRP levels, but his erythrocyte ESR was mildly elevated to 42 mm/hr. MRI showed a CSD at the C5-6 level. The patient underwent an anterior cervical C5 corpectomy and fusion. A microbiological culture revealed the presence of Propionibacterium acnes. Case 2: A 51-year-old female patient was admitted with quadriparesis. She was diagnosed with a C6-7 bulging disc and underwent a PCN two weeks prior to admission to our hospital. Laboratory tests revealed and elevated WBC count of 13.1×103/mm3, elevated ESR of 70 mm/hr, and elevated CRP of 10.1 mg/dL. The MRI showed a high signal intensity around the C5-6 vertebral body and epidural fluid collection on the axial image. The patient underwent a C6-7 anterior cervical discectomy and. No microbes were identified in blood or pus cultures. Clinicians should consider CSD, if a patient’s neurologic symptoms have deteriorated within 8 weeks after PCN. If clinical and laboratory tests show any indication of CSD, MRI should be performed facilitating appropriately timed treatment in order to prevent neurological sequelae.
Percutaneous cervical nucleoplasty (PCN) has proven to be a safe and effective technique for the management of cervical herniated or bulging discs, with a 70-90% postoperative efficacy rate7 [
Herein we discuss two patients who presented with CSD after PCN at a local hospital. One patient underwent an anterior cervical C5 corpectomy and fusion using an autologous iliac bone graft with C4-6 plate fixation, and one patient underwent a C6-7 anterior cervical discectomy and fusion (ACDF) using an autologous iliac bone graft with plate fixation.
A 53-year-old male patient was admitted to our hospital with right arm motor weakness, severe posterior neck pain, and right arm radiating pain. He had chronic myelogenous leukemia (CML) as an underlying disease. He visited a local hospital with posterior neck pain and was diagnosed with a C5-6 bulging disc and underwent a PCN two months prior to admission to our hospital. After the procedure, the patient’s posterior neck pain did not improve and he was treated with non-steroidal anti-inflammatory drugs (NSAIDs) for 2 weeks. However, the patient’s symptoms gradually worsened. Physical examination showed right arm motor weakness: right elbow flexion grade IV, wrist extension grade IV, elbow extension grade IV, and hand grasp grade III. The hypoesthesia was observed in the C6 sensory dermatome. Laboratory tests revealed normal white blood cell (WBC) counts, and C-reactive protein (CRP) levels, but his erythrocyte sedimentation rate (ESR) was mildly elevated to 42 mm/hr (normal range: 0-20mm/hr). He had no fever or chills at the time of admission. A simple cervical spine X-ray showed an osteolytic C5-6 lesion, retrolisthesis of C5 on C6, and thickening of prevertebral soft tissue (
Intra-operatively, the C5-6 disc was destructed, and granulation tissue with a small amount of dark colored pus was observed. A C5 corpectomy was performed with removal and cleaning of the abscess following collection for culture and biopsy. Afterwards, an autologous iliac bone graft with an anterior titanium cervical internal fixation was performed (
Intra-operatively, the C5-6 disc was destructed, and granulation tissue with a small amount of dark colored pus was observed. A C5 corpectomy was performed with removal and cleaning of the abscess following collection for culture and biopsy. Afterwards, an autologous iliac bone graft with an anterior titanium cervical internal fixation was performed (
When the patient was admitted to our hospital, physical examination showed both arm and leg motor weakness. The hypoesthesia was observed in the C5-6-7 sensory dermatome. Laboratory tests revealed that her WBC count had increased to 13.1 ×103/mm3, ESR was elevated to 70mm/hr, and CRP level had increased to 10.1 mg/dL. However, she had no fever or chills at the time of admission. Based on the physical examination and radiologic findings at the local hospital, we diagnosed with CSD at the C6-7 level and decided to perform surgery.
Intra-operatively, yellowish pus was observed at the posterior side of the disc. A C6-7 discectomy was performed with removal and cleaning of the abscess following collection for culture and biopsy. Afterwards, an autologous iliac bone graft with an anterior titanium cervical internal fixation was performed (
Ablation and coagulation are key PCN techniques for decompression the disc with minimal damage to the surrounding skeletal structures [
It is important to diagnose CSD early and to treat them appropriately. In order that, clinicians should understand the natural course of postoperative CSD. According to previous reports, the patients’ symptoms of postoperative CSD did not improve and became aggravated after surgery, with the development of new neurological symptoms within 4 to 8 weeks [
With widespread access and advances in neuroimaging techniques, MRIs are the gold standard for diagnosing spondylodiscitis. An MRI is considered to be the most sensitive (93%) and specific (97%) diagnostic tool for spondylodiscitis [
Clinicians should consider CSD if a patient’s neurological symptoms deteriorate within 8 weeks after a PCN. Further, inflammatory markers such as WBC count, ESR, and CRP level should be carefully checked even after minimally invasive procedures. If there are any indications of CSD in clinical and laboratory results, an MRI should be performed facilitating appropriately timed treatment in order to prevent neurological sequelae. In addition, surgical decompression and fusion should be considered as the first treatment option for CSD with neurological deficits, which could achieve the restoration of the cervical spinal alignment and the identification of microbes allowing for the selection of appropriate antibiotics.
All authors associated with this submission have no financial conflicts of interest to disclose.
Percutaneous cervical nucleoplasty
Cervical spondylodicitis
White blood cell
C-reactive protein
Erythrocyte sedimentation rate
Magnetic resonance imaging
Anterior cervical discectomy and fusion
Chronic myelogenous leukemia
Non-steroidal anti-inflammatory drugs
(A) Simple cervical spine X-ray showing an osteolytic lesion at C 5-6, retrolisthesis of C5 on C6, and thickening of prevertebral soft tissue. (B) A T1-weighted MRI showing low signal intensity in the C5-6 vertebral body. (C, D) A contrast-enhanced MRI showing enhancement of the C5-6 vertebral body and right-side epidural fluid collection. (E) A postoperative simple cervical spine X-ray showing the C5 corpectomy and fusion using an autologous iliac bone graft with C4-6 plate fixation.
(A) A pre-operative T2-weighted MRI showing a C6-7 mild bulging disc. (B) A T2-weighted MRI 1 week after PCN showing a mild high signal intensity around the C5-6 vertebral body. (C) A T2-weighted MRI 2 weeks after PCN showing an increased high signal intensity around the C5-6 vertebral body and epidural fluid collection in the axial image. (D) Postoperative simple cervical spine X-ray showing a C6-7 ACDF using an autologous iliac bone graft with a C6-7 plate fixation.