Skip to main content
SpringerLink
Log in

Infections at the Cranio-vertebral Junction

  • Chapter
  • First Online:
Surgery of the Cranio-Vertebral Junction

Abstract

Spine infections are devastating diseases with high rates of morbidity and mortality if not correctly diagnosed. As a whole, infections of cervical spine represent less than 10% of all spine infections. Bacteria can cause a pyogenic host response or a granulomatous reaction, so one way to classify spine infection is: pyogenic or granulomatous form. The incidence of vertebral osteomyelitis appears to have increased, representing 2–7% of all cases of pyogenic form. Involvement of cervical vertebrae by osteomyelitis is rare when compared with thoracic and lumbar infections, and cranio-vertebral junction localization is very rare with the odontoid process being the most affected. Staphylococcus species are the causative pathogen in 50–80% of cases. The pathogenesis of osteomyelitis in the upper cervical spine is not well determined; aside from direct cervical injury, spread is most likely hematogenous, via arterial dissemination; however, the paravertebral venous system may be involved as well. The most common form of granulomatous spine infection in the world is tuberculosis: bone, joint, and muscular system involvement develops in 10–15% of patients with tuberculosis and half of these patients manifest spine tuberculosis. Cervical tuberculosis localization is uncommon, only 10% of all cases with an incidence of C1-C2 involvement of 1%.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Capps E, Page TE, Rouse WHD. Hippocrates: on joints. In: Withington ET, editor. Hippocrates: the loeb classical library, vol. 3. London: W. Heinemann; 1927. p. 200–397.

    Google Scholar 

  2. Kuhn CG. Galen: De usupartium corporis humani. In: ClaudiiGaleni Opera Omnia, vol. 4. Hildesheim: Georg Olms; 1964. p. 42–119.

    Google Scholar 

  3. Pott P. Remarks on that kind of palsy of the lower limbs which is frequently found to accompany a curvature of the spine. London: Johnson; 1779.

    Google Scholar 

  4. Lannelongue OM. On acute osteomyelitis. Miscellaneous, pathological and practical medicine tracts. Paris; 1897

    Google Scholar 

  5. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;232:175–204.

    Article  Google Scholar 

  6. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000;25(13):1668–79.

    Article  CAS  Google Scholar 

  7. Kaufman DM, Kaplan JG, Litman N. Infectious agents in spinal epidural abscesses. Neurology. 1980;30:844–50.

    Article  CAS  PubMed  Google Scholar 

  8. Yoo JU, Hart RA. Anatomy of the cervical spine. In: Emery SE, Boden SC, editors. Surgery of the cervical spine. Amsterdam: Elsevier; 2003. p. 1–10.

    Google Scholar 

  9. Heggeness M, Doherty B. The trabecular anatomy of the axis. Spine. 1993;18:1945–9.

    Article  CAS  PubMed  Google Scholar 

  10. Panjabi M, Duranceau J, Goel V, et al. Cervical human vertebrae. Quantitative three-dimensional anatomy for the middle and lower regions. Spine. 1991;16(8):861–9.

    Article  CAS  PubMed  Google Scholar 

  11. Dvorak J, Panjabi M. Functional anatomy of the alar ligaments. Spine. 1987;12:183–9.

    Article  CAS  PubMed  Google Scholar 

  12. Steinmetz MP, Mroz TE, Benzel EC. Craniovertebral junction: biomechanical considerations. Neurosurgery. 2010;66(3 Suppl):7–12.

    Article  PubMed  Google Scholar 

  13. Parke WW. The vascular relations of the upper cervical vertebrae. Orthop Clin North Am. 1978;9(4):879–89.

    CAS  PubMed  Google Scholar 

  14. Schiff DCM, Parke WW. The arterial supply of the odontoid process (dens). Anat Rec. 1972;172:399–400.

    Google Scholar 

  15. Sherk HH, Parke WW. Normal adult anatomy. In: Bailey RW, Sherk HH, et al., editors. The cervical spine. Philadelphia: JB Lippincott; 1983. p. 8–22.

    Google Scholar 

  16. Parke WW, Rothman RH, Brown MD. The pharyngovertebral veins. An anatomical rationale for Grisel’s syndrome. J Bone Jt Surg Am. 1984;66:568–74.

    Article  CAS  Google Scholar 

  17. Menezes AH. Congenital and acquired abnormalities of the craniovertebral junction (children and adults). In: Youmans J, editor. Neurological surgery. 4th ed. Philadelphia: Saunders; 1995. p. 1035–89.

    Google Scholar 

  18. Patel A, Madigan L, Poelstra K, et al. Acute cervical osteomyelitis and prevertebral abscess after routine tonsillectomy. Spine J. 2008;8(5):827–30.

    Article  PubMed  Google Scholar 

  19. Samuel D, Thomas DM, Tierney PA, Patel KS. Atlanto-axial subluxation (Grisel’s syndrome) following otolaryngological disease and procedures. J Laryngol Otol. 1995;109(10):1005–9.

    Article  CAS  PubMed  Google Scholar 

  20. Ueki Y, Watanabe J, Hashimoto S, Takahashi S. Cervical spine osteomyelitis and epidural abscess after chemoradiotherapy for hypopharyngeal carcinoma: a case report. Case Rep Otolaryngol. 2014;2014:141307.

    PubMed  PubMed Central  Google Scholar 

  21. Goulart CR, Mattei TA, Fiore ME, Thoman WJ, Mendel E. Retropharyngeal abscess with secondary osteomyelitis and epidural abscess: proposed pathophysiological mechanism of an underrecognized complication of unstable craniocervical injuries: case report. J Neurosurg Spine. 2016;24(1):197–205.

    Article  PubMed  Google Scholar 

  22. Nurata H, Yilmaz MB, Borcek AO, Oner AY, Baykaner MK. Retropharyngeal hematoma secondary to whiplash injury in childhood: a case report. Turk Neurosurg. 2012;22(4):521–3.

    PubMed  Google Scholar 

  23. Lin JY, Wang CH, Huang TW. Traumatic retropharyngeal hematoma: case report. Auris Nasus Larynx. 2007;34(3):423–5. Epub 2006 Dec 11.

    Article  PubMed  Google Scholar 

  24. Robinson MH, Young JD, Burge PD. Retropharyngeal abscess, airway obstruction, and tetraplegia after hyperextension injury of the cervical spine: case report. J Trauma. 1992;32(1):107–9.

    Article  CAS  PubMed  Google Scholar 

  25. Kapeller P, Fazekas F, Krametter D, et al. Pyogenic infectious spondylitis: clinical, laboratory and MRI features. Eur Neurol. 1997;38(2):94–8.

    Article  CAS  PubMed  Google Scholar 

  26. Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis. 2001;33(7):527–32.

    Article  CAS  PubMed  Google Scholar 

  27. Doutchi M, Seng P, Menard A, et al. Changing trends in the epidemiology of vertebral osteomyelitis in Marseille, France. New Microbes New Infect. 2015;7:1–7.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Akiyama T, Chikuda H, Yasunaga H, Horiguchi H, Fushimi K, Saita K. Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database. BMJ Open. 2013;3(3):e002412.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Malawski SK, Lukawski S. Pyogenic infection of the spin. Clin Orthop Relat Res. 1991;272:58–66.

    Google Scholar 

  30. Perrone C, Saba J, Behloul Z, et al. Pyogenic and tuberculous spondylodiskitis (vertebral oseteomyelitis) in 80 adult patients. Clin Infect Dis. 1994;19(4):746–50.

    Article  Google Scholar 

  31. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis. 1979;1(5):754–76.

    Article  CAS  PubMed  Google Scholar 

  32. Koppel BS, Tuchman AJ, Mangiardi JR, et al. Epidural spinal infection in intravenous drug abusers. Arch Neurol. 1988;45(12):1331–7.

    Article  CAS  PubMed  Google Scholar 

  33. Fernandez M, Carrol CL. Baker Cj: discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000;105(6):1299–304.

    Article  CAS  PubMed  Google Scholar 

  34. Rosenberg AE. Bones, joints, and soft-tissue tumors. In: Kumar V, Abbas AK, Fausto N, et al., editors. Robbins and Cotran pathologic basis of disease. 8th ed. Philadelphia: Saunders Elsevier; 2010. p. 1221–3.

    Google Scholar 

  35. Sapico FL, Montgomerie JZ. Vertebral osteomyelitis. Infect Dis Clin North Am. 1990;4(3):539–50.

    CAS  PubMed  Google Scholar 

  36. Stone JL, Cybulski GR, Rodriguez J, Gryfinski ME, Kant R. Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine. J Neurosurg. 1989;70(6):879–83.

    Article  CAS  PubMed  Google Scholar 

  37. Ross J, Brant-Zawadzki M, Chen M, Moore K, Salzman K. Diagnostic imaging: spine. 1st ed. Altona: Amirsys; 2004. p. 1–14.

    Google Scholar 

  38. Busche M, Bastian L, Riedemann NC, et al. Complete osteolysis of the dens with atlantoaxial luxation caused by infection with Staphylococcus aureus. Spine (Phila Pa 1976). 2005;30(13):E369–74.. Review

    Article  Google Scholar 

  39. Thelander U, Larsson S. Quantitation of C-reactive protein levels and erythrocyte sedimentation rate after spinal surgery. Spine (Phila Pa 1976). 1992;17(4):400–4.

    Article  CAS  Google Scholar 

  40. Halla JT, Bliznak JG, Finn S. Septic arthritis of the C1–C2 lateral facet joint and torticollis: pseudo- Grisel’s syndrome. Arthritis Rheum. 1991;34(1):84–8.

    Article  CAS  PubMed  Google Scholar 

  41. Marin C, Sanchez-Alegre M, et al. Magnetic resonance imaging of osteoarticular infections in children. Curr Probl Diagn Radiol. 2004;33(2):43–59.

    Article  PubMed  Google Scholar 

  42. Brant-Zawadzki M, Burke VD, Jeffrey RB. CT in the evaluation of spine infection. Spine (Phila Pa 1976). 1983;8(4):358–64.

    Article  CAS  Google Scholar 

  43. Modic MT, Feiglin DH, Piraino DW, et al. Vertebral osteomyelitis: assessment using MR. Radiology. 1985;157(1):157–66.

    Article  CAS  PubMed  Google Scholar 

  44. Noguchi S, Yanaka K, Yamada Y, et al. Diagnostic pitfalls in osteomyelitis of the odontoid process: case report. Surg Neurol. 2000;53(6):573–8; discussion 578–9. Review.

    Article  CAS  PubMed  Google Scholar 

  45. Haridas A, Walsh DC, Mowle DH. Polymicrobial osteomyelitis of the odontoid process with epidural abscess: case report and review of literature. Skull Base. 2003;13(2):107–11.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Shamim MS, Tahir MZ, Jooma R. Isolated tuberculosis of C2 spinous process. Spine J. 2009;9(4):e30–2.

    Article  PubMed  Google Scholar 

  47. Schmit P, Glorion C. Osteomyelitis in infants and children. Eur Radiol. 2004;14(Suppl 4):L44–54. Review.

    PubMed  Google Scholar 

  48. Chang MC, Wu HT, Lee CH, Liu CL, Chen TH. Tuberculous spondylitis and pyogenic spondylitis: comparative magnetic resonance imaging features. Spine (Phila Pa 1976). 2006;31(7):782–8.

    Article  Google Scholar 

  49. Bruschwein DA, Brown ML, McLeod R. Gallium scintigraphy in the evaluation of disk-space infections: concise communication. J Nucl Med. 1980;21(10):925–7.

    CAS  PubMed  Google Scholar 

  50. Haase D, Martin R, Marrie T. Radionuclide imaging in pyogenic vertebral osteomyelitis. Clin Nucl Med. 1980;5(12):533–7.

    Article  CAS  PubMed  Google Scholar 

  51. Schofferman L, Schofferman J, Zucherman J, Gunthorpe H, Hsu K, Picetti G, Goldthwaite N, White A. Occult infections causing persistent low-back pain. Spine (Phila Pa 1976). 1989;14(4):417–9.

    Article  CAS  Google Scholar 

  52. Staab EV, McCartney WH. Role of gallium 67 in inflammatory disease. Semin Nucl Med. 1978;8(3):219–34.

    Article  CAS  PubMed  Google Scholar 

  53. Love C, Patel M, Lonner BS, Tomas MB, Palestro CJ. Diagnosing spinal osteomyelitis: a comparison of bone and Ga-67 scintigraphy and magnetic resonance imaging. Clin Nucl Med. 2000;25(12):963–77.

    Article  CAS  PubMed  Google Scholar 

  54. World Health Organization. Global tuberculosis control, WHO report. Geneva: World Health Organization; 2010.

    Google Scholar 

  55. Akhaddar A, Gourinda H, Gazzaz M, Elmadhi T, Elalami Z, Miri A. Craniocervical junction tuberculosis in children. Rev Rhum Engl Ed. 1999;66(12):739–42.

    CAS  PubMed  Google Scholar 

  56. Qureshi MA, Afzal W, Khalique AB, Pasha IF, Aebi M. Tuberculosis of the craniovertebral junction. Eur Spine J. 2013;22(Suppl 4):612–7. Epub 2012 Oct 5.

    Article  PubMed  Google Scholar 

  57. Allali F, Benomar A, El YM, Chkili T, Hajjaj-Hassouni N. Atlantoaxial tuberculosis: three cases. Joint Bone Spine. 2000;67(5):481–4.

    CAS  PubMed  Google Scholar 

  58. Mohindra S, Gupta SK, Mohindra S, Gupta R. Unusual presentations of craniovertebral junction tuberculosis: a report of 2 cases and literature review. Surg Neurol. 2006;66(1):94–9; discussion 99.

    Article  PubMed  Google Scholar 

  59. Hsu LC, Leong JC. Tuberculosis of the lower cervical spine (C2 to C7). J Bone Joint Surg Br. 1984;66(1):1–5.

    Article  CAS  PubMed  Google Scholar 

  60. Kim NH, Lee HM, Suh JS. Magnetic resonance imaging for the diagnosis of tuberculous spondylitis. Spine (Phila Pa 1976). 1994;19(21):2451–5.

    Article  CAS  Google Scholar 

  61. Goel A, Goel N, Shah A. Pathogenesis of tuberculosis of the craniovertebral junction: its implication in surgical management. In: Goel A, Cacciola F, editors. The craniovertebral junction: diagnosis, pathology, surgical techniques. Stuttgart: Georg Thieme Verlag; 2011. p. 415–22.

    Chapter  Google Scholar 

  62. Goel A, Shah A. Lateral atlantoaxial facetal dislocation in craniovertebral region tuberculosis: report of a case and analysis of an alternative treatment. Acta Neurochir. 2010;152:709–12.

    Article  PubMed  Google Scholar 

  63. Lifeso R. Atlanto-axial tuberculosis in adults. J Bone Joint Surg Br. 1987;69(2):183–7.

    Article  CAS  PubMed  Google Scholar 

  64. Tuli SM. Tuberculosis of the craniovertebral region. Clin Orthop Relat Res. 1974;104:209–12.

    Article  Google Scholar 

  65. Fang D, Leong JC, Fang HS. Tuberculosis of the upper cervical spine. J Bone Joint Surg Br. 1983;65(1):47–50.

    Article  CAS  PubMed  Google Scholar 

  66. Bhattacharya A, Banerjee S, Mukherjee SC, Gangopadhyay S. Atypical spinal tuberculosis. J Indian Med Assoc. 1996;94(9):353–4.

    CAS  PubMed  Google Scholar 

  67. Dhammi IK, Singh S, Jain AK. Hemiplegic/monoplegic presentation of cervical spine (C1-C2) tuberculosis. Eur Spine J. 2001;10(6):540–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Sharif HS, Morgan JL, al Shahed MS, al Thagafi MY. Role of CT and MR imaging in the management of tuberculous spondylitis. Radiol Clin North Am. 1995;33(4):787–804. Review.

    CAS  PubMed  Google Scholar 

  69. Stoker DJ, Kissin CM. Percutaneous vertebral biopsy: a review of 135 cases. Clin Radiol. 1985;36(6):569–77.

    Article  CAS  PubMed  Google Scholar 

  70. Mavrogenis AF, Igoumenou V, Tsiavos K, Megaloikonomos P, Panagopoulos GN, Vottis C, Giannitsioti E, Papadopoulos A, Soultanis KC. When and how to operate on spondylodiscitis: a report of 13 patients. Eur J Orthop Surg Traumatol. 2016;26(1):31–40.

    Article  PubMed  Google Scholar 

  71. Hoshino C, Narita M. Craniovertebral junction tuberculosis: a case report and review of the literature. J Infect Chemother. 2010;16(4):288–91.

    Article  PubMed  Google Scholar 

  72. Arora S, Sabat D, Maini L, Sural S, Kumar V, Gautam VK, Gupta A, Dhal A. The results of nonoperative treatment of craniovertebral junction tuberculosis: a review of twenty-six cases. J Bone Joint Surg Am. 2011;93(6):540–7.

    Article  PubMed  Google Scholar 

  73. Gupta SK, Mohindra S, Sharma BS, Gupta R, Chhabra R, Mukharjee KK, Tewari MK, Khandelwal N, Suresh NM, Khosla VK. Tuberculosis of the craniovertebral junction: is surgery necessary? Neurosurgery. 2006;58(6):1144–50; discussion 1144-50.

    Article  PubMed  Google Scholar 

  74. Edwards RJ, David KM, Crockard HA. Management of tuberculomas of the craniovertebral junction. Br J Neurosurg. 2000;14(1):19–22.

    Article  CAS  PubMed  Google Scholar 

  75. Behari S, Nayak SR, Bhargava V, Banerji D, Chhabra DK, Jain VK. Craniocervical tuberculosis: protocol of surgical management. Neurosurgery. 2003;52(1):72–80; discussion 80-1.

    PubMed  Google Scholar 

  76. Teegala R, Kumar P, Kale SS, Sharma BS. Craniovertebral junction tuberculosis:a new comprehensive therapeutic strategy. Neurosurgery. 2008;63(5):946–55.

    Article  PubMed  Google Scholar 

  77. Goel A. Tuberculosis of craniovertebral junction: role of facets in pathogenesis and treatment. J Craniovertebr Junct Spine. 2016;7(3):129–30.

    Article  Google Scholar 

  78. Chadha M, Argawal A, Singh AP. Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively. Spine (Phila Pa 1976). 2007;32(15):1629–34.

    Article  Google Scholar 

  79. Menezes AH, VanGilder JC, Graf CJ, McDonnell DE. Craniocervical abnormalities. A comprehensive surgical approach. J Neurosurg. 1980;53(4):444–55.

    Article  CAS  PubMed  Google Scholar 

  80. Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery. 2005;57(1 Suppl):E213, discussion E213.

    PubMed  Google Scholar 

  81. Burns TC, Mindea SA, Pendharkar AV, Lapustea NB, Irime I, Nayak JV. Endoscopic transnasal approach for urgent decompression of the craniocervical junction in acute skull base osteomyelitis. J Neurol Surg Rep. 2015;76(1):e37–42.

    Article  PubMed  PubMed Central  Google Scholar 

  82. Seker A, Inoue K, Osawa S, Akakin A, Kilic T, Rhoton AL Jr. Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction. World Neurosurg. 2010;74(6):583–602.

    Article  PubMed  Google Scholar 

  83. Nayak JV, Gardner PA, Vescan AD, Carrau RL, Kassam ABSC, Snyderman CH. Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease. Am J Rhinol. 2007;21(5):601–6.

    Article  PubMed  Google Scholar 

  84. Visocchi M, Di Martino A, Maugeri R, González Valcárcel I, Grasso V, Paludetti G. Videoassisted anterior surgical approaches to the craniocervical junction: rationale and clinical results. Eur Spine J. 2015;24(12):2713–23.

    Article  PubMed  Google Scholar 

  85. Visocchi M, Germano A, Umana G, Richiello A, Raudino G, Eldella AM, Iacopino G, Barbagallo G. Direct and oblique approaches to the craniovertebral junction: nuances of microsurgical and endoscope-assisted techniques along with a review of the literature. Acta Neurochir Suppl. 2017;124:107–16.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chief of Neurosurgical Unit , Ospedale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy

    Andrea Barbanera, Andrea Cattalani & Matteo Vitali

  2. Neurosurgical Unit, Ospedale SS Antonio e Biagio e Cesare Arrigo-Alessandria, Alessandria, Italy

    Andrea Barbanera

  3. Umberto Parini Hospital - USL Valle D’Aosta, Aosta, Italy

    Vincenzo Grasso

Authors
  1. Andrea Barbanera
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vincenzo Grasso
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrea Cattalani
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Matteo Vitali
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Neurosurgical Unit, Geneva University Hospitals, Geneva, Switzerland

    Enrico Tessitore

  2. Department of Neurosurgery, North Shore University Hospitals, Manhasset, NY, USA

    Amir R. Dehdashti

  3. Neurosurgical Unit, ASL Napoli 2 Nord, Naples, Italy

    Claudio Schonauer

  4. Department of Neurosurgery, Innsbruck University Hospitals, Innsbruck, Austria

    Claudius Thomé

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Barbanera, A., Grasso, V., Cattalani, A., Vitali, M. (2020). Infections at the Cranio-vertebral Junction. In: Tessitore, E., Dehdashti, A., Schonauer, C., Thomé, C. (eds) Surgery of the Cranio-Vertebral Junction. Springer, Cham. https://doi.org/10.1007/978-3-030-18700-2_34

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-18700-2_34

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-18699-9

  • Online ISBN: 978-3-030-18700-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation