Journal of Neurology, Neurosurgery, and Psychiatry, 1974, 37, 1361-1365

Infections of cervical disc space after dental extractionsJ. A. FEIGENBAUM AND W. E. STERN

From the Department of Surgery, Division of Neurosurgery,UCLA School of Medicine, Los Angeles, California 90024, U.S.A.

SYNOPSIS Two patients with infections of the cervical intervertebral disc space after dental pro-

cedures carried out by the same oral surgeon exhibited similar clinical courses and radiographicappearances. Both had bacteriological confirmation of infection by needle aspiration and were

treated with appropriate antibiotics and bracing of the neck. The presumed aetiology and the pos-

sible pathogenesis are described. Evidence suggests that the two infections were the result of needleinjection of a contaminated solution, the organisms of which haematogenously lodged in the inter-vertebral discs in the cervical region. Lymph drainage from the gums and teeth is suggested as a

possible route of inoculation.

Two patients recently developed signs suggestiveof cervical disc space infection after dentalprocedures performed by the same oral surgeon.

The temporal relationship ofthe dental work andthe onset of the symptoms, together with thesimilarity of courses, suggested a cause andeffect relationship.

CASE 1

A 17 year old girl entered the UCLA Hospital withsevere pains of the neck and shoulder dating from a

dental proeedure one month before. She had beengiven a general anaesthetic consisting of intravenoussodium methohexital for extraction of a toothbehind the left upper central incisor. The tooth haderupted in a normal direction but was removedbecause of its supernumerary status. No evidence ofintraoral infection was seen at the time of the pro-

cedure, and local anaesthetic was employed at thesite of the extraction only. After the procedure thepatient noted a diffuse headache that persisted forapproximately two hours. She had no discomfortuntil the next day when she bent over and noticedthat severe pain in the posterior cervical region pre-vented her from completely flexing her neck. Thepain radiated up to the occipital region and down tothe midthoracic area in the mid-line. She wasadmitted to her community hospital where she was

noted to have a limitation of neck movement and a

temperature of 39 4°C (103°F). Lumbar puncturewas normal with regard to pressure and cellularreaction in the cerebrospinal fluid. She remained in

hospital for five days during which time she receivedintravenous antibiotics and improved slightly. Twoweeks later she was rehospitalized for continuedposterior neck pain and limitation ofneck movement.Cervical traction increased her pain. Local anaes-thetic infiltration of cervical muscular 'trigger'points also was unsuccessful. One month after theonset of symptoms, she was admitted to the UCLAHospital where she described her pain as being con-stant, located in the posterior cervical and upperthoracic region, and radiating into the upper shoul-ders bilaterally. Movement of the neck aggravatedthe pain, but there was no radiation into the extremi-ties. Postural change provided no help. There was nohistory of serious illness, infection, or neck trauma.Physical examination was unremarkable and showedher to be well-developed and normally propor-tioned for her age. Positive physical findings wereconfined to the neck and spine. She had tendernessand spasm of the paraspinous cervical musculature,and her neck movements were limited in all direc-tions. There were no palpable spinous deformities,and there was no motor weakness, sensory abnor-mality, or reflex change. She showed a fine tremor ofthe outstretched arms, but her coordination wasnormal. Her gait, although guarded, was steady. Thestraight-leg raising manoeuvre was performed to 900bilaterally, and there were no other signs of menin-geal irritation.

Laboratory studies disclosed the following values:white blood cell count (WBC), 12,200/mm3 with 83%.segmented neutrophils, 1 1%Y lymphocytes, 4°/monocytes, and 2%0 eosinophils; haemoglobin, 12-1g/100 ml; haematocrit reading, 35-50/o; fasting blood

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FIG. 1 (left). Case 1. Lateral cervical spine radiograph showing loss of the disc space and lucencies in thevertebra at C5/6. FIG. 2 (centre). Case 1. Midline sagittal tomograph of cervical spine showing involve-ment of C5/6 disc and adjacent vertebra. FIG. 3 (right). Case 1. Follow-up radiograph of cervical spineshowing some displacement at C5/6.

sugar, 83 mg/100 ml; sedimentation rate, 41 mm/hr.Lumbar puncture revealed an opening pressure of100 mm water. The fluid was clear and colourlesswith 3 white cells/mm3 and a protein of 31 mg/100ml. Cerebrospinal fluid (CSF) glucose was 83 mg/100 ml. Radiographs of the cervical spine revealedswelling of the prevertebral soft tissues at the C4/5and C5/6 levels. There was a loss of the disc space atC5/6 with some loss of the superior margin of the C6vertebral body and lucency in the inferior aspect ofthe body ofC5 vertebra (Fig. 1). Cervical tomographsconfirmed the lytic defect at the C5/6 intervertebralspace involving the lower margin of C5 and the uppermargin of C6 vertebrae (Fig. 2). Aspirate was takenfrom the disc space under fluoroscopic control witha gauge 18 needle inserted between the carotidsheath and trachea into the intervertebral disc. Theculture grew an enterobacter species. The patientwas given kanamycin sulphate (320 mg twice daily)for 10 days and then chloramphenicol (500 mg everysix hours) for an additional four weeks. She wasplaced in a four-poster neck brace and was able towalk without discomfort by the time of her dischargesix weeks after the onset of symptoms. Follow-upradiographs taken at discharge showed some furthercollapse of the disc space and a slight anterior dis-location of C6 vertebra. However, when studied 4+months after the onset of illness, the lytic process hadnot progressed (Fig. 3).

CASE 2

A 38 year old woman entered the UCLA Hospitalwith severe posterior neck pain of one month'sduration. She had undergone general anaesthesia

with sodium methohexital for extraction of a painfulright mandibular second molar and a broken upperleft first bicuspid tooth. There was no gingival reac-tion at the time of extraction. Local anaesthesia wasused in addition to the methohexital for the extrac-tion of both teeth. When the patient awakened fromthe anaesthesia, she experienced generalized shakingchills that persisted through the evening. The nextmorning her neck was stiff and painful with move-ment. Symptoms increased, movements became morerestricted, and pain persisted at rest. She was ad-mitted to a community hospital and remained forseven days in cervical traction that exacerbated hersymptoms. The pain did not radiate into the upperextremities, and she had no weakness or sensorysymptoms. She had no history of systemic infectionsor accidents or injuries involving her cervical spine.The severe cervical pain during her fourth week ofillness led to her referral to the UCLA Hospital onemonth after the onset of her trouble.At physical examination, she held her neck stiffly

and guarded any attempts to manipulate it. Pain wasaccentuated by any movement, including verticalcompression of the cervical spine. The cervical para-spinous musculature was in spasm and tender fromthe suboccipital region to the level of the T3 spinc.There was no weakness of the upper or lower extremi-ties. Sensory examination and reflexes were normal,as was the remainder of her examination.

Laboratory findings showed the following values:WBC, 5,100 per mm3 with 60% segmented neutro-phils, 29% lymphocytes, 9%o monocytes, 1% bands,and 1% eosinophils; haemoglobin 12 3 g/100 ml;haematocrit reading, 36-5%; corrected sedimenta-tion rate, 39 mm/hr. Lumbar puncture revealed an

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FIG. 4 (left). Case 2.Radiograph of cervicalspine showing destructionof disc space at C3/4.

FIG. 5 (right). Case 2.Radiograph taken duringpercutaneous aspirationofC3/4 disc space.

10 JUNE 70

opening pressure of 150 mm water. The fluid wasclear and colourless, and no white cells were present.The CSF protein was 71-7 mg/100 ml, and the sugarwas 66 mg/100 ml. The culture was negative. Radio-graphs of the cervical spine showed a collapse of theC3/4 disc space with some minimal destruction ofthe inferior aspect of the body of C3 and thesuperior portion of the body of C4 vertebra. Therewas an anterior subluxation of C4 upon C3 vertebraof 3 mm (Fig. 4). The day after admission, a needleaspiration of the C3/4 space was performed follow-ing the method described in case 1 (Fig. 5), and theculture grew an enterobacter species. Initially,kanamycin sulphate (300 mg every 12 hours) wasgiven, but, based upon the tube dilution studies ofthe enterobacter, gentamicin sulphate (50 mg every12 hours) was substituted for a two-week course.She was discharged free of neck discomfort twoweeks after admission with a four-poster brace foruse when in the upright position. Follow-upexamination revealed no recurrence of neck pain andno evidence of neurological impairment. Repeatradiographic study demonstrated continued collapseof the C3/4 interspace and minimal subluxation. Shewas lost to follow-up five months after the onset ofher illness.

DISCUSSION

PATHOGENESIS Although most attention in theliterature has been directed toward infections ofthe disc spaces resulting from intervertebral discoperations (Turnbull, 1953; Stern and Crandall,1959; Mella, 1965), the cases described hereincaused us to focus our attention on the problem

of interspace infection introduced by needleinjection. The procedure ofdiscography, wherebya needle is introduced directly into the inter-vertebral disc to facilitate diagnosis of discdisease, is a common source of infection. Thiscomplication has been discussed by De Seze andLevernieux (1952) who reviewed 13 cases of aninflammatory response after 5000 to 700% diodonpolyvidone was used for discography. Anotherpossible route of infection is the accidental punc-ture of the disc space while performing a lumbarpuncture in the presence of a bacterial meningitis.Less obvious and more indirect routes of infec-tion have been reported by numerous authors.Eliason (1965) reported two cases of disc andadjacent vertebral body infection after needlebiopsy of the prostate gland. The presumed routeof infection was through the veins of Batson'splexus from the prostate to the anterior bordersof the lumbar vertebral canal. Cervical osteo-myelitis after the intravenous injection of con-taminated succinyl choline chloride duringinduction of anaesthesia was reported by DelToro et al. (1970). The common organism re-covered from blood culture among their patientswas Serratia marcescens. Six of their patientsshowed radiological evidence of infection of thecervical vertebral body. These authors mentionedhyperextension of the neck during intubationas a possible initial cause of injury to thevertebral column. The occurrence of vertebralbody osteomyelitis among those who indulgein narcotics with contaminated techniques of

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intravenous administration is well documented(Bryan et al., 1973).

If our cases do, indeed, signify contaminationof the vertebral discs in the cervical regionthrough needle injection of local anaesthetics,we must consider the most probable route. Thelymph drainage from the gums and teeth de-serves consideration (Grant, 1958; Pernkopf,1963). From the upper teeth, the lymph vesselspass through the infraorbital foramen and runwith the facial artery to the submandibularnodes. Those of the lower teeth run through themandibular canal to the deep cervical nodes.The submandibular nodes communicate with theupper deep cervical nodes, of which one of themore notable is the jugulodigastric node. Thisstructure lies below the posterior belly of thedigastric muscle where the common facial veinenters the internal jugular vein. Lymphaticsfrom the jugulodigastric node are believed to goto prevertebral nodes, some of which lie in thealar space immediately in front of the pre-vertebral fascia. There is, therefore, a possible,albeit circuitous, route for contaminated materialto be carried from the gums or the teeth throughthe lymphatic systems to the prevertebral tissues.In the two cases reviewed here, however, thiswould be an unlikely explanation in view of theprompt onset of symptoms of infection of thespine after the presumed inoculation.The venous drainage of the maxilla and

mandible is quite rich, and the development ofintracranial infections resulting from cavernoussinus thrombosis has been well recognized afterdental extractions (Haymaker, 1945). Intra-cranial abscesses have also been reported byHollin et al. (1967) as the result of odontogenicinfection. In their extensive review of theliterature, however, these authors failed to noteany intervertebral disc infections as a result ofintra-oral disease.The vertebral venous sytem has been well

demonstrated by the injection techniques ofBatson (1940). It is a valveless system, and itdoes appear conceivable that material injectedinto the veins of the upper or lower gums couldenter into Batson's plexus of the cervical regionwithout involving the superior vena cava system.In his study of retropharyngeal abscess, Grodin-sky (1939) noted the possibility of spread ofinfection from the veins of the pharynx to the

internal jugular veins with thrombosis andsecondary extension to the retropharyngealspaces. Another pathway for the spread of infec-tion in the head and neck is through the variousspaces delineated by the fascial planes. In hisdiscussion of deep neck infections, Beck (1947)described a route of contamination from theinfected bodies of the cervical vertebrae throughthe prevertebral fascia into the pharyngomaxil-lary space. He also noted that infections hadbeen seen along the pathway of a needle placedto perform a mandibular nerve block. In thoseinstances, the infection involved the pharnygo-maxillary space. In addition, infections from theteeth of the maxilla, especially on the labial side,might result in extension into the spheno-maxillary fissure and the pharyngomaxillaryfossa. Had a mandibular nerve block beenadministered to the patient described in ourcase 2, this might conceivably have representeda combination of the events such as described byBeck leading to the contamination of the pre-vertebral tissue. However, since the injectionswere local, in the gums immediately adjacent tothe teeth removed, this does not seem likely.Although a review of the recent dental and oralsurgery literature failed to reveal a similar case,Fein et al. (1969) reported a disc space infectionat C6/7 that began approximately three weeksafter an open comminuted fracture of the leftbody of the mandible. The case was complicatedby osteomyelitis of the mandible, and aspirationof the disc space failed to produce a positiveculture, possibly because the patient had beentreated with penicillin for 10 days before theattempt. This author noted the possible routes ofinfection as being direct extension via fascialplanes, direct venous or lymphatic spread, orsystemic haematogenous dissemination.

If our patients suffered disc space infectionssecondary to haematogenous spread, then wemust note that the organism, 'enterobacter' isnot a usual oral inhabitant (a nasopharyngealculture of case 1 did return a few colonies ofEscherichia coli). Bacteraemias after dentalmanipulation have been well recognized. Mitchelland Helman (1953). have reviewed the role ofperidontal infections in systemic infectiousdisease. They found an incidence as high as 3400of bacteraemia resulting from standardizeddental manipulations in patients without clinic-

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ally significant oral infections. With known perio-dontal disease, the bacteraemia rate more thandoubled. Although the organisms reported areusually Gram positive cocci, a recent report byGoldberg (1968) described a case of bacteraemiaafter tooth extraction in which a blood culturegrew Pseudomonas. With broad-spectrum anti-biotics, the normal oral flora may well be changedto favour potent Gram negative organisms. Al-though our evidence is inconclusive, it seemsmost probable that the two infections in thisreport resulted from the injection of contamin-ated solutions, the organisms of which werehaematogenously lodged in the vertebral column.

DIAGNOSIS AND THERAPY Severe pain andimmobility of the affected portion of the spine,together with systemic symptoms or signs ofinflammation, should suggest infection in thespinal column (Fischer, 1959). The blood shouldbe cultured in the presence of an acute febrileresponse. The sedimentation rate, elevated inboth of our patients, is a simple procedure thatshould be used as a part of the screening evalua-tion in similar clinical presentations. Lamino-grams help to delineate the disease process and todistinguish it from neoplastic conditions. Aspecific diagnosis of the offending agent may bemade by a relatively innocuous needle aspirationof the disc space. Bed rest appears to be indi-cated during the period of systemic infection.Specific antibiotic therapy aids in the promptresolution of symptoms as well as in combatingthe primary pathogen. In our second patient, theantibiotic agent was modified as a result of tubedilution studies performed on the enterobacterspecies, a valuable adjunct to specific therapythat is based upon the cultures from disc spaceaspiration. Immobilization of the infectedcervical spine is required until a stable fusiondevelops. Although it has been charged by someto interfere with internal fixation in such cases,our experience with similar problems is that afirm union will occur within a matter of months,and external bracing is well tolerated until that isachieved. This is in agreement with the majorityof authors who have discussed disc space infec-tions. The relatively benign clinical courses of

our two patients is also in accord with the usualcourse. The numerous features of our cases areconsistent with certain of the cases described byStern and Crandall (1959) after lumbar inter-vertebral disc operations. The outlook appearsfavourable.

REFERENCES

Batson, 0. V. (1940). The function of the vertebral veins andtheir role in the spread of metastases. Annals of Surgery,112, 138-149.

Beck, A. L. (1947). Deep neck infection. Annals of Otology,Rhinology, and Laryngology, 56, 439-481.

Bryan, V., Franks, L., and Torres, H. (1973). Pseudomonasaeruginosa cervical diskitis with chrondro-osteomyelitis inan intravenous drug abuser. Surgical Neurology, 1, 142-144.

Del Toro, R. A., Rullan, J. A., Torregrosa, M., Lugo, A.,and Freyre, J. L. (1970). Serratia marcescens septicemiawith osteomyelitis of the cervical spine: an unusual epi-demic. (Abstract.) Annals of Internal Medicine, 72, 796.

Eliason, O., and Dunlap, D. (1965). Osteomyelitis of thespine following needle biopsy of the prostate. Journal ofUrology, 94, 271-275.

Fein, S. J., Torg, J. S., Mohnac, A. M., and Magsamen, B. F.(1969). Infection of the cervical spine associated with afracture of the mandible. Journal of Oral Surgery, 27, 145-149.

Fischer, K. A. (1959). Osteomyelitis and disc space infectionsof the spine. Journal of the Kentucky Medical Association,57, 1066-1069.

Goldberg, M. H. (1968). Gram-negative bacteremia afterdental extraction. Journal of Oral Surgery, 26, 180-181.

Grant, J. C. B. (1958). A Method of Anatomy, 6th edn, pp793-796. Williams and Wilkins: Baltimore.

Grodinsky, M. (1939). Retropharyngeal and lateral pharyn-geal abscesses: an anatomic and clinical study. Annals ofSurgery, 110, 177-199.

Haymaker, W. (1945). Fatal infections of the central nervoussystem and meninges after tooth extraction. AmericanJournal of Orthodontics, 31, 117-188.

Hollin, S. A., Hayashi, H., and Gross, S. W. (1967). Intra-cranial abscesses of odontogenic origin. Oral Surgery, 23,277-293.

Mella, B. (1965). Inflammatory spondylitis. Journal ofNeurosurgery, 22, 393-396.

Mitchell, D. F., and Helman, E. Z. (1953). The role ofperiodontal foci of infection in systemic disease: anevaluation of the literature. Journal of the AmericanDental Association, 46, 32-53.

Pernkopf, E. (1963). Atlas of Topographical and AppliedHuman Anatomy, vol. 1, pp. 227, 246, 247, and 249.Saunders: Philadelphia.

S6ze, S. de, and Levernieux, J. (1952). Les accidents de ladiscographie. Revue du Rhumatisme et des MaladiesOstejo-articulaires, 19, 1027-1033.

Stern, W. E., and Crandall, P. H. (1959). Inflammatoryintervertebral disc disease as a complication of the opera-tive treatment of lumbar herniations. Journal of Neuro-surgery, 16, 261-276.

Turnbull, F. (1953). Postoperative inflammatory disease oflumbar discs. Journal of Neurosurgery, 10, 469-473.

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