Background Cervical spine osteomyelitis (CSO) is an uncommon and potentially debilitating disease.
Patients with CSO may present with pain, fever, and neurological deficits. Traditional
management of CSO relies on long-term antimicrobial therapy and surgical debridement
of necrotic tissue. We describe complete resolution of a case of CSO refractory to
long-term antimicrobial therapy with combined endoscopic transnasal and transoral
debridement and minimally invasive placement of a fascia lata free flap.
Method Case Presentation A 69-year-old man with a history of nasopharyngeal adenosquamous carcinoma underwent
primary chemoradiation therapy. Four months posttreatment, he presented with acute
neck pain and significant nasopharyngeal necrosis. Due to concern for persistence
of disease, he was taken to the operating room. Intraoperatively, devitalized nasopharyngeal
tissue was surgically debrided and biopsies were negative for carcinoma. Cultures
grew Escherichia coli, Aspergillus niger, Candida krusei, and Candida glabrata and patient was started on ertapenem, micafungin, and voriconazole. Despite 6 months
of intravenous antimicrobial therapy, he experienced progressive neck pain, dysphagia,
and trismus. Repeat imaging was concerning for progressive CSO. He was therefore taken
to the operating room for aggressive but nondestabilizing debridement and coverage
with vascularized tissue. Intraoperatively, there was diffuse bony necrosis from the
sphenoid floor to the second cervical vertebra. The necrotic tissue was debrided endoscopically
and a fascia lata free flap was delivered transorally via lateral palatal split to
reconstruct the defect. In a minimally invasive fashion, the flap pedicle was tunneled
and anastomosed to the facial vessels. The inferior portion of the flap was sutured
to the oropharynx and the superior portion was positioned in the nasopharynx endoscopically.
Two nasal trumpets were placed to stabilize the flap. Postoperatively, the patient
was continued on intravenous antimicrobial therapy. His neck pain, dysphagia, and
trismus resolved and imaging showed resolution of CSO. The flap was well healed on
endoscopic examination and the patient was symptom free with normal swallow and nasal
respiration at 5 months follow-up.
Discussion Radiation-related CSO is a rare disorder. Factors associated with development of
CSO include accelerated hyperfractionated irradiation and reirradiation. Cases of
CSO secondary to osteoradionecrosis are notoriously difficult to treat due to poor
vascularization, poor penetration of antimicrobials, and exposure of the field to
saliva and secretions. Management of CSO involves intravenous antimicrobial therapy,
debridement of necrotic tissue, and cervical fusion after resolution of infection
in cases of cervical spine instability. Vascularized tissue for treatment of chronic
osteomyelitis in other parts of the body has been described. The fascia lata free
flap provides pliable, vascularized tissue to cover the defect without compromising
speech, swallow, or nasal respiration. Additionally, when harvested in perforator
fashion, the long vascular pedicle of this flap allows for facile reach to angular
or facial vessels. Resolution of CSO in this patient was achieved and cervical fusion
avoided by placing vascularized fascia lata free flap over the necrotic region.
Conclusion A fascia lata free flap was successfully used to treat medically refractory CSO secondary
to osteoradionecrosis. This technique may prove to be a useful solution for challenging
reconstructive and infectious cases.
