J Millar, A Davidson, M McKenna, *C Brunton, #D Finlayson, +EK Labram
The Health Centre, Dingwall; *Medical Renal Unit, Aberdeen Royal Infirmary; #Department of Orthopaedic Surgery, Raigmore Hospital, Inverness; +Department of Neurosurgery Aberdeen Royal Infirmary
Correspondence to: Dr John Millar, The Health Centre, Dingwall IV15 9QS Email: jsmdingwall@hotmail.com
SMJ 2005 50(4): 175-176
Introduction
Neck pain is a common presenting symptom in general practice and contributes 2% of general practice consultations.1 In the majority of cases the pain is acute and self-limiting. The patient generally remains well and a diagnosis may be difficult as the pain is often poorly localised. This report relates a case of the common presentation of neck pain but with an unusual underlying cause.
Case report
A 33-year -old previously well, ex-professional footballer presented with sudden onset of neck pain. The only abnormal finding at presentation was restricted and painful neck movements. The patient had had one previous consultation four months earlier with a self-limiting episode of musculoskeletal neck pain. The following day the patient was seen again because of worsening neck pain, a slight sore throat and temperature. The clinical findings were now more in favour of a viral illness rather than musculoskeletal neck pain.
On the third day of symptoms the patient was admitted to hospital because of a persisting temperature and ongoing neck pain which was not helped by painkillers. Although he was uncomfortable and had a temperature of 38.4ºc the patient did not look unduly unwell. There was no photophobia, headache, rash, nor abnormal neurological signs but neck flexion was restricted by pain. Full blood count and serum biochemistry were normal. Lumbar puncture was normal. His autoantibody screen and monospot test were negative. His C reactive protein (CRP) level was elevated, at 148 mgs/l (normal range 0 – 9). Staphylococcus Aureus was isolated from his blood culture but only after several days incubation by which time the patient had been discharged from hospital. A cervical spine x-ray was normal. (Fig 1). The patient’s signs and symptoms were thought to be consistent with a viral illness with meningism.
Three days after coming out of hospital the CRP level had come down to 59. However, in view of the blood culture results and ongoing problems with neck pain the patient was given a 10 day course of Flucloxacillin. Initially the patient’s neck pain improved. One month after hospital discharge his CRP level had dropped to 12mg/l and the patient had returned to work.
Unfortunately the patient’s pain then worsened after jarring his neck at work suggesting a mechanical problem. His CRP level remained only slightly elevated. He was referred for physiotherapy and by now had had to give up work because of symptoms. Eight weeks after his initial presentation the patient was still in significant discomfort and now noted his right arm feeling cold on occasions. In view of his persistent symptoms a cervical spine x-ray was organized. It showed changes likely to represent infective spondylitis. (Fig 2). At this point the patient was admitted to the local orthopaedic unit where an MRI Scan demonstrated a prevertebral collection in front of C5 and C6 vertebra with erosion of the disc space and extension of the collection into the epidural space adjacent to C5 and C6. (Fig 3) Accordingly, the patient was transferred to the local neurosurgical unit 120 miles away where he underwent surgical drainage of a C5/C6 epidural abscess. Microbiology cultures confirmed a S. Aureus infection.
On discharge the patient was treated with intravenous Ceftriaxone and Rifampicin (which had to be stopped after four weeks because of neutropenia). When reviewed at the neurosurgical clinic 12 weeks after his operation the patient had a good range of neck movements in all directions and no focal neurological deficits. He was advised to resume work and normal activity.
Discussion
The case highlights a not unusual general practice dilemma. The patient presents with a common symptom, is not unduly unwell but there is a feeling that something is not quite right. The patient had a persistent sore neck for 10 weeks from presentation until eventual surgical treatment but at no point had any focal neurological deficit. His neck pain was unusual in its intensity, and interfered with his sleep. His initially very elevated CRP level quickly dropped to a level just above the normal range. His first cervical spine x-ray was normal, but there had been no mention of this investigation in his hospital discharge letter otherwise a second cervical x-ray would almost certainly not have been organised. A short course of antibiotics was given because of continuing neck pain and a positive blood culture. The organism was clearly sensitive but the problem with bone infections is, that if the commonly prescribed short course of antibiotics is given, symptoms may be masked only to recur at a later stage. In this case antibiotics were given on the basis of a septicaemia without a primary source having been identified.
Spinal epidural abscess is an elusive and rare disease. The patient reported had no recognised predisposing factors such as recent spinal surgery, trauma, instrumentation, distal site of infection, immunosuppression, diabetes or IV drug abuse. In other words the source of his S. Aureus infection remains unknown. In a retrospective study of non-tuberculous epidural abscesses in two British hospitals, the most commonly identified organism was S. Aureus.² In this series all the patients received a prolonged course of intravenous antibiotic therapy – at least four weeks in the absence of any bony involvement and up to eight weeks with osteomyelitis. All the patients remained on oral antibiotics for extended periods, which were determined by clinical evaluation and serial inflammatory markers. The authors concluded that fever is not mandatory for the diagnosis of spinal epidural abscess. They recommended that all patients with localised back/neck pain and raised inflammatory markers have an urgent MRI scan. Unfortunately MRI scanning is not universally available and there may be significant delays with priority being given to patients with tumours rather than infections. In these instances it may be worth considering a simple isotope scan which in the presence of infection will be universally positive and would direct the imaging level for a subsequent CT scan. GPs should bear in mind the importance of early referral to an orthopaedic surgeon patients with persistent neck pain and raised inflammatory markers.
REFERENCES
1 Simon C, Everett H J, Stevenson B, Oxford Handbook of General Practice, Oxford University Press, 2003.
2 Joshi S M, Hatfield R H, Martin J, Taylor W, British Journal of Neurosurgery, 2003; 17(2):160-3