Osteoradionecrosis of the cervical spine complicated by pneumocephalus and meningitis in a nasopharyngeal cancer patient radically treated with radiotherapy 11 years ago

Abstract

Superimposed infection of osteoradionecrotic cervical spine with cranial extension is difficult to treat and potentially fatal. This report describes the case of a middle-aged Chinese man 11 years post radical radiotherapy for nasopharyngeal cancer with no evidence of disease presenting initially with neck pain secondary to cervical osteoradionecrosis. He was re-admitted a month later with aspiration pneumonia associated with Streptococcus milleri bacteraemia, complicated by septic shock. The last re-admission was 2 months later with fever, expressive dysphasia and right upper motor neuron signs. There was interval increase of dental and peridental soft tissue mass, interval widening of atlantodental distance on MRI cervical spine associated with pneumocephalus, meningeal enhancement and pre-pontine soft tissue mass on CT brain consistent with infected osteoradionecrotic cervical spine complicated by cranial extension. The patient also had concomitant bilateral pneumonia and subsequently passed away from fulminant sepsis.

Figure 1

Lateral radiograph of the cervical spine done 3 months before the last admission showing cervical spondylosis, worse at the C5–C6 level, with no overt bony destruction.

Figure 2

Selected sagittal T1 weighted pre-contrast MRI images of the cervical spine done (A) 6 years before, (B) 3 months before, (C) 2 months before and (D) during the last admission. T1 weighted post-contrast sequences (E–H) are shown below their corresponding pre-contrast images. Post-radiation fatty replacement is noted from C1 down to C5, most appreciable in (A), the T1 weighted pre-contrast image done 6 years ago. On follow-up MRI studies from 3 months ago to the last admission (B–D, F–H), there is development of enhancing soft tissue mass within the dens, eventually involving the entire dens and the C2 vertebral body during the current admission (white arrowhead). This enhancing soft tissue is also seen to extend down the pre-vertebral space to the level of C5. The atlantodental distance is seen to increase from (A) a normal 2 mm 6 years ago, (B) to a mildly widened 4 mm 3 months before, and (D) to finally measure 8 mm in the last admission (white arrow).

Figure 3

Axial post-contrast CT images showing marked pneumocephalus suspicious for either a breech of the subarachnoid space secondary to the changes in the craniocervical region or be secondary to a gas-forming infection.

Figure 4

Axial T1 weighted post-contrast image at the level of the brainstem shows an enhancing soft tissue occupying the pre-pontine cistern and surrounding the basilar artery.