Occipitocervical fusion complicated with cerebellar abscess: a case report

Abstract

Background: Occipitocervical (OC) fusion is indicated for OC instability and other conditions. Surgical complications include infection, malunion, and instrument failure.

Case presentation: We described a patient who underwent OC fusion and subsequently developed complication of cerebellar abscess and obstructive hydrocephalus. A 63-year-old male patient had been suffering from long-term neck pain and limb numbness and weakness. Cervical spine examination revealed tight stenosis at C1 level and instability in the C1-C2 joints. A C1 laminectomy with OC fusion was performed, and the patient was discharged. Unfortunately, a few days later, he went to the emergency department and complained of persistent dizziness, vomiting, and unsteady gait. Computed tomography (CT) and magnetic resonance imaging (MRI) images revealed a suspicious cerebellar abscess formation and hydrocephalus. Furthermore, CT images indicated that the left screw was loose, and the diameter of the right screw hole was much larger than the size of the screw. Besides, inappropriate length of the screw penetrated the occipital bone and may cause the disruption of dura mater. The patient underwent external ventricular drainage first, followed by abscess drainage and C1-C2 fixation a few days later. He was discharged without any further neurological deficits or infectious problems. The patient recovered with intact consciousness, full muscle strength, and improved numbness throughout the extremities, with a Nurick grade of 1. A follow-up magnetic resonance imaging at 3 months after surgery revealed near total resolution of the abscess. Inform consent was obtained from this patient.

Conclusions: Carefully conducting the procedure using the most tailored approach is essential to successful surgery, but this rare complication should always be kept in mind.

Keywords: Atlantoaxial subluxation; C1 laminectomy; Cerebellar abscess; Complications; Occipitocervical fusion.

Fig. 1

MRI image of hypertrophic ossification at the odontoid process, tight stenosis at the C1, and edematous changes at the spinal cord

Fig. 2

The axial images of four continuous CT of the patient with cerebellar abscess. The four continuous CT images from a to d represented continuous section from the base of the skull to top. The arrow in (a) indicated the position where the screw penetrates the dura mater. Circled area was indicated as brain abscess

Fig. 3

The appearance of cerebellar abscess at MRI image. MRI confirmed the diagnosis of a 2.5 cm of a faint ring-enhanced cerebellar abscess based on T1-weighted images with contrast medium. Circled area was represented as brain abscesses

Fig. 4

Possible VA injury by C3 screw. The arrow indicated that the C3 screw has been inserted into the transverse foramen, which may cause VA injury

Fig. 5

CT sagittal images of the failure of the OC fusion instruments. (a) The arrow showed the dislodgement of the occipital screw and the screw hole. The screw was loose and not in their original position. (b) The arrow indicated the oversized diameter of the screw hole. The diameter of the screw hole is much larger than the size of the screw, indicating that the screw has no fixing effect

Fig. 6

CT image after C1-C2 instrumentation. The white arrows indicated the newly operated C1-C2 instruments, and the black arrow indicated the original occipito-C3-C4 fixation instruments

Fig. 7

MRI image of cerebellar abscess resolution after surgery.MRI image showed that abscess in the right cerebellum was almost completely resolved 3 months after surgery. The arrow indicated the abscesses that has not resolved