Patient's progress and assistant examinations
The cervical MRI showed obvious degeneration of C4/5 disc with Modic type 2 changes, and slight herniation of C6/7 disc without compression of spinal cord or nerve root (Figure 1).
Figure 1 Magnetic resonance imaging showed obvious degeneration of C4/5 disc with Modic type 2 changes, and slight herniation of C6/7 disc without compression of the spinal cord or nerve root.
The initial diagnosis for the patient was cervical disc degenerative disease with cervicogenic dizziness. However, we could not confirm which cervical disc finally caused above symptoms according to the radiological data and physical examination. Therefore, analgesic discography on C4/5 and 6/7 discs was then performed successively.
Under the guidance of fluoroscopy, a 22 G discographic needle was inserted into the center of C4/5 disc through anterolateral approach and judged from anteroposterial and lateral views (Figure 2A and B). Then a small volume (0.3 mL) of 0.25% bupivacaine was injected. The patient only felt a slight relief of neck pain, while her dizziness and tinnitus remained unchanged in the following several hours. At 2 d after the first injection, the patient’s vital signs were stable with a normal body temperature. Therefore, we used the same method to manipulate the C6/7 disc (Figure 2C and D). This time, the patient experienced significant relief of neck pain as well as dizziness and tinnitus in the next 4 h. Based on this situation, the C6/7 disc was finally thought to be the diseased disc. In addition, routine intravenous administration of antibiotic Rosafine (Ceftriaxone Sodium) 2 g was used to prevent infection during above two operations.
Figure 2 Image of stages in cervical intradiscal analgesia.
A: Anterior view of a needle inserted into C4/5 intervertebral disc; B: Lateral view of the needle inserted; C: Anterior view of a needle inserted into C6/7 intervertebral disc; D: Lateral view of the needle inserted.
Unfortunately, the patient felt more severe neck pain than before, which rapidly became unbearable on the night of the second injection. Strong painkillers had limited effect. The next morning, neck stiffness and shoulder pain became the main symptoms associated with low fever (37.9 °C). Blood routine showed that the white blood cell count was 14.68 × 109/L and the percentage of neutrophils was 96.7%. Erythrocyte sedimentation rate was 17 mm/h, and general C-reactive protein (CRP) was 94.24 mg/L. Acute discitis was suspected and the patient was treated with Rocephin 2 g twice a day.
Over the next few days, the patient’s temperature gradually increased, reaching a maximum of 40 °C. Physical examination showed tenderness of spinous processes between C5 and T2, stiffness of neck, and normal strength of limbs. Pathological signs were negative. The cervical MRI scan showed that the signal intensity of C6/7 disc was enhanced (Figure 3), which supported the diagnosis of cervical discitis. On day 10, the patient suddenly experienced limited neck rotation, limb weakness and numbness, as well as sphincter dysfunction. Physical examination showed that biceps brachii muscle strength was grade 3/5 (Medical Research Council, MRC), hand grip strength decreased (grade 3/5, MRC), skin sensation below the navel gradually decreased, the strength of bilateral iliopsoas, quadriceps femoris, anterior tibialis and long fibula muscles was about grade 1/5. Her deep tendon reflexes were hyperreflexive and pathological signs were positive. The suspicion of an anterior epidural abscess was confirmed by a new cervical MRI scan (Figure 4).
Figure 3 At 5 d after the second injection, the cervical 6/7 disc (arrow) showed increased signal intensity.
Figure 4 At 10 d after the second injection, epidural inflammation (arrows) could be seen with increased signal intensity from the lower margin of C5 to the lower margin of T1 as well as within the C6/7 disc.