JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Syrinx was an Arcadian virgin who, when pursued by
Pan, turned into a reed, from which Pan made his pipes.
She gave her name to the tubular cavitation of the spinal
cord. Post-traumatic syrinx is well described in patients
with delayed neurological deterioration after spinal cord
injury3'4. The period from injury to onset of symptoms is
up to 33 years3. Proposed pathophysiological mechanisms
include the slosh theory, the suck theory and coalescence of
microcysts4. There is probably no benefit in operating on a
patient with a small post-traumatic syrinx4.
Cord tethering has only occasionally been reported as a
late complication of spinal trauma5'6. Repeated abnormal
movement at the damaged region and the spinal canal
stenosis occurring with age might explain its delayed onset6.
Once tethering occurs, it impairs cord function by
mechanical distortion or ischaemia5. Detethering has been
reported to improve the clinical condition5'6 and in our
Neck pain with fever
A R Saha BM MRCP A M Blackburn MD FRCP
J R Soc Med 1999;92:304-306
Cervical osteomyelitis is an uncommon but wholly treatable
condition; the diagnosis is frequently delayed and is
considerably aided by magnetic resonance imaging.
CASE HISTORY
An Afro-Caribbean man aged 71 was referred by his general
practitioner because of inability to cope at home. He had an
indwelling urinary catheter and was complaining of rigors
which had not improved despite a course of trimethoprim.
He also complained of back and shoulder pain for which he
had been given a non-steroidal anti-inflammatory drug.
Two weeks earlier he had been discharged from hospital
with an indwelling catheter after a transurethral prostatic
resection. Postoperatively a trial without catheter had been
unsuccessful on two occasions. He was an insulin-requiring
diabetic and was being followed up by a community
psychiatric nurse because of recurrent bouts of depression.
On admission he was pyrexial and the catheter was
draining cloudy urine. Although he complained of pain in
the right shoulder there was no local tenderness or
Department of Healthcare of the Elderly, King's College Hospital, Denmark Hill,
London SE5 9PJ, UK
304 Correspondence to: Dr A M Blackburn
Volume 92 June 1999
patient it abolished Lhermitte's sign and the upper limb
symptoms.
REFERENCES
1 Kohout MP, Percy J, Sears W, Yeo JD. Tiger mauling: fatal spinal
injury. Aust N ZJ Surg 1989;59:505-6
2 Wiens MB, Harrison PB. Big cat attack: a case study. J Trauma
1996;40:829-31
3 Hida K, lawasaki Y, Imamura H, et al. Post-traumatic syringomyelia: its
characteristic magnetic resonance imaging findings and surgical
management. Neurosurgery 1994;35:886-91
4 Rossier AB, Foo D, Shillito J, et al. Posttraumatic cervical
syringomyelia. Brain 1985;108:439-61
5 Berrington NR. Posttraumatic spinal cord tethering. J Neurosurg
1993;78: 120-1
6 Ragnarsson TS, Durward QJ, Nordgren RE. Spinal cord tethering after
traumatic paraplegia with late neurological deterioration. J Neurosurg
1986;64: 397-401
restriction in movement. Haemoglobin was 8.3 g/dL and
white cell count 16.2 x 109/L with neutrophilia. Urine
culture grew Pseudomonas aeruginosa. Blood cultures were
sterile. He was rehydrated with intravenous fluids, given a
single dose of intravenous gentamicin and had his urinary
catheter changed. Clinically, initial progress was good; but
on the third day after admission there was a spike in
temperature to 380C. Blood cultures at this stage grew
Staphylococcus aureus and he responded well to a 10-day
course of intravenous flucloxacillin with rapid loss of
pyrexia. However, he continued to complain of persisting
pain, first in the right shoulder and then in the cervical area,
despite an increase of his analgesia from regular paracetamol
and codeine to transcutaneous nerve stimulation (TENS)
and oral opioids. There was no evidence of cervical
myelopathy or restriction in any joint movements. Cervical
spine X-rays taken at this time were reported as showing
only minor degenerative disease. A full biochemical profile
including tumour markers was normal.
Over the next month, his clinical condition steadily
deteriorated, with recurrent bouts of pyrexia and rigors.
Repeat blood and urine cultures were negative; and there
was no response to empirical treatment with cephalosporin
antibiotics. At this stage the erythrocyte sedimentation rate
(ESR) was 72 mm/h and C-reactive protein (CRP) 75 mg/
L; while a myeloma screen was negative. The patient
became more anaemic, requiring a 2-unit blood transfusion,
and complained bitterly of worsening neck pain. High-dose
opioids were used for analgesia, as well as topical capsaicin
cream. Diazepam was added for the associated cervical
muscle spasm and dothiepin was given at night. Despite
these measures, the pain severity was such that the patient
was unable to sleep and he became profoundly depressed
 JOURNAL OF THE
1W a... A ~
Figure 1 (a) Sagittal T2-weighted spin-echo magnetic resonance
some reduction in C5-C6 exit foramina dimensions with
and withdrawn; he expressed suicidal thoughts and was
transferred temporarily to psychiatric care.
Two months after admission, he still complained of neck
pain and a technetium bone scan highlighted a focal area of
increased tracer uptake in the lower cervical spine. A
magnetic resonance imaging (MRI) scan of the cervical area
then revealed a large destructive lesion from levels C5 to
TI with wedged and collapsed vertebral bodies and an
associated soft tissue mass [Figure I ,aJ. A histological
specimen taken by percutaneous MRI guided needle biopsy
showed extensive new bone formation with infiltration by
polymorphs and lymphocytes and fragments of necrotic
bone undergoing osteoclastic resorption all in keeping
with chronic osteomyelitis. No organisms were seen, either
on direct tissue stains (Gram and Ziehl-Neelsen) or on
prolonged culture of biopsy tissue or blood; however, the
staphylolysin antibody titre was positive at >8 units/mL.
The patient was fitted with a hard cervical collar and
intravenous flucloxacillin and fusidic acid was started. His
condition dramatically improved: his pain became con-
trollable on a fraction of the previous opioid doses, his
mood lifted and he started to regain weight. He remained
apyrexial, and his white cell count, ESR and CRP returned
to within normal limits. After 6 weeks of intravenous
flucloxacillin and fusidic acid, a repeat bone scintiscan
showed reduced tracer uptake in the cervical area while a
cervical spine X-ray showed minimal movement at C4-C5
in flexion and extension with no evidence of instability.
Oral antibiotics were continued for a further 6 weeks and a
repeat MRI scan confirmed improvement [Figure 1 ,bl.
ROYAL SOCIETY OF MEDICINE Volume 92 June 1999
(a) (b)
~~ ~ ~ ~
image of cervical spine. After twelve weeks of treatment (b) there is
no evidence of an epidural collection
Eighteen months later he remains well albeit complaining of
some neck discomfort, well controlled by a TENS machine;
his ESR has remained < 20 mm/h.
COMMENT
Pyogenic osteomyelitis is commonly diagnosed late, as it was
in this case. In most series the mean delay from symptom
onset has been about six weeksl-3, but when neck or back
pain and fever are the main symptoms it may be up to five
months. Of patients with cervical osteomyelitis, 90%
complain of neck pain which often radiates to the trapezial
and shoulder regions. In most series, less than half the
patients have neurological symptoms on presentation.
Moreover (and surprisingly), under half have fever or a
raised white cell count2. Conventional spinal X-rays do not
become abnormal until 3-8 weeks after disease onset3, when
soft tissue swelling, piecemeal necrosis of one of the
vertebral plateaux and narrowing of the disc spaces are seen.
Progressive sclerosis follows after two to four months and
may result in fusion six months to two years later. A bone
scintiscan with technetium is helpful since this radionuclide
binds to sites of increased bone metabolic activity, but it is
not specific for infection. MRI, with its excellent anatomical
resolution, is now the investigation of choice to define the
extent of the bone disease and adjacent soft tissue
involvement4. Since blood cultures are frequently sterile,
MRI-guided bone biopsy is recommended to determine the
micro-organism responsible5. MRI may also indicate
whether there is a hazard of spinal cord compression. 305
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 92 June 1999

For treatment, spinal immobilization is essentiall. In
most cases the pathogen is S. aureus; and for this organism
intravenous antibiotics must be continued for a total of eight
weeks6. Serial ESRs together with imaging techniques,
especially MRI scans, can be used to monitor the
effectiveness of treatment.
REFERENCES
I Osenbach RK, Hitchon PW, Menezes AH. Diagnosis and management of
pyogenic vertebral osteomyelitis in adults. Surg Neurol 1990;33: 266-75
2 Heller JG. Infections of the cervical spine. In: An HS, Simpson
JM, eds. Surgery of the Cervical Spine. London: Martin Dunitz,
1994:335-56
3 Cahill DW, Love LC, Rechtine GR. Pyogenic osteomyelitis of the spine
in the elderly. J Neurosurg 1991 ;74:878-86
4 Lew DP, Waldvogel FA. Osteomyelitis. N Engi J Med 1997;336:
999-1007
5 La Rocca SH, Eismont FJ. Other infectious diseases. In: Sharh HH,
Dunn EJ, Eismont FJ, eds. The Cervical Spine. Philadelphia: Lippincott,
1989:552-63
6 Jensen AG, Espersen F, Skinhoj P, Frimodt-Moller N. Bacteremic
Staphylococcus aureus spondylitis. Arch Intern Med 1998;158:509-17

Streptococcus viridans Vertebral osteomyelitis was diagnosed and she was started
on intravenous benzylpenicillin 2.4 g four times daily and
vertebral osteomyelitis gentamicin 120mg twice daily. For analgesia she required
morphine and a non-steroidal anti-inflammatory drug.
Olumide Adeotoye MRCP Richard Kupfer MA FRCP Despite intravenous antibiotics she developed a swinging
pyrexia, so magnetic resonance imaging (MRI) of the
J R Soc Med 1999;92:306-307
SECTION OF GERIATRICS & GERONTOLOGY, 24 NOVEMBER 1998

Back pain is a common symptom in older people, and

detection of the rare case of vertebral osteomyelitis is a
challenge.

CASE HISTORY
A woman aged 88 was admitted with a six-week history of
low back pain which had become more severe in the past
week. She was now having difficulty walking. She was
pyrexial (37.40C) and had a systolic murmur at the left
sternal edge but there were no stigmata of infective
endocarditis. The nervous system was normal and dental
caries was absent. She had a normochromic, normocytic
anaemia with a haemoglobin of 8.6g/dL, an erythrocyte
sedimentation rate > 100 mm/h, and a serum C reactive
protein of 99 mg/L. Radiographs of her lumbar spine showed
erosion of the end plates above and below the L3/L4 disc and
degenerative changes in the lumbar spine. Subsequently a
technetium bone scan indicated areas of greatly increased
activity within the vertebral body of L4 and the left posterior
aspect of L3 with relative preservation of the disc space.
These changes were reported as consistent with skeletal
metastases rather than infection. Two sets of blood cultures
grew Streptococcus viridans sensitive to penicillin. Echocardio- .3
graphy revealed mitral regurgitation but no vegetations.
Figure 1
Magnetic
Department of Health Care of the Elderly, Queen's Medical Centre, Nottingham, l! S1 ....resonance
IIl -
UK
image of
Correspondence to: Dr 0 A Adeotoye, Department of Integrated Medicine,
306 Derby City General Hospital, Uttoxeter Road, Derby DE22 3NE, UK 122 splumbar
spine