Commentary

Haridas and associates describe their management of a patient with osteomyelitis of the odontoid process with an epidural abscess causing myelopathic symptoms and respiratory distress from neural compression. Initially, the patient was treated with halo immobilization followed by delayed emergent posterior decompression with craniocervical fusion after neurological decline. Of interest is that preoperative blood cultures revealed Staphylococcus aureus whereas intraoperative cultures from the epidural abscess revealed Proteus mirabilis. The patient recovered neurologically and was left in halo immobilization. Some evidence of osteomyelitis of the occipital bone was seen on follow-up computed tomography. The discrepancy between the bacteria cultured from the blood and from the abscess stresses the importance of obtaining cultures from the involved bony territory.

The authors point out that a transoral approach for decompression of the spinal cord in this scenario also would have been possible. However, the posterior approach was favored because it was familiar. Given a rapidly declining patient suffering from an epidural abscess of the odontoid process, this response was appropriate. We would favor the transoral approach because it allows both decompression and extensive debridement of involved bone and resection of the infected odontoid process. As demonstrated in Figure [2]B, the bony involvement had extended to the occipital bone. This finding likely reflected insufficient local debridement of osteomyelitic bone, which can occur if treatment with antibiotics alone is insufficient. Whether treatment was planned for the osteomyelitic changes on follow-up is unclear.

Another issue is the timing of the initial decompressive surgery. At presentation the patient had no focal neurological symptoms but displayed a positive Lhermitte's sign. This finding in conjunction with magnetic resonance imaging evidence of epidural compression at the dens suggestive of abscess would have been a sufficient indication to proceed with decompression, debridement, and local cultures combined with antibiotic treatment and immobilization rather than pursuing conservative treatment initially.

Figure 2 (A) Axial CT at C1-2 showing bony destruction of the odontoid process (closed arrow), the right side of the C1 vertebral body (arrowhead), and an epidural soft tissue mass (open arrow). (B) Axial CT of the craniovertebral junction showing additional destruction of the right occiput (arrow).