Cervical Osteomyelitis-Discitis Attributed to Post-Radiation Esophageal Fistula Communicating with the C6-C7 Disc Space: A Case Report

Case Diagnosis: Osteomyelitis-discitis at C6-7

Case Description or Program Description: At the recommendation of physical therapy, a 52-year-old male presented with two months of progressive midline neck pain, burning bilateral posterior shoulder and arm pain, and bilateral triceps weakness. Past medical history included metastatic esophageal squamous cell carcinoma treated with chemoradiation six years prior, which was complicated by tracheoesophageal fistula status post stent placement.

Setting: Outpatient General PM&R Clinic

Assessment/Results: Examination demonstrated tenderness of the C7-T1 spinous processes, reduced cervical spine range of motion, and bilateral elbow extension weakness. He endorsed a cough but denied constitutional symptoms. Electromyography (EMG) demonstrated acute right C7-C8 radiculopathies. Magnetic resonance imaging (MRI) with and without contrast showed erosive changes of the C6-C7 vertebral bodies, associated kyphotic angulation, and a tubular area of enhancement extending from the esophagus to the C6-C7 disc space. Positron emission tomography-computed tomography (PET-CT) showed intense fluorodeoxyglucose (FDG) uptake along the C6-C7 disc space, suggestive of osteomyelitis-discitis. The patient was admitted for further management.

CT-guided biopsy was negative for malignancy and cultures showed no growth, however neck pain improved after empiric treatment with 12 weeks of broad-spectrum antibiotics. Follow-up MRI was stable and esophagogastroduodenoscopy (EGD) was inconclusive. Surgical stabilization is planned pending lateral esophagram and clinical course.

Discussion (relevance): Patients with a prior history of head and neck malignancy and radiation are at increased risk of osteoradionecrosis, soft-tissue necrosis, radiation-induced malignancy, post-radiation plexopathies, fistula formation, and osteomyelitis-discitis. In this case, collaborative care, EMG, and prompt advanced imaging were essential in making the diagnosis and expediting treatment.

Conclusions: This case describes a rare presentation of cervical osteomyelitis-discitis attributed to a post-radiation esophageal fistula. When evaluating new neck pain in patients with a history of head and neck malignancy and radiation therapy, there should be a lower threshold for consideration of MRI with and without contrast to evaluate for post-radiation complications.