79

島 根 県 中 病 医 誌 48
7 9頁 〜 8 5頁

症 例 報 告Clinical Characteristics of Cervical Infection andCervical Inflammation: A Retrospective Cohort Study
Shohei FUMITA1） Tsukasa NAKAMURA2）3）
Toshihiro IMADA1）
Hiroshi HIGUCHI4） and Takeshi MORIMOTO3）5）
Abstract： Background: Cervical spine infectious diseases such as pyogenic spondylitis and epiduralabscess can be fatal if diagnosis is delayed; however, it is diﬃcult to distinguish them from non-infectious
inﬂammatory diseases, especially from pseudogout. This study aim to identify clinical indicator facilitate
the swift diagnosis of pseudogout.
Methods: Patients diagnosed with cervical spine infectious diseases and cervical spine non-infectious
inﬂammatory diseases between January 1, 2000, and December 31, 2020, at Shimane Central Hospitalwere included. Data on patient’s characteristics, vital signs, physical examination ﬁndings, underlying
diseases, laboratory tests, medication history, lifestyle history, and imaging tests were extracted from theintegrated information system; multivariate analysis was performed using descriptive statistics, univariate
analysis, and logistic analysis.
Results: The study included 265 participants; of them, 147（56% ）were male, the mean age was
73 ± 16 years, and 84（32%）had infectious diseases. In the univariate analysis, infectious diseases wereprevalent in male, younger patients, and those with a history of alcohol consumption, patients withsmoking history, patients with paralysis, patients who experienced numbness, and patients who usedpsychotropic medication. Dyslipidemia was potentially associated with non-infectious diseases. In themultivariate analysis of infectious diseases, the odds ratios were higher for paralysis（odds ratio［95%conﬁdence interval ］: 5.5［2.4–12.5 ］）and psychotropic medication use（3.2［1.4–7.2 ］）and lower for
older age（0.9［0.9 –0.95］）and dyslipidemia（0.2［0.1–0.6］）.
Conclusion: Paralysis, psychotropic medication use, age, and dyslipidemia are important factors in
diﬀerentiating cervical spine infectious diseases.
Key words：cervical infection, cervical inﬂammation, logistic regression

頸椎の炎症性疾患と感染性疾患の臨床的特徴について
文田

概昌平1） 中村

要：はじめに

嗣2）3） 今田

敏宏1） 樋口大4） 森本剛3）5）

化膿性脊椎炎や硬膜外膿瘍などの頸椎感染性疾患は，診断が遅れると致命的となるが，非感染性の炎症性疾患，特に偽痛風との鑑別が困難である．本研究では，偽痛風の迅速診断に役立つ臨床所見を検討することを目的とした．

１）島根県立中央病院 総合診療科
２）島根県立中央病院 感染症科
３）島根県立中央病院 臨床教育・研修支援センター
４）島根県立中央病院 地域総合医育成科
５）兵庫医科大学 臨床疫学

１） Department of General Medicine, Shimane
Prefectural Central Hospital, Izumo, Japan
２） Department of Infectious Diseases, Shimane
Prefectural Central Hospital, Izumo, Japan
３） Clinical Education and Research Center, Shimane
prefectural Central Hospital, Izumo, Japan
４） Department of Human Resources Development for
General Practitioner, Shimane Prefectural Central
Hospital５） Department of Clinical Epidemiology, Hyogo
College of Medicine, Nishinomiya, Japan島根県立中央病院医学雑誌80

方法

第48巻（令和５年）

2000 年１月１日から2020 年 12 月 31 日までに島根県立中央病院で頸椎感染性疾患および頸椎非感染性炎症性疾患と診断された患者を対象とした．患者情報，バイタルサイン，身体所見，基礎疾患，臨床検査，薬歴，生活歴，画像検査などのデータを統合情報システムから抽出し，記述統計，
単変量解析，ロジスティック解析を用いて多変量解析を行った．
結果

対象者は265 名で，うち男性 147 名（56％），平均年齢 73 ± 16 歳，感染症罹患者 84 名（32％）

であった．単変量解析では，感染症は男性，若年者，アルコール摂取者，喫煙歴のある患者，麻痺のある患者，しびれを経験した患者，向精神薬使用者に多かった．脂質異常症は非感染性疾患の可能性のある症状であった．感染症の多変量解析では，オッズ比は麻痺（オッズ比［95％信頼区間］：
5.5［2.4-12.5］）と向精神薬使用（3.2［1.4-7.2］）で高く，高齢（0.9［0.9-0.95］）と脂質異常症（0.2［0.1-0.6］）で低かった．
結論

麻痺，向精神薬，年齢，脂質異常症は頸椎感染症を鑑別する上で重要な因子である．

索引用語：頸椎炎症性疾患，頸椎感染性疾患，ロジスティック解析

In primary care, both of these conditions may be treatedIntroduction

by sending the patient to a tertiary hospital. However,

Cervical spine infections, including cervical epidural

considering medical resources and patient beneﬁt, it was

abscesses, can lead to fatal outcomes, resulting in

not always necessary to send the patient to a tertiary

1）

They typically cause

hospital immediately. However, it was not always

midline back pain, neck pain, fever, and progressivenecessary to send the patient to a higher-level hospitalpermanent neuropathy and sepsis.
2）

The white blood cell count,

immediately, considering the medical resources and theerythrocyte sedimentation rate, and C-reactive protein

patient's beneﬁt. This study aimed to examine the clinicallevel usually increase. Treatment with rapid diagnosis andﬁndings that can help distinguish infectious from non-surgical drainage can minimize the risk of mortality andinfectious cervical spine disorders, especially in the

weakness of the limbs.

1）

the incidence of neuropathy.

However, cervical spine

infections rarely occur and often are diﬃcult to diagnose.
The diagnosis of epidural abscess of the spine may bedelayed in up to 75% of the patients.3）

primary care setting.

Methods
Study design and patients

Non-infectious cervical spine disorders such as

This cross-sectional study was conducted in patients

pseudogout have similar symptoms to cervical spine

aged > =16 years who were diagnosed with cervical

infections such as fever and tenderness of the cervical

infection and inﬂammatory disease from January 2000

4）

The red ﬂag

to December 2020 at the Shimane Prefectural Central

symptoms include fever and severe back pain, which are

Hospital. We wanted to know mainly the difference

also common in infectious and non-infectious inﬂammatory

between infection and inﬂammation, so we designed thisdiseases and make diﬀerentiation diﬃcult. Although it canstudy to address these two diseases.

spine and can be diﬃcult to distinguish.

be distinguished by magnetic resonance imaging（MRI）,

The clinical data, laboratory data, and outcomes ofthis procedure is not easy to perform in the primary carethe eligible patients were retrieved from the integrated

5）

setting. It is often diﬃcult to diﬀerentiate fever and backintelligent management system, which is a uniﬁed databasepain of infectious etiology from those of non-infectiousthat stores data from the electronic medical records,

etiology.

images, data from the ordering system, and other hospitalInﬂammation can often be treated with non-steroidal

information. This study was approved by the Ethics

anti-inflammatory drugs （NSAIDs ） and other drugs

Review Board of Shimane Prefectural Central Hospitalcompared to abscesses, which require urgent treatment.

（approval number: R20-067; approval date: 2023-3-23）.

Clinical Characteristics of Cervical Infection and Cervical Inﬂammation: A Retrospective Cohort Study

81

Because all data were obtained as part of routine clinicalThe associations were expressed as odds ratio （OR）

practice, the requirement for obtaining informed consent

and 95% conﬁdence interval（CI）. All reported p-values

was waived by the Ethics Review Board of Shimane

were two tailed, and a p-value of <0.05 was considered

Prefectural Central Hospital in accordance with thesigniﬁcant. All statistical analyses were performed using

guidelines of the Ministry of Health, Labor and Welfare of

Stata 14（StataCorp LLC, Texas）and JMP 12.2（SASJapan.

Institute Inc., Cary, North California）.

Results

Measurements
Data on age, sex, history of alcohol consumption

Patients’ characteristics（DRINK）, history of smoking（SMOKE）, height, weight,

This study included 265 patients, and the patients’ mean

vital signs, symptoms, comorbidities, medications,age was 73 years（range: 18–100 years）（Table 1）. Alaboratory data, and imaging tests were retrieved. The

total of 147 （55.5%） patients were male, 82 （30.9%）

patients’ vital signs including temperature, blood pressure

were DRINK patients, and 95 （35.9%） were SMOKE（systolic and diastolic）, heart rate, respiratory rate andpatients. With regard to the presenting symptoms, paralysis

oxygen saturation were measured. Symptoms such as

occurred in 47（17.7%）patients, numbness in 16（6.0%）

paralysis, numbness, and vomiting were assessed. The

patients, and vomiting in 6（2.3%）patients. In terms ofpatients were examined for presence of comorbidities,

comorbidities, 138（52.1）patients had hypertension, 60

such as valvular heart disease, tooth decay, hypertension,（22.6） had dyslipidemia, 39 （14.7） had diabetes, anddyslipidemia, diabetes, and pseudogout. The medications

34（12.8）had a history of pseudogout. In terms of theused were also determined: steroids, NSAIDs, andmedication history, 12（4.5%）used steroids, 47（17.7%）

psychiatric drugs. The following laboratory data wereused NSAIDS, and 48（18.1%）used psychiatric drugs.

obtained: white blood cell count, hemoglobin level,

The mean body temperature was 37.2 ± 0.8℃, while theplatelet cell count, total protein level, albumin level,mean respiratory rate was 18 ± 5 times/minute. The mean

total bilirubin level, aspartate transaminase level, alanine

systolic blood pressure was 135 ± 24 mmHg, while thetransaminase level, lactate dehydrogenase level, γ-glutamyl

mean diastolic blood pressure was 75 ± 15 mmHg. CT

transpeptidase level, blood urea nitrogen level, creatinine

imaging was performed in 190（71.7）patients, of whomlevel, and C-reactive protein level at the time of admission.

98 （51.6） were diagnosed with pseudogout. MRI was

The imaging tests performed were computed tomography

performed in 78（29.4）patients, of whom 56（71.8）were（CT）and MRI.

diagnosed with cervical spine infection.

Statistical analyses

Univariate analysis of cervical infection and cervicalContinuous variables were expressed as mean andinflammation

standard deviation（SD）or median and interquartile range,

A total of 84 patients comprised the infection groupand categorical variables were expressed as numbers and（Table 1）. Infection group was younger than the non-percentages. To explore the factors associated with cervical

infection group （62 ［SD =16］ vs. 79 ［SD =13］ years;

infection, continuous variables were compared using

p <0.001）. The infection group had higher proportion of

student’s t test or Wilcoxon rank-sum test. The categoricalmale patients（56［66.7%］vs. 91［50.3%］, p= 0.012）,

2

variables were compared using χ test or Fisher’s exact

DRINK patients（33［39.3%］vs. 49［27.1%］, p=0.005）,

test. Then, multivariate logistic regression models wereand SMOKE patients （38 ［45.2% ］ vs. 57 ［31.5% ］,

constructed using clinically important items （age, sex,

p = 0.03 ）. The mean body height was higher in the

DRINK, SMOKE, paralysis, hypertension, dyslipidemia,

infection group（160.1［SD 10.5］vs. 154.2［SD 10.1］

diabetes, and psychotropic drug use）.

cm; p<0.001）, but no signiﬁcant diﬀerences were observed島根県立中央病院医学雑誌

82

Table 1

第48巻（令和５年）

Patients’ characteristics and univariate analysis of infectionALL（n=265）variables
Age, year
Male
DRINK
SMOKE
Height, cm
Vital signs
Body weight, kg
Body temperature, ℃
Systolic blood pressure, mmHg
Diastolic blood pressure, mmHg
Heart fate, /minRespiratory rate, /min
Saturation, ％Symptom
Paralysis
Numbness
Vomiting
Comorbidities
Valvular heart disease
Tooth decay
Hypertension
Dyslipidemia
Diabetes
History of pseudogout
Medication
Steroids
NSAIDsPsychiatric drugs
Laboratory data
White blood cell count, 10^3/μL
Hemoglobin, g/dL
Platelet count, 10^4/μL
Total protein, g/dL
Albumin, g/dL
Total bilirubin, mg/dL
AST, U/L
ALT, U/L
LDH, U/L
γ-GTP, U/L
BUN, mg/dL
Cr, mg/dL
CRP, mg/dL
ImagingCT
Pseudogout
MRI
Cervical spine infection

Cervical infection
Cervical inﬂammation
n=84
n=181
no（%）or mean ± sd or median［IQR］
73 ± 1662 ± 1679 ± 13147（55.5）56（66.7）
91（50.3）
82（30.9）33（39.3）
49（27.1）
95（35.9）38（45.2）
57（31.5）
156.1 ± 10.6
160.1 ± 10.5
154.2 ± 10.1

p-value<0.001
0.012
0.005
0.030
<0.00154.0 ± 10.9
37.2 ± 0.8
135 ± 2475 ± 1581 ± 1518 ± 596 ± 255.2 ± 11.7
36.9 ± 0.7
130 ± 2176 ± 1280 ± 1515 ± 597 ± 253.4 ± 10.5
37.3 ± 0.8
138 ± 2675 ± 1682 ± 1520 ± 596 ± 20.24<0.001
0.025
0.58
0.42
<0.0010.14

47（17.7）16（6.0）6（2.3）

29（34.5）
12（14.3）3（3.6）

18（9.9）4（2.2）
3（1.7）<0.001<0.0010.39

2（0.8）
2（0.8）
138（52.1）60（22.6）
39（14.7）
34（12.8）0（0.0）
1（1.2）
36（42.9）6（7.1）
13（15.5）34（18.8）2（1.1）
1（0.6）
102（56.4）
54（29.8）
26（14.4）0（0.0）

1.00
0.53
0.041
<0.0010.81<0.00112（4.5）47（17.7）
48（18.1）5（6.0）
14（16.7）23（27.4）7（3.9）
33（18.2）25（13.8）

0.53
0.76
0.008

8,130［6,460–10,640］
12.1［10.8–13.4］
23.1［18.0–29.0］
6.9［6.2–7.3］
3.5［2.9–3.9］
0.7［0.5–1.0］
21［16–31］
16［11–29］
210［178–239］
28［18–77］
14.0［11.0–19.1］
0.68［0.55–0.89］
6.61［2.89–12.34］

7,870［5,650–10,070］
12.3［10.7–13.3］
26.0［21.0–32.9］
6.9［6.7–7.4］
3.6［3.2–4.1］
0.5［0.4–0.7］
20［15–28］
18［13–33］
199［164–230］
52［24–121］
13.0［9.9–17.3］
0.68［0.52–0.87］
4.94［0.69–9.71］

8,410［6,840–10,750］
12.1［10.8–13.4］
22.3［17.8–27.3］
6.8［6.2–7.3］
3.4［2.8–3.8］
0.8［0.6–1.3］
21［16–32］
15［11–27］
216［184–248］
23［15–53］
14.5［11.5–22.0］
0.68［0.56–0.91］
8.00［4.23–12.63］

0.14
0.81
<0.001
0.040
0.012<0.001
0.090
0.037
0.016
<0.0010.007
0.28<0.001190（71.7）
98（51.6）
78（29.4）
56（71.8）

DRINK; history of alcohol consumption, SMOKE; history of smoking, NSAIDs; non-steroidal anti-inﬂammatory drugs, AST; aspartatetransaminase, ALT; alanine transaminase, LDH; lactate dehydrogenase, γ-GTP; γ-glutamyl transpeptidase, BUN; blood urea nitrogen, Cr;creatinine, CRP; C-reactive protein, CT; computed tomography, MRI; magnetic resonance imaging

Clinical Characteristics of Cervical Infection and Cervical Inﬂammation: A Retrospective Cohort Studyin the body weight（55.2［SD 11.7］vs. 53.4［SD 10.5］

83

Discussion

kg; p = 0.24）. The infection group showed lower systolicblood pressure（130［SD 21］vs. 138［SD 26］mmHg;

We explored the clinical ﬁndings to distinguish between

p= 0.025）, body temperature（36.9［SD 0.7］vs. 37.3［SDinfectious and inflammatory cervical spine disorders.

0.8］℃; p <0.001）, and respiratory rate（15［SD 5］vsParalysis and psychotropic drug use were associated with

20［SD 5］bpm; p <0.001）, but no signiﬁcant diﬀerences

infectious cervical spine disorders（e.g., cervical abscess）,

were observed in the diastolic blood pressure and heart

while higher age and dyslipidemia were associated with

rate. With regard to the symptoms, paralysis and numbness

non-infectious cervical spine disorders （e.g., cervical

were more prevalent in the infection group（paralysis: 29

pseudogout）［34.5%］vs 18［9.9%］, p <0.001, numbness: 12［14.3%］

In our study, the mean age of patients with cervicalvs 4［2.2%］, p < 0.001）. In terms of comorbidities, theinfections was 62 years, and male were significantly

incidence of hypertension, dyslipidemia, and history of

predominant in the infected group1）. The mean age ofpseudogout was relatively low（hypertension: 36［42.9%］

patients with epidural abscess was 65 years,1） while thatvs 102［56.4%］, p = 0.041; dyslipidemia: 6［7.1%］vs 54

of patients with pseudogout was 72 years.6,7） The ﬁndings［29.8%］, p<0.001; and history of pseudogout: 34［18.8%］of our study were align with those of previous studies,vs. 0 ［0.0%］, p <0.001）. The proportion of psychiatricthough the age of our study’s patients with non-infectious

drug users was higher in the infection group（23［27.4%］

diseases was higher. This could be due to the high aging

vs. 25［13.8%］, p= 0.008）. With regard to the laboratory

population in the area.8） In a previous study of cervical

data, the white blood cell count, hemoglobin level, and Cr

epidural abscesses, 173 patients were analyzed, and 61.3%

level were not signiﬁcant highly.

were men,3） which were similar to that reports of ourstudy.

Multivariate analysis of Infection

Previous studies on epidural abscesses have

The multivariate logistic regression model showed that

identiﬁed diabetes, drug abuse, alcohol abuse, humanyounger age（OR: 0.93, 95% CI: 0.90–0.95）, paralysis

immunodeficiency virus infection, knee osteoarthritis,（OR 5.53, 95% CI 2.38 –12.8）, and psychotropic drug

and history of trauma as risks factors.2） In our study, theuse（OR: 3.25, 95% CI: 1.46–7.56）were independently

incidence of diabetes mellitus and alcohol abuse wereassociated with cervical infections（Table 2）. Dyslipidemia

signiﬁcantly higher in the infection group compared to（OR: 0.16, 95% CI: 0.06 –0.48）was associated with non-the non-infection group according to the results of theinfectious disease.

univariate analysis, but the diﬀerence was relatively small.

Table 2

Logistic regression analysis of cervical infection

INFECTION

Odds ratio

95% Conﬁdence Interval

p-value

Age, year

0.93

0.90–0.95

0.000

Male

0.99

0.44–2.22

0.987

DRINK

1.11

0.50–2.47

0.801

SMOKE

1.45

0.61–3.44

0.402

Paralysis

5.53

2.38–12.8

0.000

Hypertension

1.20

0.60–2.40

0.598

Dyslipidemia

0.16

0.06–0.48

0.001

Diabetes

1.56

0.59–4.14

0.373

Psychotropic drug use

3.25

1.40–7.56

0.006

DRINK; history of alcohol consumption, SMOKE; history of smoking

島根県立中央病院医学雑誌

84

第48巻（令和５年）

Non-infectious diseases, particularly pseudogout, showed

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（受付日：2023年10月24日，掲載決定日：2023年12月12日）