a 33-year - old male ( height 172.3 cm and weight 61.5 kg ) visited our pain clinic due to neck pain radiating to both shoulders , which started 3 years ago .
he complained of tingling sensations of the bilateral hand along with shoulder pain , and difficulty in neck flexion . upon physical examination
, the results of the jackson compression test and the spurling 's test did not appear positive .
on the cervical mri , c5/6 and c6/7 intervertebral disc protrusions were found and chronic right c6 radiculopathy was found on the electromyography .
this patient had already received an epidural steroid injection and decompressive neuroplasty using a racz 's catheter at a local hospital .
therefore , we decided to perform cervical nucleoplasty at the c5/6 and c6/7 intervertebral discs . on the pre - procedural laboratory tests , there were no abnormalities in the cbc , esr , and blood chemistry test ( table 1 ) .
nucleoplasty was performed on the c5/6 and c6/7 intervertebral discs without any perioperative events . under a supine position ,
skin preparation was performed with betadine soap and 2% chlorhexidine-70% isoprophyl alcohol solution , and a sterile surgical drape was applied .
after the internal carotid was laterally displaced , a 19 gauge 3 inch introducer needle was introduced till the anterolateral annulus fibrosus .
after the needle was advanced deeper , the position of the needle was adjusted to reach the target site of the herniated disc under a c - arm guide .
when the needle reached the proper target site , the stylet of the introducer needle was withdrawn , and the perc dc spine wand ( arthrocare co. , sunnyvale , ca , usa ) was replaced and fastened to the needle hub .
next , the perc dc spine wand was connected to the arthrocare system 2,000. after confirming that there was no cervical root stimulation , coblation was then carried out by rotating the flange 180 for 20 seconds .
after this , the wand was retracted 1 - 2 mm under c - arm guidance and the same procedure was repeated 3 times .
stay , the body temperature was 36.7 - 36.9 and there were no signs or symptoms of acute complications .
an additional amount of intravenous cefazolin was administered three times a day and a routine prophylaxis for 2 more days during the hospital stay .
additional oral cefradine was prescribed 1,000 mg / day for 1 week after the patient 's discharge .
after 8 days , the patient revisited our outpatient clinic for routine postoperative checkup , but there were no improvements in the patient 's symptoms .
in addition , there were no symptoms or signs of infection including fever or chills , and the laboratory findings , such as the cbc and esr , were in the normal range .
after 2 months , during his second postoperative visit to our clinic , the patient complained of right shoulder pain and worsening neck pain during flexion .
he also complained of feelings of weakness in both arms , but his motor functions were intact when a physical examination was performed .
in addition , new physical signs developed ; the jackson compression test and spurling 's test were positive , with radiating pain in both shoulders .
there was tenderness on the right cervical facet joint , but no tenderness was observed on the left side .
the body temperature was normal , and there was no sensation of chills . in order to evaluate the focus of the pain ,
a cervical mri was performed , and the findings were compatible with spondylodiscitis at the c6/7 intervertebral disc and the vertebral body ( fig .
the patient was referred to the neurosurgery department immediately , and intravenous antibiotics therapy was planned . however , with the patient 's will , he was transferred to another hospital for long - term antibiotics therapy .
early diagnosis and treatment of spondylodiscitis is important for the prevention of catastrophic sequelae and huge additional expenses .
therefore , it is essential to understand the natural course of postoperative spondylodiscitis . usually , short - term relief of the symptoms comes first after surgery , and then back pain recurs within 6 weeks . according to bavinzski et al .
in addition , fever was a typical symptom associated with this infection . in our case ,
neck pain was aggravated and new positive signs in the physical exam appeared 8 weeks after the procedure .
moreover , our patient was afebrile , which can be explained by the lack of elevation of an inflammatory marker .
the esr and crp are known as the earliest and most sensitive screening tools for the infection .
meyer et al . suggested the sensitivity and specificity of crp as 100% and 95.8% , respectively , when predicting postoperative infections .
in addition , mustard et al . conducted a study on 108 patients , and a positive crp response was defined as meeting two criteria :  on days 3 and 4 , the crp level is > 80% of day 2 ( positive diagnosis by day 4 ) ; and  after day 4 , the crp rises on 2 consecutive days with a level greater than 15 mg / l for each day ( positive diagnosis by day 6 ) .
the above criteria had a sensitivity of 63% , a specificity of 82% , a positive predictive value of 68% and a negative predictive value of 78% .
recommended that an esr of more than 50 mm / hr for more than 2 weeks after surgery be used as an early diagnostic marker for spondylodiscitis , indicating a need to perform more tests .
however , during the early postoperative period , the crp and esr may rise as a consequence of tissue damage caused by the surgery itself .
kwon et al . found that the crp and white blood cell ( wbc ) rose starting on the first day of surgery and decreased after the third postoperative day , and the esr elevation lasted up to 11 days after spine surgery . to screen postoperative infections with laboratory tests ,
adequate follow up periods and tests should be considered , with further evaluations being needed to confirm spondylodiscitis .
based on the previous studies , crp should be checked 4 days after the surgery and compared with a baseline value ( preoperative value ) , while the esr should be checked 12 days after the surgery .
there has been a reported case of spondylodiscitis following cervical nucleoplasty : in theat case , the complication was detected 3 weeks after the procedure . in our case ,
outpatient follow - ups were performed 9 days and 8 weeks after the operation . during the first visit ,
in our case , neither the infection nor the procedure itself increased the esr and crp .
further research is needed to clarify the changes of the inflammatory marker after nucleoplasty . at the second visit ,
the crp was checked and was identified to be within the normal range . during the 8-week postoperative follow - up , we could not find any abnormalities in the laboratory tests even when the mri showed apparent infection .
bavinzski et al . reported a series of 13 patients with postoperative disc space infection .
all patients suffered from severe local lumbar pain with muscle cramps and radiating pain to the hips , abdomen , legs , scrotum , groin , or perineum .
many patients were unable to stand , with the pain exacerbated by motions of the spine segments . in a recent review article ,
the typical course of spondylodiscitis is the return of low back pain approximately six weeks later .
similar to the previous studies , our patient also complained about pain being aggravated by motion and local tenderness around the infection site about 8 weeks after the spinal procedure .
therefore , clinicians should be careful if patients complain of aggravated pain about 6 weeks post - operation , while additional studies are required to diagnose the infection .
if there is no neurologic or structural instability , it is recommended that antimicrobial therapy should be withheld until positive identification of the organism is achieved unless back pain is accompanied by systemic symptoms .
however , in our case , the infection was identified at the site of nucleoplasty 2 months later , and the patient 's symptoms were aggravated .
therefore , the infection was considered to be a procedure - related problem and empirical antibiotics therapy was initiated .
surgical intervention is recommended in cases of impending pathologic fractures , functionally significant neurologic deficits , paravertebral or epidural abscess formations , persistent septicemia despite antibiotic treatment , intractable pain , and unacceptable saggital or coronal plane deformity .
we postulate that the pathogen may be sequestrated from the blood stream completely , therefore , systemic inflammatory changes were not triggered , or the immunity of this patient ( 33 year - old man ) was strong enough to overcome the dispersion of the pathogen . for detecting postoperative discitis , mri is the imaging method of choice , with its high sensitivity and specificity .
mri is considered to be the most sensitive and specific method , 93% and 97% , as reported . furthermore , mri is the gold standard for diagnosing spondylodiscitis . in conclusion ,
therefore , an mri should be taken when there is clinical suspicion of infection in order to not miss the complications after interventional procedures , even if the laboratory findings were normal .
 infective spondylodiscitis is a rare complication that can occur after interventional spinal procedures , of which symptoms are usually back pain and fever 
 . early diagnosis of infective spondylodiscitis is critical to start antibiotics and to improve prognosis . 
 laboratory examinations including complet blood cell count ( cbc ) , erythrocyte sedimentation rate ( esr ) , and c - reactive protein ( crp ) are conventional tools for the early detection of infectious spondylitis . 
 however , we experienced infective spondylodiscitis after cervical nucleoplasty which did not display any laboratory abnormalities , but was diagnosed through an mri . 
 a patient with cervical disc herniation received nucleoplasty at c5/6 and c6/7 . 
 one month later , the patient complained of aggravated pain . 
 there were neither signs of chill nor fever , and the laboratory results appeared normal . 
 however , the mri findings were compatible with infectious spondylodiscitis at the nucleoplasty site . in conclusion , 
 infectious spondylodiscitis can develop after cervical nucleoplasty without any laboratory abnormalities . 
 therefore , an mri should be taken when there is a clinical suspicion for infection in order to not miss complications after interventional procedures , even if the laboratory findings are normal . 