Cervical spondylosis is a disease in which degenerative changes in the cervical spine cause compression of the spinal cord, resulting in degeneration and necrosis of neuronal cells and a series of symptoms of nerve damage. 13–15The frequently accompanying organic changes are cervical disc herniation, synovial joint hyperplasia, and ossification of the posterior longitudinal ligament. Single-opening spinal decompression stabilizes the cervical spine on the basis of increasing the volume of the spinal canal, with an open surgical view and less risk of spinal nerve injury. 3,16,17Large samples of reports on infections after single-opening spinal decompression studies alone are rare, and most also focus only on infections associated with posterior cervical spine surgery.
Risk factors associated with posterior cervical spine infection include obesity (BMI > 35), steroid use, poor glycemic control, fusion surgery or not, prolonged surgery, etc. 3,9,10,18−20In the case we reported, the patient did not have the associated risk factors mentioned above. However, associated with predictable late wound infection was the presence of abnormal postoperative drainage. Swelling of the drainage bag was associated with subcutaneous pneumatization. However, how the subcutaneous pneumatization occurred is controversial. The more convincing multidisciplinary diagnosis is the tracheal injury caused by intubation. During tracheal intubation in general anesthesia surgery, there may be no significant abnormalities in the airways injured by balloon compression. But after postoperative extubation, there is a risk that the gas will spill out of the injured leak and spread around along the loose tissue. In fact, intubation-related tracheal injury is indeed a relatively rare but very serious complication of iatrogenicity, with reports of a 0.005% incidence of airway injury in a single luminal canal and a 0.05–0.19% incidence of double luminal canal injury.21–26 The clinical presentation of most patients is mainly subcutaneous emphysema in the chest and neck, or in more severe cases, leading to mediastinal emphysema, pneumothorax or even respiratory failure. In this case, the patient underwent a tracheal intubation adjustment in the prone position after preoperative intubation due to unsatisfactory positioning, and most of the intubation process was completed in the supine position. Because of the cervical spine surgery performed in this case, gas could escape through the posterior incision, thus avoiding the possibility of mediastinal emphysema and respiratory failure, which are potentially life-threatening complications.
Postoperative infection is not difficult to diagnose by typical local symptoms, CT/MRI of the neck, laboratory tests including erythrocyte sedimentation rate, C-reactive protein, white blood cell count, etc. But before debridement, we also performed a gastrointestinal contrast to rule out the presence of an esophageal fistula. In fact, esophageal injuries are not uncommon in posterior cervical fusion surgery, but are a rare complication in single-door spinal decompression because the screws we choose are only 5 mm or 7 mm, which is not penetratable for both the lamina and the vertebral body, let alone puncture the esophagus in front of the vertebral body.27,28
Some articles believe that the use of vancomycin in the fixed area can effectively prevent the occurrence of infection, and the local use of infection can also play an anti-infective role, but considering the large amount of drugs used and the cost of the problem, we finally chose the aminoglycoside amikacin as a substitute.29,30 Although we performed a second debridement later, rinsing with dilute amikacin saline still provided a great help for this difficult-to-control surgical area infection. After the second debridement, we used a skin tractor that provided a simple means of mattress suturing, including vertical mattress sutures and horizontal mattress sutures. Sinus tracts appear at the lower pole of the wound after the second debridement, but after subsequent operations of continuous removal of secretions to ensure that the wound is bright red, the sinus tracts can heal slowly. But it's really a rather long process.
Overall, our case suggests that more attention should be given to cervical wounds and drainage, and early identification facilitates rapid postoperative recovery. In cases where there is a possibility of airway injury, tracheoscopy should be scheduled early, which may prevent the subsequent presence of other side injuries due to tracheal leakage. Flushing the wound with diluted antibiotic fluid is beneficial for infection, and for identifying the lesion of infection, early debridement is undoubtedly the best way to control infection.