Purpose or Case Report: Odontoid osteomyelitis is a rare disease in children. As the condition is not commonly known, children are frequently initially misdiagnosed with torticollis and treated symptomatically, leading to delayed diagnosis. We present two illustrative cases of odontoid osteomyelitis and a literature review summarizing clinical presentation, risk factors, diagnostic methods, radiological findings and therapies of all previously reported cases.
Methods & Materials: A literature review was performed using Medline, Embase and Web of Science (1950 to September 2015) using the search terms ‘odontoid osteomyelitis’ or ‘osteomyelitis odontoid peg’ or ‘dens osteomyelitis’ or ‘vertebral osteomyelitis’. References were hand-searched for additional articles. Only cases of patients with odontoid osteomyelitis and sufficiently detailed description of clinical presentation, diagnostic methods and therapies were included.
Results: In the cases reviewed, the mean age at presentation was 23 months (range 1 - 84). Children usually presented in good general condition with no fever. Most common radiological findings include bone destruction of the odontoid and prevertebral soft tissue swelling on computed tomography (CT). Magnetic resonance imaging (MRI) can show edematous signal alterations within the odontoid and adjacent joint spaces as well as enhancing abscesses in surrounding soft tissues. The most common symptoms were reduced head movement or neck stiffness. While the white blood cell count (WBC) or C-reactive protein (CRP) was normal or only mildly elevated, the erythrocyte sedimentation rate (ESR) was commonly elevated. Even though the mean duration from the initial presentation to the time of the diagnosis was 27 days (range 0 - 90), patients showed a favourable outcome either under antibiotic treatment only or additional surgical intervention.
Conclusions: Odontoid osteomyelitis should be considered in children presenting with decreased head movement and an elevated ESR, especially without improvement under anti-inflammatory therapy. History of a trauma may be misleading. Even MRI- and CT- findings may be subtle and difficult to differentiate from non-ossified cartilaginous parts of the atlas and axis, variants of synchondroses, and osseous gaps. In most cases plain radiographs are not reliable enough. Thus evaluation should include CT or MRI. A delay in diagnosis may lead to destruction of the vertebral bodies, subluxation of the atlanto-axial joint or cervical cord compression.