CERVICAL FACET JOINT SEPTIC ARTHRITIS: A CASE REPORT
James M. Stecher, MD; Georges Y. El-Khoury, MD, Patrick W. Hitchon, MD
Abstract
Facet joint septic arthritis is a rare but severe
infection with the possibility of significant morbid-
ity resulting from local or systemic spread of the
infection. Pain is the most common complaint on
presentation followed by fever, then neurologic
impairment. While the lumbar spine is involved
in the vast majority of cases presented in the
literature, the case presented here occurred in
the cer vical spine. The patient presented with a
three week histor y of neck and left shoulder pain
and was diagnosed by MRI when his pain did not
respond to analgesics and muscle relaxants. The
only predisposing factor was a histor y of diabetes
mellitus and the infection most likely resulted from
hematogenous spread. MRI is highly sensitive in
diagnosing septic arthritis and it is the preferred
modality for demonstrating the extent of infection
and secondar y complications including epidural
and paraspinal abscesses as seen in this case.
Without familiarity with this entity’s predisposing
factors, clinical symptoms and appropriate lab/
imaging work up, many patients experience a
delay in diagnosis. Treatment involves long term
parenteral antibiotics or percutaneous drainage.
Surgical debridement is reserved for cases with se-
vere neurologic impairment. The incidence of facet
joint septic arthritis is increasing likely related to
patient factors (increasing number of patients >50
yo, immunosuppressed patients, etc), advancement
in imaging technology, availability of MRI, and
heightened awareness of this rare infection which
is the aim of this case presentation.
Introduction
Septic arthritis of the facet joint is a rare clinical entity
with a similar clinical presentation to spondylodiscitis.
Septic arthritis most commonly affects the larger periph-
eral joints and rarely the facet joint, however many of
the same principles apply regarding predisposing factors,
clinical presentation, lab/imaging work up and treatment
modalities. Without appropriate diagnosis and treatment,
infection can spread to adjacent structures resulting in
Department of Radiology, University of Iowa
Department of Orthopaedics and Rehabilitation, University of Iowa
182    The Iowa Orthopaedic Journal
abscess formation, spinal cord/nerve root impingement
and sepsis. Two retrospective reviews of case reports in
the literature found that septic arthritis of the facet joint
causes 4-20% of pyogenic spinal infections, the average
patient age is 55-59 and the overwhelming majority, 86-
97%, occur in the lumbar spine.1,2 While most cases are
thought to occur via hematogenous spread, there are a
number of case reports in the literature where septic
arthritis of the facet joint resulted from iatrogenic causes
including corticosteroid injection3-7 and epidural catheter-
ization.8,9 These infections can also occur secondary to
spread from adjacent infections such as spondylodiscitis,
epidural or paraspinal abscess, psoas muscle abscess
or other intraabdominal infections. MRI has become
the imaging modality of choice for diagnosis and de-
termining extent of the infection. Timely and accurate
diagnosis of septic arthritis of the facet joint followed
by definitive therapy of this entity requires a multidis-
ciplinary approach. Most cases are treated with up to 6
weeks of parenteral antibiotics, percutaneous drainage
or open debridement depending on clinical symptoms
and severity. While most patients typically experience
some delay in diagnosis, the majority of patients fully
recover or experience mild residual pain/neurologic
sequela following appropriate therapy.1
Case presentation
The patient is a 57 year old male with a past medical
history significant for type 2 diabetes mellitus who pre-
sented to an outside hospital with a three week history
of left shoulder and neck pain after a trial of analgesics
and muscle relaxants did not improve his symptoms. The
patient was afebrile with no focal neurological deficits on
physical exam. He had a normal white blood cell count
with elevated Erythrocyte Sedimentation Rate (ESR) of
91 (normal 0-15 MM/HR) and C-reactive protein (CRP)
of 3.2 (normal <0.5 Mg/Dl). Cervical spine MRI revealed
left C5-C6 facet joint septic arthritis with extension of the
infection into the paraspinal musculature, prevertebral
soft tissues and epidural space with abscess formation
and spinal canal narrowing. (Figure 1, Figure 2, and
Figure 3).
The patient was then transferred to the University of
Iowa for further care. He was started on IV Vancomycin
and Ceftriaxone. Cultures from a CT guided aspiration
(Figure 4) revealed Staphylococcus aureus as the caus-
ative agent. As the patient had no neurolgic deficits,
 Cervical Facet Joint Septic Arthritis: A Case Report

A
B
Figures 1A, B. Contiguous axial T2 weighted MR images at C5-6. There is high T2 signal in the left facet joint space with adjacent bony destruc-
tion. Both images show fluid collections in the paraspinous tissues consistent with abscess (white arrows). Figure 1A shows direct extension
of the infection into the epidural space (arrowhead) with abscess formation.

Figure
2A

Figure
2C

Figure
2B

Figures 2A-C. Two contiguous axial (A and B) and a coronal (C) T1 weighted fat saturation post gadolinium images. Figure 2A shows bony
destruction at the left C5-C6 facet joint with extension into both the epidural space and bilateral paraspinal soft tissues. Figure 2B shows
paraspinal abscess formation (white arrow) and enhancement extending anteriorly into the prevertebral soft tissues. Figure 2C shows direct
extension of the paraspinal abscess from the level of the left C5-C6 facet (black arrow).

Volume 30    183

J. M. Stecher, G. Y. El-Khoury, P. W. Hitchon

A B
Figures 3A, B. Sagittal T2 weighted images in the midline and left of midline. Figure 3A shows the epidural abscess (white arrow) with pos-
terior mass effect on the cer vical spinal cord at C5-C6. Figure 3B demonstrates the paraspinal abscess and adjacent high T2 signal in the
musculature consistent with inflammation.

Figure 4. Axial CT scan in bone windows at the time of CT-guided

aspiration shows sclerosis, erosions and facet joint space widening
at the left C5-C6 facet joint (white arrow).

184    The Iowa Orthopaedic Journal


negative blood cultures and no signs of sepsis, he was
placed on IV Vancomycin for 6 weeks followed by two
weeks of oral Linezolid by the Infectious Disease ser-
vice. The patient remained afebrile, his pain subsided
and the ESR and CRP returned to normal within a few
weeks. Six week follow up MRI showed resolution of
the abscesses and decreased soft tissue enhancement.
There was no evidence of infection on the six month
follow up study as well.
Discussion
Septic arthritis is most commonly secondary to a
bacterial infection with less common, more indolent
infections resulting from fungal or mycobacterial causes.
Predisposing factors include elderly patients, diabetes
mellitus, immunosuppressed patients, rheumatoid ar-
thritis, skin infection, IV drug abuse, and previous joint
manipulation including joint prosthesis, recent joint sur-
gery and intra-articular corticosteroid injections.10 Septic
arthritis is caused by hematogenous spread (where the
presenting sign can be bacterial endocarditis), direct
inoculation of the joint from corticosteroid injection, sur-
gery or trauma, or from spread of adjacent infection into
the joint space. One retrospective review of 191 cases of
septic arthritis found that 72% of cases were thought to
arise from hematogenous spread.11 The majority of cases
in adults is caused by Staphylococcus aureus and occur
in the larger peripheral joints including knees, wrists,
shoulders, elbows, ankles and hips. Smaller joints are
rarely affected including the sternoclavicular joint, sac-
roiliac joint, pubic symphysis and the spinal facet joint.
One or more predisposing factors was seen in 38-58%
of patients diagnosed with facet joint septic arthritis with
the most common being concomitant infection and im-
munosuppression (most notably diabetes mellitus, liver
disease, transplant patients, long-term corticosteroid use
and malignancy).1,2 Another predisposing factor is under-
lying joint disease which is reportedly found in almost
50% of cases of septic arthritis.12 Related to underlying
facet disease, there was a retrospective study where
209 consecutive lumbar spine MRIs were reviewed re-
gardless of patient history or clinical indication which
revealed that 41% of patients were found to have facet
synovitis based on signal abnormality within the joint
capsule and peri-articular region.13
A high index of suspicion is needed to prevent a delay
in diagnosis and therapy. Mean time from symptom onset
to diagnosis has been reported to be 36-43 days with a
large range from 2 days to 6 months.1,14 This delay in
diagnosis can result in increased patient morbidity and
highlights the need for consideration of this disease in
the differential diagnosis of patients presenting with
neck/back pain, fever and with any of the risk factors
Cervical Facet Joint Septic Arthritis: A Case Report
discussed above. Further evaluation includes lab work up
(white blood cell count, ESR, CRP, and blood cultures)
followed by appropriate imaging studies.
Plain radiographs are not sensitive in diagnosing early
disease as radiographic findings may not be evident
for weeks to months following onset of symptoms.1,14-18
However there are a few reports where facet joint space
widening suggesting joint pathology was noted at 4 and
21 days after onset of symptoms.14,15 Radionuclide studies
including Technitium-99m MDP bone scan, Gallium-67,
and In-111 labeled white blood cell scans have shown
very high sensitivity for this entity as early as one week
after onset of symptoms.2 Tc-99m MDP bone scan can
be helpful for assessing osteoblastic activity or bony
remodeling secondary to infection. However, the low
specificity of this test limits its utility in diagnosing septic
arthritis. Ga-67 and more recently In-111 are being used
to evaluate for infection/inflammation with very high
sensitivity, more specificity than Tc-99m bone scans and
improved spatial resolution with the implementation of
SPECT and co-registered SPECT-CT images.
Non-contrast CT is able to show joint space widening,
pre-existing joint disease, bony erosions and either a fluid
collection or soft tissue air that could suggest abscess
formation. CT is also very helpful for establishing the
diagnosis via obtaining synovial fluid for isolation of the
organism and for drainage of the affected joint. MRI
is the imaging modality of choice for diagnosing facet
joint septic arthritis due to its high sensitivity, specificity
and soft tissue contrast.15-17,19,20 MRI is also essential for
therapeutic planning.
Soft tissue gadolinium enhancement may be seen
on MRI within 2 days from the onset of symptoms.17
Reportedly 81% of cases show epidural and/or paraspi-
nal extension of the infection,1 and MRI is superior at
demonstrating extension into the epidural or disc spaces,
paraspinal soft tissues, vertebra and abscess formation.
Many case reports of facet joint septic arthritis are as-
sociated with epidural or paraspinal abscesses.1,2,5-8,15,19-23
It may be difficult to distinguish on imaging whether
the infection started in the facet joint or if the infection
spread to the facet joint. Some authors have postulated
that the incidence of this infection may be underesti-
mated if the infection decompresses into the surrounding
paraspinal tissues or epidural space prior to diagnosis.17
Facet joint septic arthritis should be considered when
a patient presents with back pain, fever and elevated
inflammatory markers (ESR and CRP), however the
presentation and at risk populations are nearly identical
to that of spondylodiscitis. Over 90% of patients present
with pain, roughly 75% present with fever and about 33-
50% present with neurologic symptoms. Facet joint septic
arthritis may be suspected in patients with unilateral
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J. M. Stecher, G. Y. El-Khoury, P. W. Hitchon
symptoms or when there is a more rapid symptom pro-
gression (4 weeks) compared to the typical presentation
of the more common spondylodiscitis (2-3 months).2
Other differential diagnosis considerations include
non-pyogenic infection such as Tuberculosis, degenera-
tive or inflammatory arthritis and malignancy. Lytic or
destructive lesions involving the posterior elements are
most often neoplastic in etiology. One retrospective study
using CT to determine infection vs. tumor in the spine
noted that severe neurological impairment was more
common with spinal infection (39%) than tumor (14%).24
Complications of septic arthritis of the spinal facet
joint include chronic pain, joint/bony destruction,
pyomyositis, abscess (epidural, psoas muscle and
paraspinal), neurologic sequelae, spondylodiscitis, en-
docarditis, meningitis, septic emboli and rarely death.
In one review of 42 patients excluding cases involving
pediatric patients, IV drug users and prior surgical in-
strumentation/surgery, the most severe complications
were paraplegia in one patient and death during surgery
in another patient.1 The majority of patients in the case
reports recovered fully or had minimal residual pain
following treatment.
Patients are typically treated with long-term (at least 6
weeks) parenteral antibiotics followed by oral antibiotics
or a combination of percutaneous drainage and long-
term antibiotics. Open arthrotomy and surgical drain-
age/debridement is typically reserved for the patient
with infection refractory to antibiotic trial or with acute
neurological compromise. MRI is less helpful in assess-
ing for treatment response as soft tissue enhancement
can persist following clearance of infection. Treatment
response can be assessed using the patient’s subjective
improvement in symptoms and improvement in inflam-
matory serum markers.
In conclusion, septic arthritis of the facet joint is an
uncommon infection that requires a high clinical sus-
picion for accurate and timely diagnosis. This infection
shares many features with septic arthritis in the more
commonly affected large peripheral joints as well as with
spondylodiscitis. The incidence of this entity is increas-
ing and MRI will continue to play an important role
in diagnosis and surgical planning. Lastly, while most
patients recover with little or no neurologic sequlae,
prompt diagnosis and definitive therapy are essential for
decreasing patient morbidity and mortality.
186    The Iowa Orthopaedic Journal
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