Thyroid storm following anterior cervical spine surgery for tuberculosis of cervical spine.

OBJECTIVE: The primary objective was to report this rare case and discuss the probable mechanism of thyroid storm following anterior cervical spine surgery for Kochs cervical spine.

INTRODUCTION

Thyroid storm or thyrotoxic crisis is a rare but severe and potentially life-threatening complication of hyperthyroidism (overactivity of the thyroid gland). We report a case of thyroid storm following anterior cervical spine surgery done for tuberculosis of C7 vertebra with very large anterior and posterior epidural abscess. This patient is 21-year-old girl, undergone surgery for C7 Kochs spine and landed in postoperative clinical picture suggestive of thyroid storm.

CASE REPORT

A 21-year-old girl was admitted in the hospital for neck pain, deformity of neck for last 6 months. Her neurological examination was normal except her poor mental function and anxiety or apprehensiveness. Her preoperative vitals showed pulse 120/min, blood pressure (BP) was normal. Routine laboratory was normal. Her magnetic resonance imaging and computed tomography cervical spine showed destruction of C7 [Figures 1 and 2] with very large anterior epidural abscess up to C2 and posterior C6C7 epidural granulation tissue [Figure 3]. She was planned for surgery, C7 corpectomy with C6D1 fusion done [Figures 4 and 5]. Postoperative she started getting fever and it was around 102 F, late evening she had pulse around 130/min, restlessness. Next morning her general condition deteriorated, she had hypotension, tachycardia (pulse 150/min), fever (temp 105 F), and difficulty in breathing with lowering of oxygen saturation. Thus in Intensive Care Unit, her BP was 50 systolic and needed ventilator. Subsequently, detail laboratory tests were carried out, reports are: Cortsol-14.12, adrenocorticotropic hormone-228 pg/ml, T3-3.41, T4-138, thyroid-stimulating hormone 0.11,[3] D-Diamer-1034 ng/ml, which was suggestive of thyroid crisis or storm. The severity of hyperthyroidism, thyrotoxicosis and thyroid storm can be assessed with the Burch and Wartofsky score, first introduced in 1993.[1] A score is derived from various clinical parameters (such as temperature, severity of agitation); a score below 25 excludes thyroid storm, 25-45 suggests impending storm, and above 45 is suggestive of thyroid storm. This patient had score 105 (temperature >104, coma, pulse >140, moderate basal rales, precipitating factor).

Figure 1

Magnetic resonance imaging cervical spine showing C7 destruction with very large anterior epidural abscess with posterior epidural granulation tissue with significant cord compression

Figure 2

Postoperative X-ray showing C6 to D1 fusion with plate and cage

Figure 3

Computed tomography cervical spine C7 Axial view showing destruction of body, right pedicle, facet, transverse process

Figure 4

Postoperative picture showing C6 to D1 anterior cervical plate

Figure 5

Computed tomography scan cervical spine showing C7 destruction with kyphosis

DISCUSSION

Thyroid storm is serious life threatening complication of hyperthyroidism. This young girl had subtle clinical features of hyperthyroidism before surgery, but underdiagnosed as she had tachycardia, anxiety and poor mental function, and because of poor socioeconomic status detail laboratory tests such as thyroid functions were not possible. During surgery for doing C7 corpectomy medial retraction of thyroid gland along with contamination of surgical area by cold abscess[2] might have precipitated thyroid storm due to acute rise in hormonal levels.[3] She was given systemic decompensation with supportive therapy, antiadrenergic drugs, corticosteroids, and subsequently neomercazole. She responded very well to the treatment. The diagnosis of thyroid storm must be made on the basis of suspicious but nonspecific clinical findings, rather than thyroid function testing. Serum thyroid levels are always elevated. Due to the high mortality it is of vital importance to initiate treatment as soon as diagnosis is strongly suspected. Delay in the implementation of the treatment, whilst waiting for the results of the biochemical tests will be associated with a greater risk of progression to death. Thyroid storm following surgery of anterior cervical spine for tuberculosis has not been reported.