Post-Radiotherapy Osteomyelitis: A Devastating Complication Requiring a Multidisciplinary Approach

Purpose: Osteomyelitis of the cervical spine and skull base are rare, devastating complications of radiotherapy for head and neck cancer. The study evaluated patient characteristics, risk factors and described the disease course and management. Material and methods: A clinical case series from a tertiary cancer center. We conducted a retrospective review of the medical files from 2012 to 2021, including clinical characteristics, treatment, and outcome data. Descriptive statistics were applied. Results: Nine patients (78% male) with post-radiation cervical osteomyelitis were reviewed. Median patient age was 68 years. The maximal radiation dose was 61.71Gy. The mean delay in diagnosing osteomyelitis was 6.32 years from the first radiotherapy course and 2.9 years from the last period. Sites affected were the cervical vertebrae (6 patients) and the clivus, clavicle, and sternum (1 patient each). The main symptoms were dysphagia and cervicalgia (55%). A medical or surgical event preceded the diagnosis in 6 patients (66%) by a mean of 51.33 days. Common imaging findings were free to air within the cervical structures and fluid collection. Cultures grew mainly typical polymicrobial flora. Treatment consisted of surgery and antibiotics or long-term broad-spectrum intravenous antibiotics alone. Eight patients have recovered from osteomyelitis during the follow-up within an average of 100 days. Five patients have died during the follow-up period. Conclusion: Post-radiation osteomyelitis is characterized by a subtle presentation, challenging diagnosis, prolonged treatment, and poor outcome. Clinicians should maintain a high index of suspicion for the long term after radiotherapy. Multidisciplinary evaluation and management are warranted.