Ulceration and Alopecia of the Scalp Owing to C2 Radiculoneu
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Cutaneous ulcerations of the scalp are infrequent and pose a diagnostic challenge. Infectious origins, malignant diseases, vasculitides, neutrophilic dermatoses, and trigeminal trophic syndromes should be considered.1 This report describes a patient with alopecia and an ulcer in the occipital region of the scalp, which developed following atlanto-axial fixation surgery of the cervical spine resulting in C2 nerve dysfunction. Cutaneous complications of atlanto-axial fixation surgery have been so far underreported in the dermatological and the orthopedic literature.

A man in his 50s presented with alopecia and an ulcer involving the occipital region that had developed over 1 year. The patient had a 30-year history of ankylosing spondylitis. Because of progressive deformities, he underwent a series of posterior cervical spine decompression procedures and laminectomies. This included an atlanto-axial fixation to achieve fusion at the C1-C2 level. The patient subsequently complained of localized numbness in the occipital area. On examination, within the occipital region there was an area of alopecia measuring 6 × 8 cm centered by an ulceration measuring 3 × 6 cm, and its base was covered by an adherent yellowish fibrinous exudate (Figure, A). There was sensory loss with substantial hypoalgesia of the occipital parietal area that was 12 cm wide, ascending para medially from the subocciput to the vertex, corresponding to the C2 dermatomes.

Histological examination revealed a superficial dermal ulceration covered by cellular debris, and fibrinoid necrosis was observed. There was total loss of hair follicles and dermal fibrosis. Microbiological examination results with cultures from a skin biopsy for bacteria, fungi, and mycobacteria were negative. Full blood cell count and liver and renal function test results were within normal range. The C reactive protein levels were 26 mg/L (normal, <20 mg/L). Serologic test results for syphilis and hepatitis B, C, and HIV infections were negative. The patient underwent debridement of the ulcer (Figure, B), received a moisture-retentive dressing, and took offloading measures to avoid pressure. There was an improvement within 4 weeks with wound cleaning measures, but at 5-month follow-up there was only partial epithelial coverage of the wound (Figure, C).

The treatment of radiculopathic ulcers is challenging, as in the present case. Barrier wound protection, pressure offloading, cellular therapies, and other advanced wound care technologies are indicated. For neuralgia, specific therapies can be given, such as gabapentin.

Source: https://jamanetwork.com/journals/jamadermatology/article-abstract/2737329