Vertebral Body Avascular Osteonecrosis: An Unusual Late Complication of Tracheostomy

Vertebral body erosion is a rare late complication of tracheostomy. Here we present the case of a 30-year-old female patient, in a vegetative state after severe brain injury, with a permanent tracheostomy and prolonged mechanical ventilation, who suffered from recurrent episodes of severe air leakage with oxygenation drop due to a puncture in the tracheostomy tube cuff. A neck computed tomography (CT) detected destruction of two vertebral bodies, C7 and Th1, and a bony fragment - a remnant of C7 penetrated the trachea and probably repetitively punctured the inflated cuff. A biopsy of the C7 vertebral body was performed under CT guidance to rule out osteomyelitis. The biopsy revealed necrotic bone spicules surrounded by vascular-rich fibrous tissue, without evidence of inflammation. C7 vertebral body avascular osteonecrosis was diagnosed. The case highlights the importance of monitoring cuff pressure during long-term use of cuffed endotracheal tubes to avoid hyperinflation and subsequent ischemic complications.