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Septic Ischial Bursitis in Patients with Spinal Cord Injury

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Septic Ischial Bursitis in Patients with Spinal Cord Injury Paraplegia 30 (1992) 200-203 © 1992 International Medical Society of Paraplegia Septic ischial bursitis in patients with spinal cord injury S Rubayi MD FICS,l J Z Montgomerie FRACP2 1 Pressure Ulcer Management Service, Department of Surgery, Rancho Los Amigos 2 Medical Center, Downey, California 90242, USA; University of Southern California School of Medicine, Los Angeles, California 90033 and Infectious Disease Division, Department of Medicine, Rancho Los Amigos Medical Center, Downey, California 90242 USA. Septic ischial bursitis is described in 4 patients with spinal cord injury. In these patients a pre-existing ischial bursitis probably became secondarily infected. Because these patients lack sensation, diagnosis may be difficult. The disease process in one patient with a prolonged fever was only recognized after a leucocyte scan detected an abscess extending to the thigh. At surgery it was found that the infection extended from the ischial bursa to the upper lateral thigh. Infection in these patients was due to beta hemolytic streptococcus,l S. aureus ,1 and S. epidermidis. 2 The patients all responded well to local drainage and excision of the bursa. Key words: septic ischial bursitis; spinal cord injury. Introduction admission to the hospital her physical exam­ Ischial bursitis (also known as Weaver's or ination was consistent with T4/T5 paraple­ Tailor's bottom), a disease that has been gia with no other abnormalities and investi­ associated with trauma from sitting for long gations at that time showed a leucocytosis periods of time, is usually associated with (WBC 21,000 x 109/L). A urine specimen E. perianal pain. 1 Ischial bursitis is not uncom­ cultured coli, but this was not felt to be mon in patients with spinal cord injury2 the source of the fever. A leukocyte scan where it may be a significant component of showed increased activity in the medial ischial pressure ulcers.3,4 These ulcers may aspect of the right hip. Repeat physical not heal without excision of the bursa, and examination of the area did not show the bursa may recur after musculocutaneous swelling or erythema. Ultrasound of the flap surgery. area showed an abscess. Aspiration and In those patients without pressure ulcers culture of the abscess was positive for beta the problem may not be recognized because hemolytic streptococcus. A large abscess patients with spinal cord injury lack sensa­ extending from the lateral mid thigh to the tion. We recently treated a patient with ischial tuberosity was drained and the spinal cord injury who appeared to have an wound left open, and she had systemic ischial bursitis that became infected and antibiotics. Drainage from the wound con­ presented with a fever of unknown origin. tinued for 2 months and at further surgery a We describe this patient and 3 additional very large ischial bursa extending under the patients with spinal cord injury and infected gluteal muscle and inferiorly over the ischial bursitis. hamstring muscle and laterally to the greater trochanter area was found, and was excised. The wound was closed without any Case 1 flap procedure and healed without compli­ This 29 year old female T4/T5 paraplegic cation. was injured in 1975, and had competed in wheelchair racing for many years. Apart Comment from a recent pharyngitis she had been well We believe that the ischial bursitis deve­ until she developed a fever (102-103°F). On loped as a result of the wheelchair racing Septic ischial bursitis 201 and was not detected because of lack of Comment sensation and lack of local swelling or This patient developed ischial bursitis asso­ redness. The bursa may have become in­ ciated with obvious swelling over the ischial fected with the beta hemolytic streptococcus tuberosity over 2 years. Although S. epider­ at the time of the pharyngitis, a few days midis was cultured at the time of surgery, before the patient developed a high fever. there was no other evidence of infection. Even after the infection was detected in the thigh by leucocyte scan, the extensive in­ fected bursa could not be detected on Case 3 physical examination. Only at the time of This 28 year old female, with T12 complete surgery was it recognized that the infection traumatic paraplegia, developed a swelling had originated in the ischial bursa. The over the left buttock area a few weeks drainage persisted for over 2 months, and following a fall and injury to her buttock. discontinued only after the bursa was exc­ The patient denied fever and chills. On ised. physical examination there was fluctuating swelling over the left ischial region. Fluid aspirated from the swelling was Case 2 turbid and red in color and contaned This 42 year old male, a T6 traumatic 3.7 x 1-10/L RBC and 0.9 x 109/LWBC. S. paraplegic, developed a swelling over the epidermidis was cultured from the aspirate. left ischial region which gradually increased The peripheral WBC count was 6.3 x 109/L in size over 2 years. There was no history of with normal differential. The bursal swelling fever and chills or previous skin breakdown. was surgically excised and this defect was Clinical examination revealed a soft fluctu­ closed with a gluteus maximus muscle rota­ ating mass over the ischial region, about 6 x tion flap. The patient was treated with 8 cm in size (Fig 1). X-rays of the pelvis and cefazolin for 7 days. hip joint were within normal limits. A Histology of the bursal tissue showed clinical diagnosis of ischial bursitis was made synovitis with mild chronic and acute in­ and the bursa was surgically exposed flammation. Bone histology showed no through the lower gluteal muscle approach. evidence of osteomyelitis. The wound Complete excision of the bursa was followed healed completely without complication. by a rotation flap using the lower portion of the gluteus maximus muscle. Cultures from the bursal cavity grew S. epidermidis and Comment histology of the bursa showed chronic syno­ Injury with or without hematoma may also vitis. Bone biopsy from the ischium showed precede septic bursitis at other sites such as normal bone histology. The wound healed olecranon and prepatellar bursae. completely without further problems. Case 4 This patient was an 18 year old male with low level myelomeningocele and a long standing history of right ischial ulcer, tre­ ated with a gluteus maximus flap that was revised one year later. Three weeks after discharge from the hospital he was read­ mitted with a history of fever of 102 OF and swelling in the right ischial region of one day duration. On examination, a fluctuating swelling over the right ischial region in the previous flap scar was seen. Pus that was Figure 1 Large mass over left ischial tuberosity aspirated cultured S. aureus. The peripheral of patient (Case 2). WBC was 10.6 x 109/L. The swelling was 202 Rubayi and Montgomerie drained surgically and antibiotics were given ischial bursitis. Infection of the ischial bursa for 14 days. The bursa was then excised has been described in a patient with sys­ completely and the wound closed by ad­ temic lupus erythematosus.6 A large ischial vancement of the old flap. The ischial bone bursa secondarily infected with tuberculosis biopsy taken for histology showed no evi­ that involved the ischium was described by dence of osteomyelitis, and cultures were Chafetz et al . 7 negative. The wound healed completely We have described 4 patients with in­ without complication. fected ischial bursitis. The 2 patients with positive cultures for S. epidermidis had limited evidence of infection other than Comment inflammatory changes on the histopath­ This is the more common presentation of ology. ischial bursitis after an ischial pressure The bacteria isolated from the infected ulcer. Although he had previous surgeries bursitis in our experience (Streptococcus with removal of the bursal sac, it had hemolyticus, Staphylococcus epidermidis redeveloped and became infected after and Staphylococcus aureus) were similar to myocutaneous flap surgery. microorganisms isolated from septic bursitis elsewhere in the body8-JO and were different from the bacteria isolated from patients with Discussion infected pressure ulcers. Shea2 described the pathogenesis of ischial Managing ischial bursitis depends on the bursitis in patients with spinal cord injury, clinical presentation. If the patient presents and called it the closed pressure ulcer. with gluteal swelling, diagnostic aspiration Ischial bursitis is seen mainly in the thin of the bursa should be done. Surgery com­ patient with prominent ischial tuberosity or prises exploration of the bursa. Surgical pelvic deformity. Sitting for long periods of drainage of the bursa should be done in the time with excessive shearing forces over the gluteal crease to help further closure with ischial area predisposes to bursal develop­ myocutaneous flap. The patient should be ment. In patients with normal sensation the treated with appropriate antibiotics. Later, main clinical features are buttock pain that when the infection subsides completely, may radiate down the leg,1 pain that is excision of the bursa and closure with aggravated by sitting, and tenderness and gluteus maximus myocutaneous flap can be swelling over the ischial tuberosity. The done. If the ischial tuberosity is found to be tender bursa may be felt in the lateral wall involved, a bone biopsy may be obtained to on rectal examination. The bursa can reach exclude osteomyelitis. Osteomyelitis of the an enormous size; an enlarged bursa weigh­ ischial tuberosity, however, can usually be ing 2lbs was removed surgically in 1932.5 managed by local debridement, and does Ischial bursitis may be a diagnostic prob­ not require long courses of antibiotics. II lem in patients with spinal cord injury Many disorders including abdominal dis­ because they lack sensation. Comarr3 and eases12 and spinal osteomyelitis 13 may be Constantian4 described the existence of difficult to diagnose in patients with spinal atypical ischial bursa with ischial ulcer.
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