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Iatrogenic spondylodiscitis

Case report and review of literature

EROL TAS¸DEMIROG˘LU, M.D., AHMET SENGÖZ, M.D., AND ERDEM BAGATUR, M.D. Neurosurgery and Orthaopedic Surgery Services, Istanbul Education Hospital of the Institute of Social Security, Istanbul, Turkey

Iatrogenic space infection is encountered following microsurgical discectomy, percutaneous laser disc decompression, automated percutaneous lumbar nucleotomy operations, and discography. The purpose of this paper is to present a case report and review the literature on the uncommon origins of pyogenic spondylodiscitis and to emphasize the significance of prophylactic antibiotic therapy following transrectal ultrasonography-guided needle biopsy of the prostate (TUGNBP). According to the authors, this is the first reported case of pyogenic spondylodisci- tis as a complication of TUGNBP in the English language literature.

KEY WORDS • pyogenic spondylodiscitis • vertebral osteomyelitis • complication

Hematogenous infections of the spine have been de- lower-back and leg pain for 4 weeks. Since January 5, scribed as , spondylodiscitis, , vertebral 2001, he had been unable to walk because of progressive pyogenic osteomyelitis, and epidural abscess. This varied lower-extremity weakness. His medical and surgical his- nomenclature creates confusion in those who read the lit- tories were unremarkable, except for the presence of poor- erature.23 In general, hematogenous pyogenic infection of ly controlled DM for 4 years and high serum PSA levels the spine has been referred to as either “spondylodiscitis” for 3 years. Because of the high serum PSA levels, he had or “pyogenic osteomyelitis.” Pure discitis has been en- undergone an uncomplicated TUGNBP in October 1998. countered rarely. Pyogenic spondylodiscitis is an uncom- The histopathological features were consistent with mon primary infection of the nucleus pulposus with sec- chronic prostatitis and adenomyomatous hyperplasia. Be- ondary involvement of the cartilaginous endplate and VB. cause the high serum PSA levels persisted he underwent a Its primary incidence represents only 2 to 4% of all cases second biopsy on December 5, 2000. At the time of the of bone infection and 8 to 16% of cases of hematogenous- biopsy procedure the patient was fasting because of ly spread osteomyelitis.42 Most cases occur in the lumbar Ramadan, the holy month for Muslims. After this second spine and, in fact, may occur spontaneously or following biopsy, he did not take the prophylactic antibiotic agents. some procedures, as outlined in Table 1. Iatrogenic inter- He had, however, taken the prophylactic antibiotics fol- vertebral disc space infection is encountered following lowing the first biopsy procedure. The day after the sec- microsurgical discectomy, percutaneous laser disc decom- ond biopsy, the patient experienced intermittent high fever pression,17 automated percutaneous lumbar nucleotomy,14 and fatigue. A urine analysis and hemogram showed and discography.22,38 hematuria and an increased white blood cell count (14,000 The purpose of this report is to review the literature for cells/ml), respectively. A week following the biopsy, his uncommon origins of pyogenic spondylodiscitis. started, became severe, and progressed to an unbearable level in just a few days. Two weeks after the biopsy he experienced bilateral groin pain and muscle CASE REPORT cramps in the lower extremities. During this period, the intermittent high fever persisted and he was treated for his History and Examination. This 53-year-old man was symptoms. admitted to the Neurosurgery Service on January 10, 2001 Four days before admission to our service, he began to suffering from severe back and leg pain and bilateral experience bilateral progressive lower-extremity weak- lower-extremity weakness. He had been experiencing ness. On neurological deterioration, he underwent MR im- aging of the lumbar spine with contrast enhancement. The Abbreviations used in this paper: DM = diabetes mellitus; MR = T1-weighted contrast-enhanced sagittal and axial MR magnetic resonance; PSA = prostate specific antigen; TUGNBP = images (Fig. 1) revealed spondylodiscitis with epidural transrectal ultrasonography-guided needle biopsy of the prostate; abscess at the L2–3 level together with L2–3 listhesis and VB = vertebral body. osteomyelitis of the L-2 and L-3 VBs. The epidural ab-

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TABLE 1 Literature review of cases involving pyogenic spondylodiscitis*

Authors & Year Incident

Kerdiles, et al., 1975 following translumbar aortography Bouvenot, et al., 1978 following spinal injury (L-1 fracture) Herbiere, et al., 1981 after insertion of Mobin-Uddin caval umbrella filter Baudrillard, et al., 1985 following embolization of extramedullary intraspinal arteriovenous fistula Fieve, et al., 1986 following translumbar aortography Griffet, et al., 1986 following lumbar puncture Brunet, et al., 1989 following tracheal intubation Durance, 1989 following urinary catheter placement Cabezudo, et al., 1990 following placement of percutaneous lumbo- peritoneal shunt for benign intracranial hypertension Cailleux, et al., 1991 following genital prolapse op (fixing uterus

to promontory of sacrum) Fig. 1. Axial (A) and sagittal (B) T1-weighted MR images of the MGH Case Records, 1991 following pulmonary op lumbar spine obtained with gadopentetate, revealing spondylodisc- Bogaert, et al., 1992 following infection of abdominal aortic itis with epidural abscess at the L2–3 level along with L2–3 listhe- graft sis and osteomyelitis of both the L-2 and L-3 VBs. The epidural Hummel, et al., 1993 after heart transplantation abscess at the L2–3 level caused compression of the dural sac and Marlier, et al., 1993 following colonoscopy L-3 nerve roots bilaterally. In addition, the infectious process ex- Schulze & Mayer, 1995 following stab wound & vertebral fracture tended into the paravertebral muscles at the same level and multi- Fonga-Djimi, et al., 1996 following perforation due to swallowed radiolucent foreign body ple microabscesses developed in both psoas muscles. Hamilton & Stambough, following transpedicular screw fixation 1996 Mascalchi, et al., 1996 following percutaneous femoral artery and he was discharged home with a thoracolumbosacral catheterization Eisenberger, et al., 1998 following renal transplantation orthosis on Day 8 postsurgery. At the 3-year follow-up Ortiz, et al., 1998 following allogenic bone marrow examination, he was neurologically intact and free of pain. transplantation Plubel, et al., 1998 after peridural infiltration w/ prednisolone DISCUSSION Kikuchi, et al., 1999 following femoral vein catheterization for hemodialysis We reported on a case of pyogenic spondylodiscitis van Ooij, et al., 1999 following removal of fishbone that occurred following a TUGNBP complication. This is Chiapparini, et al., 2000 following lumbar epidural anesthesia Junquera Crespo, et al., following prostatic biopsy the first reported case of discitis following a TUGNBP in 2000 the English language literature. Genitourinary infections Porter & Wray, 2000 following long-term antibiotic (tetracycline) are the most common coexisting infection in patients with therapy spinal osteomyelitis.50 In this report, pyogenic spondylo- Coapes & Roysam, 2001 caused by epidural catheter use * MGH = Massachusetts General Hospital. scess at the L2–3 level was compressing the dural sac and the L-3 nerve roots bilaterally. In addition, the infectious process extended into the paravertebral muscles at the same level, and multiple microabscesses developed in both psoas muscles. Because of chronic back pain, the patient underwent additional MR imaging studies of the lumbar spine 6 months before the second biopsy pro- cedure, which demonstrated only degenerative changes (Fig. 2). Operation and Postoperative Course. Because his low- er-extremity weakness progressively worsened, a right L2–3 hemilaminectomy, drainage of epidural and intradis- cal abscesses, and an L2–3 discectomy were performed. The disc material was soft and liquefied. Following surg- ery, he was able to walk without a cane. The culture and antibiogram of the infected disc material was positive for Escherichia coli. Intravenous ceftriaxone sodium (1 g twice daily) and gentamycin (160 mg/day) were adminis- tered immediately following sensitivity testing. On post- Fig. 2. Magnetic resonance image of the lumbar spine obtained 6 operative Day 7, the patient’s back and leg pain improved, months prior to biopsy, demonstrating only degenerative changes.

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Unauthenticated | Downloaded 10/01/21 04:13 PM UTC Iatrogenic spondylodiscitis discitis occurred following iatrogenic inoculation of the quences. Characteristic findings may occur 3 to 5 days bacteria into the prostate gland. Although genitourinary after the onset of symptoms. Following Gd injection ad- infections are the most common coexisting infections in jacent vertebral bone marrow, disc space, and posterior patients with pyogenic spondylodiscitis,4,40,47 the coexis- anulus fibrosus enhance. The MR imaging examina- 36 tence of spondylodiscitis and endocarditis and other in- tions of spondylodiscitis include T1-weighted sequences fections46 have also been reported. with and without paramagnetic contrast enhancement and

Pyogenic discitis has occurred due to urinary tract in- T2-weighted sequences. The T1-weighted image demon- fection,4 and acute bacterial prostatitis47 has been reported. strates an extension of soft tissue into the spinal canal, but Although pyogenic spondylodiscitis in the present case does not differentiate between granulation tissue and did not originate from primary prostate infection, it did purulent material. Nonetheless, T1-weighted images with occur after an iatrogenic bacterial inoculation into the Gd contrast reveal infection or granulation tissue as high- prostate gland by a needle passing through the highly con- intensity areas or a high intensity halo surrounding a cen- taminated rectum. Thompson, et al.,48 reported that bacter- ter of low intensity (abscess).33 emia develops in every patient after transrectal needle Staphylococcus aureus has been the most commonly biopsy: 27% of their patients demonstrated symptoms isolated pathogen in association with spondylodiscitis, and 87% had a urinary tract infection. A prophylactic an- followed by Streptococcus spp. and Gram-negative bacil- tibiotic regimen reduced the bacteremia rate to 53% and li.23,27 In one series multiple organisms involved 25% of prevented urinary tract infection. Although minor compli- the patients; however, polymicrobial infections did not al- cations following TUGNBP appear to be extremely fre- ter patient outcome. In our case, isolation of E. coli as an quent, major complications are rare.43 Most attention has originating agent is not surprising, because this bacteria is been given to the incidence of infectious complications. present in the gastrointestinal flora. Irrespective of the or- Rodriguez and Terris43 reported an infectious complica- iginating organisms, the histological features of pyogenic tion rate of 2.5%, and all patients were treated on an out- spondylodiscitis include vascular proliferation associated patient basis with no significant sequelae or they required with granulation tissue, myxoid degeneration, and vari- no treatment. Analysis of the literature indicates that a able acute and chronic inflammation.33 more prolonged course of antibiotic therapy decreases Antibiotic treatment usually involves 6 weeks of intra- the rate of infection following transrectal prostate biopsy. venous administration followed by 6 weeks of oral admin- In different series, by extending the prophylaxis for at istration. Therapy lasting less than 4 weeks in duration is least 4 days, the infection rate dropped to between 0 associated with a 25% relapse rate. Therapeutic failure and 0.8%.2,12,45 In our case, however, the patient refused to was defined as persistent or worsening symptoms plus take his prophylactic antibiotic drugs during the daytime elevated serum erythrocyte sedimentation rate and/or C- following the second TUGNBP because he was fasting reactive protein levels, or worsening imaging findings during the holy month of Ramadan. Following the first such as increased uptake of 67Ga on radionuclide scanning TUGNBP he had taken the prophylactic antibiotics and after a long course of antibiotic therapy. With appropriate did not experience any major or minor complication from treatment, relapse rates vary from 0 to 4%.23,27 the biopsy. The rate of sequelae in pyogenic spondylodiscitis var- Identified risk factors for the development of pyogenic ies from 25 to 45% of cases. Jiminez-Mejias, et al.,27 re- spondylodiscitis include increased patient age, liver dis- ported that only 45% of patients returned to work and ease, DM, , rheumatoid arthritis, daily normal activities. Most patients with pyogenic disci- trauma, ethanol abuse, intravenous drug abuse,32 other ini- tis, even those with associated epidural abscess, can be tial sites of infection,36,40,46 immunosuppression due to ster- successfully treated using intravenous antibiotics, bedrest, oid use, organ transplantation16,26 or infection with human and external immobilization. Nonetheless, a small subset immunodeficiency virus, and malignancy. Rheumatoid of patients (25%) will require surgery. This latter catego- arthritis, DM, advanced patient age, and steroid use also ry is characterized by uncertain diagnosis with suspicion increase the risk of developing paralysis caused by spinal of neoplasm, decompression of neural structures due to osteomyelitis. The patient in our case had poorly con- epidural abscess, and compressed granulation tissue. trolled DM. Rarely, the patients require fusion for unstable spine as a In diagnosis, the laboratory findings most predictive of complication of nonsurgical management. pyogenic spondylodiscitis include an elevated erythrocyte At the postoperative 4th week in our case, the patient sedimentation rate and C-reactive protein level. White was neurologically intact and pain free, although his con- blood cell counts were elevated to more than 10,000 in trol MR image of the lumbar spine revealed L-3 compres- only 8% of cases. Blood cultures may be positive in 50% sion and progressed L2–3 listhesis along with dural sac of cases. Conventional x-ray studies may not demonstrate compression. His lateral plain flexion–extension x-ray characteristic diagnostic changes until 2 to 6 months after studies of the lumbosacral spine demonstrated solid fusion the onset of symptoms, and thus long delays can occur in with no instability at the L2–3 level. Because he had solid obtaining the correct diagnosis.33 fusion and no neurological abnormality, the fusion opera- The MR imaging study has demonstrated very high tion was cancelled. sensitivity and specificity for the evaluation of pyogenic spondylodiscitis. Characteristic MR imaging findings of discitis include decreased signal from the disc and adja- CONCLUSIONS cent portion of VBs on T1-weighted sequences and an Acute pyogenic spondylodiscitis should be considered increased signal from these structures on T2-weighted se- among the major complications of TUGNBP. Following

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Unauthenticated | Downloaded 10/01/21 04:13 PM UTC E. Tas¸demirog˘lu, A. Sengöz, and E. Bagatur the procedure, prophylactic antibiotic therapy should al- and mediastinitis after esophageal perforation owing to a swal- ways be given to the patient. Persistent back pain and lowed radiolucent foreign body. J Pediatr Surg 31:698–700, fever following TUGNBP, despite the administration of 1996 antibiotic agents prophylactically, indicate that the patient 20. Fox JA, Sexton DJ, Hardaker WT Jr, et al: Pyogenic osteo- myelitis of the spine, in Wilkins RH, Rengachary SS (eds): should be evaluated by performing lumbar MR imaging Neurosurgery, ed 2. New York: McGraw-Hill, 1996, Vol III, studies for early diagnosis of this serious complication. pp 3333–3339 21. Griffet J, Albertini M, Bastiani F, et al: [Spondylodiscitis in References children following lumbar puncture. Apropos of a case.] Chir 1. Anonymous: Case records of the Massachusetts General Pediatr 27:354–355, 1986 (Fre) Hospital. 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40. Ponte CD, McDonald M: Septic discitis resulting from Escher- 47. Soda T, Ogura K, Ishitoya, et al: Pyogenic vertebral osteomyel- ichia coli urosepsis. J Fam Pract 34:767–771, 1992 itis after acute bacterial prostatitis: a case report. Int J Urol 3: 41. Porter P, Wray CC: Enterobacter agglomerans spondylodiscitis: 402–405, 1996 a possible, unrecognized complication of tetracycline therapy. 48. Thompson PM, Pryor JP, Williams JP, et al: The problem of in- Spine 25:1287–1289, 2000 fection after prostatic biopsy: the case for the transperineal ap- 42. Przybylski GJ, Sharan AD: Single-stage autogenous bone graft- proach. Br J Urol 54:736–740, 1982 ing and internal fixation in the surgical management of pyo- 49. van Ooij A, Manni JJ, Beuls EA, et al: Cervical spondylodisci- genic discitis and vertebral osteomyelitis. J Neurosurg (Spine tis after removal of a fishbone. A case report. Spine 24: 1) 94:1–7, 2001 574–577, 1999 43. Rodriguez LV, Terris MK: Risks and complications of tran- 50. Wiley AM, Trueta J: The vascular anatomy of the spine and its srectal ultrasound guided prostate needle biopsy: a prospective relationship to pyogenic vertebral osteomyelitis. J Bone Joint study and review of the literature. J Urol 160:2115–2120, 1998 Surg Br 41:796–809, 1959 44. Schulze CJ, Mayer HM: Exogenous lumbar spondylodiscitis following a stabwound injury and vertebral fracture. A case re- port and review of the literature. Eur Spine J 4:357–359, 1995 45. Sieber PR, Rommel FM, Agusta VE, et al: Antibiotic prophy- Manuscript received April 16, 2004. laxis in ultrasound guided transrectal prostate biopsy. J Urol Accepted in final form May 17, 2004. 157:2199–2200, 1997 Address reprint requests to: Erol Tas¸demirog˘lu, M.D., Incirli 46. Sloss JM, Pailthorpe CA: Thoracic discitis following ‘Wood- Caddesi Deniz Apt. 74/7, Bakırköy, Istanbul, 34340-TR, Turkey. bury’ rash. J R Army Med Corps 140:45–46, 1994 email: [email protected].

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