A case of late-onset spondylodiscitis within the longest duration: 9 years after posterior instrumentation – Egyptian Journal of Neurosurgery

A 66-year-old female patient presented with back and right leg pain that had persisted for 1 month. She also complained of night sweats, tremors, and fever that increased up to 39 degrees. It turned out that she had lumbar spinal stenosis and had been operated 9 years ago with bilateral transpedicular screws in the L4 and L5 vertebrae and two rods (Fig. 1). There were no other chronic diseases or previous infections in her medical history. Physical examination revealed restricted range of motion in the proximal muscle groups of both lower extremities, which was due to hyperalgesia. Right lower extremity thigh flexion and extension strength was 3/5; right dorsiflexion and EHL were 4/5.

Preoperative lumbo-sacral spinal direct graphy—lateral and AP views

On blood tests, the patient’s white blood cell count was 18,800, with an erythrocyte sedimentation rate of 119 mm/h, a C-reactive protein value of 139.15 mg/dL, and a procalcitonin value of 0.83 ng/mL. Blood cultures were obtained, and tests performed to determine the cause of infection revealed no evidence of Brucella, tuberculosis, or infective endocarditis.

Computed tomography of the lumbar spine revealed pedicle screw fixators at the level of the L4–5 vertebrae. A degenerative vacuum phenomenon was noted in the lumbar intervertebral disc (Fig. 2). Because of the patient’s allergy to contrast media, non-contrast-enhanced lumbar spine magnetic resonance imaging (MRI) was performed. In addition to an anterior bone fusion at the L4–5 level, prominent oedematous inflammatory changes were observed in both vertebrae and paravertebral areas (Fig. 3). At the same time, the intervertebral disc was found to be markedly narrowed, so spondylodiscitis was considered as a preliminary diagnosis.

Preoperative lumbo-sacral spinal CT—axial, sagittal, and coronal sections

Preoperative lumbo-sacral spinal MRI—axial and sagittal sections

The screws were surgically removed and thorough debridement of the infected tissue was performed (Fig. 4). A specimen from the lumbar region with an open biopsy was sent for pathological and microbiological examination. There was no multiplication in the patient’s cultures. Microscopy revealed a strong neutrophilic leukocyte infiltration and palisading epithelioid histiocyte populations. Pathology revealed severe necrosis, inflammatory and focal granulomatous reaction.

Postoperative lumbo-sacral spinal CT—axial, sagittal, and coronal sections

She received ampicillin and sulbactam as her first empiric intravenous antibiotherapy. Five days later, treatment with piperacillin–tazobactam was started on the recommendation of the Infectious Diseases Clinic. One week later, antibiotherapy was switched to imipenem and cilastatin sodium. The patient was discharged with an oral antibiotic after intravenous antibiotic treatment was completed for 6 weeks.

Significant regression was observed on lumbar spine MRI scan in the first month of treatment (Fig. 5). It was observed that the pain of the patient, whose spine was immobilized and in whom no additional neurological deficits were noted, regressed with the infection markers. On blood tests at discharge, the patient’s white blood cell count was 5940 with a sedimentation rate of 60 mm/h, a C-reactive protein value of 7.95 mg/dL, and a procalcitonin value of less than 0.12 ng/mL.

Postoperative lumbo-sacral spinal MRI—axial and sagittal sections