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Home » Features » Ortho Dx


ORTHODX: PAIN AFTER DISKECTOMY

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SLIDESHOW

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FIGURE. MAGNETIC RESONANCE IMAGING OF THE LUMBAR SPINE. CREDIT: DAGAN CLOUTIER,
MPAS, PA-C.



 * CASE STUDY:

 * EXPLANATION:

A 65-year-old man presents to the emergency department with worsening lower back
pain 4 months after a right-sided L3-L4 diskectomy. The pain from surgery never
subsided and seems to be getting worse over the last 3 to 4 weeks. He denies
having fevers but has noticed intermittent chills and sweats over the last few
weeks as well. He is hemodynamically stable and is afebrile in the emergency
department at 98.1 °F. On physical examination, he has no neurological deficits
in the lower extremity and his prior lumbar incision is well healed without
signs of infection. Blood cultures in the emergency department are positive for
Staphylococcus aureus. Magnetic resonance imaging of the lumbar spine (Figure)
shows bone marrow edema at the L3 and L4 vertebral bodies and fluid signal in
the intervertebral space compatible with acute diskitis-osteomyelitis with
surrounding prevertebral phlegmon and edema. No epidural abscess or neural
compression is observed.

The patient is presenting with vertebral osteomyelitis/diskitis that was caused
by a postoperative infection. Other causes of diskitis other than surgical
inoculation include hematogenous dissemination (most common), which may be from
intravenous drug use or recent systemic infection. The most...

Submit your diagnosis to see full explanation.

The patient is presenting with vertebral osteomyelitis/diskitis that was caused
by a postoperative infection. Other causes of diskitis other than surgical
inoculation include hematogenous dissemination (most common), which may be from
intravenous drug use or recent systemic infection.

The most common pathogen is Staphylococcus aureus followed by Staphylococcus
epidermidis and then gram-negative organisms associated with respiratory or
genital urinary infections. The most common symptoms of diskitis include diffuse
lower back pain that is worse at night. The most common location for diskitis
includes the lumbar spine followed by thoracic spine, then cervical spine, and
lastly the sacrum. Fever is present in one-third of patients and neurological
symptoms occur in less than 20% of patients.

Treatment involves identifying the causative organism, either by blood culture
or computed tomography (CT)-guided bone biopsy, and administration of
appropriate antibiotics. If blood cultures are positive, a CT biopsy can be
avoided. Surgical management is recommended when evidence of neurological
deficits, large abscess formation, or spinal instability is found.1,2

REFERENCES

1. Ahsan K, Hasan S, Khan SI, Zaman N, Almasri SS, Ahmed N, Chaurasia B.
Conservative versus operative management of postoperative lumbar discitis. J
Craniovertebr Junction Spine. 2020;11(3):198-209.
doi:10.4103/jcvjs.JCVJS_111_20.

2. Adult pyogenic vertebral osteomyelitis. www.orthobullets.com. Accessed
September 10, 2022.

QUESTION

What is the next best step in treatment?
 * Intravenous antibiotics covering Staphylococcus aureus
 * Computed tomography-guided bone biopsy for culture
 * Surgical debridement
 * Surgical debridement with posterior instrumentation

1/1
Submit
Please mark all the Question(s) to submit your Quiz.


TOPICS:

Case Studies Ortho Dx Orthopedics


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