A particular case of pyogenic spondylodiscitis misdiagnosed as a vertebral fragility fracture and erroneously treated with balloon kyphoplasty

Thoracic Pyogenic Spondylitis Misdiagnosed As Osteoporotic Compression Fracture Status Post Vertebral Augmentation With Resultant Paraplegia: A Case Report

This paper describes a case of serious complications following vertebral augmentation resulting from a misdiagnosis of pyogenic spondylitis as osteoporotic compression fracture (OCF). A 56-year-old female with systemic lupus erythematosus underwent vertebral augmentation following a diagnosis of T10 OCF based on plain film analysis. Note that preoperative computed tomography (CT) and magnetic resonance imaging (MRI) were not performed. One day after vertebral augmentation, the patient experienced a recurrence of low back pain with fever and paraplegia. MRI findings revealed paravertebral and epidural soft tissue over T9 and T10 with cord compression. Subsequent laminectomy of T9 and T10 revealed devitalized lamina, epidural abscess, and granulation tissue. Pathological analysis indicated a combination of acute and chronic inflammation. A pus culture identified Staphylococcus aureus, indicative of pre-existing pyogenic spondylitis. Further revision surgery was performed at another hospital. The patient remained in a paraplegic state one year after surgery. Infectious spondylitis often manifests with nonspecific symptoms similar to those of compression fracture, and plain radiographs are insufficient to differentiate between the two, often leading to misdiagnosis and mistreatment. Nonetheless, many practitioners base preoperative planning solely on plain film imaging. We advocate the routine usage of CT and/or MRI for patients diagnosed with compression fractures, particularly for immunocompromised individuals.

Debridement and corpectomy via single posterior approach to treat pyogenic spondylitis after vertebral augmentation

Background

Infection after vertebral augmentation (VA) often limits the daily activities of patients and even threatens their life. The operation may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of the treatment of pyogenic spondylitis after vertebral augmentation (PSVA) with Single posterior debridement, vertebral body resection, and intervertebral bone graft fusion and internal fixation (sPVRIF).

Methods

The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA.

Results

A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture(OVF) in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities. The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment. The surgical time was 175.0±16.8 min, and the intraoperative blood loss was 465.6±166.0 mL. Pathogenic microorganisms were cultured in 12 patients.

Conclusion

PSVA is a severe complication that can even threaten the life of the patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Infection following percutaneous vertebral augmentation with polymethylmethacrylate

Although the incidence of infection following vertebroplasty or kyphoplasty is rare, postoperative infection and cement augmentation in preexistent spondylitis can cause life-threatening complications in frail patients with notable comorbidities. In such cases, urgent culture and biopsy and the long-term use of proper antibiotics are necessary.

PURPOSE

Infection following vertebral augmentation with polymethylmethacrylate (PMMA) is rare. We aimed to analyze 11 cases of pyogenic spondylitis and spondylodiscitis that occurred after vertebroplasty or kyphoplasty and to review similar cases in the literature.

METHODS

All cases of postoperative spinal infections in our institution between January 2005 and November 2016 that primarily underwent percutaneous vertebroplasty or kyphoplasty were retrospectively reviewed. Eleven patients (mean age 76.3 years) were included.

RESULTS

The incidence of infection following vertebroplasty/kyphoplasty was 0.36%. Postoperative infection occurred in 3 of 826 cases. All patients underwent combined surgical and antibiotic treatment because of neurologic deficit on the initial diagnosis of the infection or failure of prior medical treatment of the infection. The surgical procedure was thorough debridement of infected tissue and material including PMMA following anterior column reconstruction via anterior/posterior/combined approach in 10 patients and percutaneous pedicle screw fixation alone in 1 patient aged 96 years. The mean follow-up period was 21.1 months after the revision operation, excluding one patient who died 17 days after revision surgery. Ten patients recovered from infection.

CONCLUSIONS

Although the incidence of infection following vertebroplasty or kyphoplasty is rare, postoperative infection and cement augmentation in preexisting spondylitis can develop into a life-threatening complication in frail patients with notable comorbidities. In treating infected vertebroplasty and kyphoplasty, immediate culture and biopsy and the long-term use of proper antibiotics are critical. Prompt surgical treatment should be considered in case of significant neurologic deficit, severe instability due to infected fracture, and resistance to antibiotics.