Tuberculous spondylitis and paravertebral abscess formation after kyphoplasty: a case report

Spinal infection after vertebral augmentation: a covert complication with serious havoc

INTRODUCTION

Vertebral augmentation, including percutaneous vertebroplasty (PVP) or kyphoplasty (PKP), is the current least invasive surgical option and has been widely used to treat the painful osteoporotic vertebral compression fractures (OVCF). However, the postoperative infections could be life-threatening, even though they rarely occur. Our studies aim to clarify the causation and outcomes of spinal infections following augmentation and meanwhile to identify the risk factors.

METHODS

A retrospective study was conducted on patients with OVCF who underwent PVP or PKP, and were subsequently admitted to our institution with postoperative spinal infection between January 2010 and December 2022. A total of 33 patients were finally included.

RESULTS

The rate of spinal infection after augmentation in our single institute was 0.05% (2/3893). In addition to these 2 patients, the remaining 31 were referred from other hospitals. All 33 patients exhibited elevated inflammatory parameters, 14 patients presented with fever, and 9 patients experienced neurological deficits. Additionally, 29 patients had comorbidity and risk factors. Pathogens were identified in 26 patients, while only 7 patients were examined as culture negative. 27 patients underwent revision surgery and 6 patients only received conservative therapy. Anterior surgery was performed in 2 patients, while posterior surgery was performed in 20 patients. A combined anterior-posterior surgery was performed in 5 patients. At the final follow-up, 18 patients had unrestricted mobility, 10 patients required assistance from crutches or a walker for ambulation, 4 patients needed a wheelchair, and 1 patients died after revision surgery.

CONCLUSIONS

Spinal infection after vertebral augmentation is rare, but it cannot be ignored. Surgeons should make every effort to detect the potential preoperative spondylitis or discitis. Once postoperative spinal infection is confirmed, a prompt intravenous antibiotic therapy is warranted. If medication therapy fails, revision surgery involving debridement and spinal reconstruction should be considered.

Investigation of preoperative asymptomatic bacteriuria as a risk factor for postvertebroplasty infection

BACKGROUND

Postvertebroplasty infection (PVI) is a catastrophic complication after vertebroplasty (VP). Although the urinary tract has been considered as a source of infectious pathogens, whether asymptomatic bacteriuria (ASB) is a risk factors for PVI remains unknown.

METHODS

This retrospective study included 716 patients (207 males; 509 females) treated with VP for osteoporotic vertebral fractures in a single medical center between May 2015 and December 2019. Clinical symptoms, urinalysis results, and culture data were collected preoperatively to identify patients with ASB. The primary outcome was PVI at the index level during follow-up. Demographic data and laboratory test results were compared between the PVI and non-PVI groups.

RESULTS

The mean age of the cohort was 78.6 ± 9.6 (range, 63-106). The prevalence of ASB was 14.1%, with female predominance (63.4%). The overall PVI rate was 1.26% (9/716). The PVI group had more patients with ASB (4/9, 44.4%) than did the non-PVI group (97/707, 13.7%) (p = 0.027). The rate of ASB treatment was similar between the PVI and non-PVI groups (25% vs. 23.7%, respectively). No case of PVI was caused by the urine culture pathogen. Multivariate analysis identified the following risk factors for PVI: ASB (odds ratio [OR], 5.61; 95% CI, 1.14-27.66; p = 0.034), smoking (OR, 16.26; 95% CI, 2.58-102.65; p = 0.003), and malignancy (OR 7.27; 95% CI, 1.31-40.31; p = 0.023).

CONCLUSION

ASB was not uncommon among patients admitted for VP and should be considered a marker of relatively poor host immunity. Preoperative ASB, a history of malignancy, and smoking were identified as significant risk factors for PVI.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Risk factors for tuberculous or nontuberculous spondylitis after percutaneous vertebroplasty or kyphoplasty in patients with osteoporotic vertebral compression fracture: A case-control study

Objectives

The contributing factors for spondylitis after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) remain unclear. Here, we sought to investigate the factors affecting spondylitis occurrence after PVP/PKP. We also compared the clinical characteristics between patients with tuberculous spondylitis (TS) and nontuberculous spondylitis (NTS) following vertebral augmentation.

Methods

Literature searches (from January 1, 1982 to October 16, 2020) using MEDLINE, EMBASE, Google Scholar and Web of science databases were conducted to identify eligible studies according to predefined criteria. The local database was also retrospectively reviewed to include additional TS and NTS patients at our center.

Results

Thirty studies from the literature and 11 patients from our local institute were identified, yielding a total of 23 TS patients and 50 NTS patients for analysis. Compared with NTS group, patients in the TS group were more likely to have a history of trauma before PVP/PKP treatment. Univariate analyses of risk factors revealed pulmonary tuberculosis and diabetes were significant factors for TS after PVP/PKP. Analyzing NTS, we found obesity, a history of preoperative trauma, urinary tract infection, diabetes and multiple surgical segments (≥2) were significantly associated with its occurrence following PVP/PKP treatment. Multivariate logistic analyses showed a history of pulmonary tuberculosis and diabetes were independent risk factors for TS after PVP/PKP, while diabetes and the number of surgically treated segments independently influenced NTS development.

Conclusions

A history of pulmonary tuberculosis and diabetes were independent risk factors for TS. For NTS, diabetes and the number of surgically treated segments significantly influenced the occurrence of postoperative spinal infection. These data may be helpful for guiding risk stratification and preoperative prevention for patients, thereby reducing the incidence of vertebral osteomyelitis after PVP/PKP.

Simultaneous-onset infectious spondylitis with vertebral fracture mimicking an acute osteoporotic vertebral fracture erroneously treated with balloon kyphoplasty: illustrative case

BACKGROUND

Early balloon kyphoplasty (BKP) intervention for acute osteoporotic vertebral fracture (OVF) has been reported to be more effective than the conservative treatment. However, complications of early BKP intervention are still unknown.

OBSERVATIONS

A 71-year-old patient with OVF of L2 underwent BKP 2 weeks after symptom onset. Preoperative magnetic resonance imaging (MRI) and radiograph were compatible with new L2 OVF. Although computed tomography (CT) images revealed the atypical destruction of lower endplate of L2 as OVF, L2 BKP was planned. After BKP, his back pain improved dramatically. Two weeks after BKP, his lower back pain recurred. MRI and CT confirmed the diagnosis of infectious spondylitis with paravertebral abscess formation. With adequate antibiotic treatment and rehabilitation, he was symptom-free and completely ambulatory without signs of infection.

LESSONS

Signal changes on the fractured vertebral bodies during initial MRI and fractured vertebral instability on radiograph can mislead the surgeon to interpret the infection as a benign compression fracture. If the patients exhibit unusual destruction of the endplate on CT imaging, “simultaneous-onset” spondylitis with vertebral fracture should be included in the differential diagnosis. To determine the strategy for OVF, preoperative biopsy is recommended if simultaneous-onset spondylitis with vertebral fracture is suspected.

A case of postoperative tubercular spondylitis following microdiscectomy for lumbar disc herniation

Background:

Postoperative infections are one of the most common complications of spine surgery. However, following a lumbar microdiscectomy, a postoperative infection involving Mycobacterium tuberculosis (MTB) is extremely rare.

Case Description:

One and half months after a L4-5 microdiscectomy, a 47-year-old immunocompromised male with hepatitis B infection presented with low back and bilateral gluteal pain. The MRI revealed a large intraspinal/paraspinal fluid collection spanning from L4 to S1 along with an anterior epidural collection at L5. The patient underwent a L4 lumbar laminectomy for abscess drainage and wound debridement. After obtaining a positive culture for MTB, four antitubercular drug therapies (ATTs) were started, that is, isoniazid (H), rifampicin (R), ethambutol (E), a. One month later, the patient had minimal pain and no residual neurological deficit.

Conclusion:

MTB infection, although rare, should be considered among the differential diagnoses of postoperative infections following lumbar spine surgery in immunocompromised patients living in areas where tuberculosis is endemic.

Tuberculous spondylitis after percutaneous vertebroplasty: A case series of 9 cases

Background

Percutaneous vertebroplasty has become the treatment of choice for compression fractures. Although the incidence is low, infection after vertebroplasty is a serious complication. The pathogens most often responsible for infection are bacteria. Meanwhile, mycobacterium tuberculosis-induced infection is extremely rare. In this study, we reported our treatment experience with 9 cases of tuberculous spondylitis after vertebroplasty.

Methods

Between January 2001 and December 2015, 5749 patients underwent vertebroplasty or kyphoplasty in our department. Nine cases developed tuberculous spondylitis after vertebroplasty (0.16%). Data on clinical history, laboratory examinations, image, treatment and outcomes were examined.

Results

One male and 8 female patients with a mean age of 75.1 years developed tuberculous spondylitis after vertebroplasty. 5 patients had a history of pulmonary tuberculosis (TB). Revision surgeries were performed from 5 days to 1124 days after vertebroplasty. Seven patients underwent anterior debridement and fusion with or without posterior instrumentation, and 2 cases received posterior decompression and instrumentation only. After operation, the diagnosis of tuberculous spondylitis was confirmed by TB polymerase chain reaction (TB-PCR) or mycobacteria culture. Mean follow-up period after revision surgery was 36.8 months. At the end of follow-up, 1 patient with paraplegia had passed away, 2 needed a wheel chair, 4 required a walker and 2 were able to walk unassisted.

Conclusions

Vertebroplasty is a minimally invasive procedure but still retains some possibility of complications, including TB infection. Patients with a history of pulmonary TB or any elevation of infection parameters should be reviewed carefully to avoid infective complications.

Surgical outcomes of infectious spondylitis after vertebroplasty, and comparisons between pyogenic and tuberculosis

Background

Infection after vertebroplasty (VP) is a rare but serious complication. Previous literatures showed most pathogens for infection after VP were bacteria; tuberculosis (TB) induced infection after VP was extremely rare. We reported our treatment experiences of cases with infectious spondylitis after VP, and compared the differences between developed pyogenic and TB spondylitis.

Methods

From January 2001 to December 2015, 5749 patients had undergone VP at our department were reviewed retrospectively. The causative organisms were obtained from tissue culture of revision surgery. Parameters including type of surgery, the interval between VP and revision surgery, neurologic status, and visual analog scale (VAS) of back pain were recorded. Laboratory data at the time of VP and revision surgery were collected. Charlson comorbidity index (CCI), preoperative bacteremia, urinary tract infection (UTI), pulmonary TB history were also analyzed.

Results

Eighteen patients were confirmed with developed infectious spondylitis after VP (0.32%, 18/5749). Two were male and 16 were female. The median age at VP was 73.4 years. Nine patients were TB and the other nine patients were pyogenic. The interval between VP and revision surgery ranged from 7 to 1140 days (mean 123.2 days). The most common type of revision surgery was anterior combined with posterior surgery. Seven patients developed neurologic deficit before revision surgery. Three patients died within 6 months after revision surgery, with a mortality of 16.7%. Finally, VAS of back pain was improved from 7.4 to 3.1. Seven patients could walk normally, the other 8 patients had some degree of disability. Both pyogenic and TB group had similar age, sex, and CCI distribution. The interval between VP and revision surgery was shorter in the patients with pyogenic organisms (75.9 vs 170.6 days). At revision surgery, WBC and CRP were prominently elevated in the pyogenic group. Five in the pyogenic group had UTI and bacteremia; five in TB group had a history of lung TB.

Conclusions

Infection spondylitis after VP required major surgery for salvage with a relevant part of residual disability. Before VP, any bacteremia/UTI or history of pulmonary TB should be reviewed rigorously; any elevation of infection parameters should be scrutinized strictly.

Postoperative Infection in Patients Undergoing Posterior Lumbosacral Spinal Surgery: A Pictorial Guide for Diagnosis and Early Treatment

Surgical site infections after posterior spinal surgery may lead to spondylodiscitis, pseudarthrosis, correction loss, adverse neurological sequelae, sepsis, and poor outcomes if not treated immediately. Infection rates vary depending on the type and extent of operative procedures, use of instrumentation, and patients' risk factors. Image evaluation is crucial for early diagnosis and should be complementary to clinical routes, laboratory survey, and treatment timing. Magnetic resonance imaging detects early inflammatory infiltration into the vertebrae and soft tissues, including hyperemic changes of edematous marrow, vertebral endplate, and abscess or phlegmon accumulation around the intervertebral disk, epidural, and paravertebral spaces. Aggressive surgical treatment can eradicate infection sources, obtain a stable wound closure, decrease morbidity, and restore spinal integrity. Organ/space infection is defined as any body parts opened to manipulate other than superficial/deep incision. Advanced magnetic resonance imaging evaluating abnormal fluid accumulation, heterogenous contrast enhancement of the endplate erosion due to cage/screw infection is categorized to inform a presumptive diagnosis for early implant salvage. However, patients' defense response, infection severity, bacteriology, treatment timing, spinal stability, and available medical and surgical options must be fully considered. Revision surgery is indicated for pseudarthrosis, implant loosening with correction loss, recalcitrant spondylodiscitis, and adjacent segment diseases for infection control.

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.

Tuberculous spondylitis after vertebral augmentation: A case report with a literature review

Tuberculous spondylitis of vertebral augmentation following percutaneous vertebroplasty or kyphoplasty is rare. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous kyphoplasty (PKP). A 54-year-old woman presented to hospital complaining of back pain following a fall 20 days prior. Radiology showed an acute osteoporotic compression (L3 fracture). The patient denied a history of pulmonary tuberculosis and there were no signs of infection. The patient was discharged from hospital 2 days after undergoing L3 PKP with a dramatic improvement in her back pain. The patient was readmitted 10 months later with a history of recurrent back pain and low-grade fever for 3 months. Imaging examinations showed severe spondylitis at the L2-L3 level, with paravertebral abscess formation and bony destruction of L2 and L3. A positive result of the T-SPOT test preliminarily confirmed the diagnosis of tuberculous spondylitis. The tuberculosis test was positive, and serum C-reactive protein levels and erythrocyte sedimentation were relatively high. Treatment for tuberculous spondylitis was started. She underwent posterior fusion and instrumentation from T12-L5 after markers for infection returned to normal. After surgery, the patient continued antituberculous and anti-osteoporosis treatments. Her low back pain was relieved and low-grade fever and sweating disappeared.

Tuberculous Spondylitis Following Kyphoplasty: A Case Report and Review of the Literature

Tuberculous spondylitis of the augmented vertebral column following percutaneous vertebroplasty or kyphoplasty has rarely been described. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous kyphoplasty (PKP). A 61-year-old woman presented to our institution complaining of back pain following a fall 7 days before. Radiologic studies revealed an acute osteoporotic compression L1 fracture. The patient denied history of pulmonary tuberculosis (TB) and there were no signs of infection. The patient was discharged from hospital 4 days after undergoing L1 PKP with a dramatic improvement in her back pain. Two years later, the patient was readmitted with a 1 year history of recurrent back pain. Imaging examinations demonstrated long segmental bony destruction involving L1 vertebra with massive paravertebral abscess formation. The tentative diagnosis of tuberculous spondylitis was made, after a serum T-SPOT. The TB test was found to be positive. Anterior debridement, L1 corpectomy, decompression, and autologous rib graft interposition, and posterior T8-L4 instrumentation were performed. The histologic examination of the resected tissue results confirmed the diagnosis of spinal TB. Anti-TB medications were administered for 12 months and the patient recovered without sequelae. Spinal TB and osteoporotic vertebral compression fractures are similar clinically and radiologically. Spinal surgeons should consider this disease entity to avoid misdiagnosis or complications. Early surgical intervention and anti-TB treatment should be instituted as soon as the diagnosis of spinal TB after vertebral augmentation is made.

Enhanced Drug Delivery of Antibiotic-Loaded Acrylic Bone Cements Using Calcium Phosphate Spheres

Background

Local infection near an implant may pose a serious problem for patients. Antibiotic delivery from acrylic (poly(methyl methacrylate)-based) cements is commonly used to prevent and treat infections in the proximity of, e.g., hip joint implants. However, at present, the drug release properties of PMMA cements are not optimal. An initial burst followed by very slow release means that an unnecessarily large amount of antibiotic needs to be added to the cement, increasing the risk of bacterial resistance. The main purpose of this study was to enhance drug delivery from PMMA cements without influencing the mechanical properties.

Methods

We incorporated strontium-doped calcium phosphate spheres (SCPS) into PMMA cement to enhance the antibiotic release and potentially improve the bone-cement integration. The release of strontium and vancomycin was investigated using inductively coupled plasma atomic emission spectroscopy and UV spectrophotometry, respectively.

Results

It was found that incorporating SCPS into PMMA could enhance the antibiotic release and deliver strontium ions to the surroundings. The incorporation of SCPS also increased the radiopacity as well as the working time of the cement. The compressive strength and Young's modulus were not affected.

Conclusions

Our results showed that SCPS/PMMA antibiotic-loaded cement had enhanced antibiotic release, delivered strontium ions and maintained mechanical properties, indicating that the SCPS additive could be a good alternative for controlling the drug-delivery properties of PMMA cement.

Spinal tuberculosis of the lumbar spine after percutaneous vertebral augmentation (vertebroplasty or kyphoplasty)

BACKGROUND CONTEXT

Spinal tuberculosis occurring after percutaneous vertebral augmentation has rarely been described. To date, only two such cases have been documented in the literature. Vertebral augmentation may reactivate a quiescent tuberculous lesion and promote the infective process in elderly patients with or without immunosuppression, thereby resulting in poor outcomes.

PURPOSE

The purposes of this study were to present two cases in which spinal tuberculosis occurred after vertebroplasty or kyphoplasty, to highlight the clinical features and need for early diagnosis of this pathology, and to postulate probable reasons for this association.

STUDY DESIGN

This study is based on a clinical case series and literature review.

METHODS

In this report, we review the clinical histories of two old women undergoing vertebral augmentation with subsequent spinal tuberculosis.

RESULTS

The first patient responded favorably to conservative treatment with multidrug antitubercular therapy and spinal braces. The second patient underwent surgical debridement through a posterior approach alone, without instrumentation, combined with adjuvant chemotherapy. By 1 year after treatment, both patients had experienced almost complete recovery and continued to be seen for follow-up visits.

CONCLUSIONS

Suspicion should be high, and magnetic resonance imaging is warranted in cases with deteriorating clinical symptoms and signs of acute infection after vertebral augmentation. We propose obtaining exhaustive microbiologic and histologic evidence via needle biopsy or open surgery in a timely fashion to establish an accurate diagnosis because tubercular spondylitis occurring in such a situation may progress rapidly.

Infection after vertebroplasty or kyphoplasty. A series of nine cases and review of literature

BACKGROUND CONTEXT

Percutaneous augmentation with bone cement is a widely accepted modality of treatment for thoracic and lumbar vertebral osteoporotic fractures. Infection after vertebroplasty or kyphoplasty is a serious, yet, rarely reported complication.

PURPOSE

To present a case series with a long-term follow-up of spinal infection after vertebroplasty/kyphoplasty with analysis of preoperative condition, risk factors, diagnostic findings, time before reoperation, causative organism, treatment, and outcome.

STUDY DESIGN

A retrospective, uncontrolled clinical case series in a single institution.

PATIENT SAMPLE

Between January 1997 and June 2012, 1,307 patients underwent percutaneous vertebroplasty or kyphoplasty. Six cases had postoperative infection (0.46%) and three additional cases were referred from other institutions for salvage treatment.

OUTCOME MEASURES

Perioperative assessment included visual analog scale, clinical, laboratory, and imaging findings, and activities of daily living at the end of the follow-up.

METHODS

Nine patients were included: six females and three males (mean age 73.8 years). Comorbidities were found in all patients. Kyphoplasty had been done in five patients and vertebroplasty in four.

RESULTS

The interval between augmentation and revision surgery ranged from 10 to 395 days with a mean of 118.4 days. Three cases with early infection presented within 1 month. Infection parameters were high in all patients at readmission. All patients were treated surgically except one case who died before the planned revision surgery. In all cases, debridement and corpectomy were done through anterior approaches combined with posterior instrumentation. The most common causative organism was Staphylococcus aureus in three cases. Mean follow-up period after the revision surgery was 26.68 months, excluding two patients who died early in the follow-up (within 4 months). This amounts to a mortality rate of 33.3% perioperatively. At the end of follow-up, two patients had unrestricted activities and one patient required a walker. Of three paraparetic patients, two improved functionally and could walk unassisted and one improved but still used a wheelchair.

CONCLUSIONS

Although vertebroplasty and kyphoplasty are minimally invasive interventions, postoperative infection can develop into life-threatening complications. This should be accounted for, in decision making in the elderly age group most commonly affected by osteoporotic fractures and especially in suspicious and high-risk immune-compromised patients.

Triparesis caused by gas-containing extensive epidural abscess secondary to Aeromonas hydrophila infection of a thoracic vertebroplasty: a case report

BACKGROUND CONTEXT

Aeromonas hydrophila is a motile gram-negative non-sporeforming rod with facultative anaerobic metabolism. Except for gastrointestinal disease, skin and soft-tissue infections represent the second most common site of human Aeromonas infections. However, to our knowledge, A. hydrophila infection of the spine has not been reported to date.

PURPOSE

To report the first case of A. hydrophila spinal infection of the T7 vertebra after vertebroplasty.

STUDY DESIGN

Case report.

METHODS

A 72-year-old man was transferred to our emergency department with chief complaints of severe midthoracic pain and triparesis. He had undergone vertebroplasty for a painful vertebral fracture at T7 5 weeks before transfer. Magnetic resonance imaging showed an infection of the T7 vertebroplasty and an extensive epidural abscess. The epidural abscess originating from the infected T7 vertebroplasty extended from the T8 to the C4 epidural space. Computed tomography demonstrated sparsely scattered gas in the epidural abscess, strongly suggestive of an anaerobic infection.

RESULTS

Emergency multilevel laminectomies from C5 to T8 and a posterior instrumentation from T3 to T10 were performed. A. hydrophila was isolated from the blood cultures. The patient was treated with intravenous ampicillin/sulbactam. Posterior decompression and stabilization in combination with appropriate antibiotic treatment completely resolved the neurologic deficit and infection without the need for further anterior corpectomy of the infected T7 vertebroplasty.

CONCLUSIONS

This is the first reported case of spine infection caused by A. hydrophila. The infection developed after vertebroplasty for the management of a painful vertebral fracture. Triparesis occurred rapidly due to an extensive epidural abscess containing gas. Emergency decompression and stabilization in combination with appropriate antibiotic treatment achieved a successful clinical outcome.

Late onset tuberculous spondylitis following kyphoplasty: a case report and review of the literature

A 76-year-old woman with compression fracture of L1 underwent percutaneous balloon kyphoplasty using polymethyl methacrylate. Three years after kyphoplasty of L1, the patient was readmitted with severe low back pain. Magnetic resonance imaging revealed progressive collapse of L1 vertebra and new compression fracture at T12. There were no signs of infection. As conservative treatment failed, combined surgery consisting of anterior corpectomy of T12 and L1, interposition of a titanium mesh cage filled with autologous rib graft, and anterior instrumentation of T11-L2 was performed. Histologic examination showed granulomatous inflammation surrounding the cement. Polymerase chain reaction and culture of the specimen confirmed the diagnosis of tuberculosis. The anti-tuberculous medications were administered for 10 months, and the patient recovered without any sequelae. Tuberculous spondylitis should be included in the differential diagnosis of spondylitis after cement augmentation. If conservative antibiotic therapy fails, resection of the infected bone-cement complex is indicated.

Troublesome Tuberculosis: A Case Report on Multi-focal Tuberculous Osteomyelitis in An Immunocompetent Patient

Bone and joint tuberculosis is a chronic debilitating condition that leads to progressive damage and even deformity of joints. It may affect one or multiple sites. It could present in a myriad of ways which may result in an incorrect diagnosis being made. Common misdiagnoses include seronegative inflammatory arthritis, septic arthritis, malignancy, osteoporotic fractures and mechanical type back pain. It was initially only diagnosed in patients with previous active tuberculosis or latent tuberculosis. However, in recent years, it has also been reported in patients without a history of previous tuberculosis infection. Making a diagnosis of bone and joint tuberculosis is challenging. As the symptoms are not always typical, a delay in initiating anti-tuberculosis treatment is not uncommon in clinical practice. Systemic features are not always present in multi-drug resistant tuberculosis of joints which makes the diagnosis even more challenging. Multi-drug resistant tuberculosis is an increasingly common problem. It is not only limited to immunocompromised patients, but also found in immunocompetent patients. Multifocal tuberculous osteomyelitis is an uncommon condition and may involve any bone such as the skull, ribs, long bones, spine and phalanx. Tuberculous pyomyositis and tuberculous tenosynovitis may also be the presenting features of multifocal tuberculosis. Identification of mycobacterium tuberculosis in synovial fluid and biopsy, tissue culture, tissue fluid cytology and tissue polymerase chain reaction are crucial investigations in these cases. As the presentation of extra pulmonary tuberculosis can be very variable, it is important to maintain a high index of suspicion. The diagnosis and therefore treatment may be expedited using a clinically directed multidisciplinary approach.

KEYWORDS

Bone and joint tuberculosis; Multi focal tuberculous osteomyelitis; Extra-pulmonary tuberculosis; Multi-drug resistant tuberculosis; Latent tuberculosis.