Septic arthritis of unilateral lumbar facet joint with contiguous abscess, without prior intervention

Septic Arthritis of the Spinal Facet Joint: Review of 117 Cases

Background

Septic arthritis of the spinal facet joints is increasingly recognized in the era of magnetic resonance imaging, but its epidemiology, clinical features, management, and prognosis are ill-defined.

Methods

We review 101 previously published cases and report 16 cases occurring at our institutions between 2006 and 2018.

Results

Most patients presented with fever (60%) and back or neck pain (86%). Radiation into the hip, buttock, or limb was present in 34%. The lumbosacral vertebral segments were involved in 78% of cases. Most cases (64%) were due to Staphylococcus aureus. Bacteremia was present in 66% and paraspinal muscle abscesses in 54%. While epidural abscesses were present in 56%, neurologic complications were seen in only 9%, likely because most abscesses arose below the conus medullaris. Neurologic complications were more common with cervical or thoracic involvement than lumbosacral (32% vs 2%, P < .0001). Extraspinal infection, such as endocarditis, was identified in only 22% of cases. An overall 98% of patients survived, with only 5% having neurologic sequelae.

Conclusions

Septic arthritis of the facet joint is a distinct clinical syndrome typically involving the lumbar spine and is frequently associated with bacteremia, posterior epidural abscesses, and paraspinal pyomyositis. Neurologic outcomes are usually good with medical management alone.

Septic Arthritis of Facet Joint in Children: A Systematic Review and a 10-year Consecutive Case Series

BACKGROUND

Due to the low resolution of historical imaging technologies, descriptions of Septic Arthritis of Facet Joint (SAFJ) in children are scarce, though severe cases are known. We first aimed to estimate the incidence rate of SAFJ in children; we further aimed to specify SAFJ clinical, imaging and laboratory findings, and identify avenues for appropriate management.

METHODS

A 10-year consecutive SAFJ case series using our imaging center database combined with a 50-year systematic review of literature cases.

RESULTS

The mean ± SD incidence of pediatric SAFJ was 0.23 ± 0.4/100,000 children-years. The key symptoms were potty refusal (in toddlers) or painful sitting (78%) and lateralized signs (paravertebral tenderness and/or swelling, 88%). SAFJ diagnosis and extension were obtained using magnetic resonance imaging (MRI) (94%), and found an epidural extension in 8/16 cases. The mean duration of antibiotic treatment was 5.1 weeks. The compliance with guidelines was 79% for empiric and 62% for targeted antibiotic therapies.

CONCLUSIONS

SAFJ incidence in children is much greater than expected from the literature. Half of cases were complicated by an epidural infection. Simple clinical symptoms detected as early as the bedside allow a strong suspicion of SAFJ, justifying the use of a first-line MRI to confirm the diagnosis and precisely describe the extension. Focusing on simple clinical signs is key to justify the transfer of a child or the shortening of the delay to obtain an MRI. However, as MRI availability increases in most Western countries, and the capacity for diagnosis increases, the awareness of SAFJ must be spread to avoid missed cases.

Spinal cord disorder due to spinal epidural abscess secondary to thoracic facet joint septic arthritis-a rare case with a surprising evolution

INTRODUCTION

Septic arthritis of a facet joint (SAFJ) is a relatively rare medical entity and the lumbar segment is its most frequent location. Although unusual, a spinal epidural abscess (SEA) can occur as a complication of SAFJ and possibly damage the spinal cord.

CASE PRESENTATION

A 53-year-old woman presented with acute right dorsal pain, fever, loss of sphincters control, and paraparesis without causal factor. Forty-eight hours after the symptoms started, imaging revealed a thoracic posterior epidural collection causing compression of the spinal cord and features suggestive of septic arthritis of right T5-T6 facet joint. She underwent an urgent laminectomy and drainage of the abscess. Both blood and abscess cultures isolated Staphylococcus aureus. A diagnosis of complete paraplegia grade A of the ASIA (American Spinal Injury Association) Impairment Scale (AIS) with neurologic level T10 was made 5 days after surgery. She took 3 months of an intensive rehabilitation program at our Physical and Rehabilitation Medicine ward. With an unexpected favorable evolution, both neurological and functional, she was discharged with an incomplete paraplegia AIS D and functionally independent in all tasks.

DISCUSSION

This case reveals an infrequent medical condition on a rarely affected spinal segment. An early diagnosis and proper treatment of SAFJ and SEA are of major importance to avoid severe related consequences. Patients with spinal cord injury with severe neurological deficits due to these conditions greatly benefit from an interdisciplinary rehabilitation program to improve neuromotor and functional status.

Acute medullar compression secondary to a septic arthritis of a thoracic facet joint: a case report and review of literature

Introduction

Septic arthritis of a facet joint (SAFJ) is a rare entity and frequently underdiagnosed. It is most frequently localised in the lumbar segment.

Case presentation

A 48-year-old woman presented at our emergency room with a chief complaint of lumbar pain and perineal hypoesthesia. An urgent lumbar Magnetic Resonance Imaging (MRI) was performed showing no signs of compressive pathology. Intravenous painkillers were administered improving her clinical symptoms, so she was discharged from the emergency department to be followed at our out-patient clinic. After 12 h, the patient presented again referring an acute loss of strength in her lower limbs and paresthesias at a T10 sensitive level. Due to the severity of the symptoms, we performed an urgent dorsal MRI that showed a septic arthritis of the left T8-T9 facet joint and an epidural abscess causing a medullar compression. Blood cultures were performed before surgical treatment. An urgent laminectomy of T8 and debridement of the abscess were performed. Intraoperative microbiology and blood cultures were positive for Streptococcus constellatus. After surgery, the patient presented a progressive improvement of her symptomatology.

Discussion

Physicians should have in mind and rule out this clinical entity to avoid severe consequences that a misdiagnosed SAFJ could develop.

Ultrasound diagnosis and therapeutic intervention in the spine

Spine pathology afflicts people across the globe and is responsible for a large portion of physician visits and healthcare costs. Imaging such as plain radiographs, CT, MRI, and ultrasound is vital to assess structure, function, and stability of the spine and also provide guidance in therapeutic interventions. Ultrasound utilization in spine conditions is less ubiquitous, but provides benefits in low costs, portability, and dynamic imaging. This study assesses ultrasound efficacy in diagnosis and therapeutic interventions for spine pathology. A systematic review conducted via PubMed, MEDLINE, and Google Scholar identified 3,630 papers with eventual inclusion of 73 papers with an additional 21 papers supplemental papers subsequently added. Findings highlighted ultrasound utilization for different structural elements of the spine such as muscle, bone, disc, ligament, canal, and joints are presented and compared with radiographs, CT, and MRI imaging where relevant. Spinal curvature and mobility are similarly presented. Ultrasound efficacy for guided therapeutics about the spine is presented and assessed against other modalities. Ultrasound is a widely used and efficacious modality to guide injections about the spine. Diagnostic utility is less well studied, but shows promise in assessing fractures, posterior ligamentous stability, and intra-operative hardware placement. The low cost, portability, and dynamic imaging ability make it an attractive modality particularly for developing health systems and resource limited environments such as combat settings and the International Space Station. Further study is recommended before broad adoption in diagnostics.

Idiopathic septic arthritis of a lumbar facet joint associated with paraspinal abscess

A 48-year-old woman presented with a 1-month history of severe lower back pain on a background of 24 h of mild fever and general tiredness with an associated right-sided foot drop. Five weeks after the onset and with no improvement in symptoms in spite of analgesia and physiotherapy, the patient had a lumbar spine MRI which demonstrated a collection extending from the facet joints of L5 and L6 to the iliacus muscle on the right. A CT-guided aspiration was performed with a lengthy hospital stay for intravenous antibiotic treatment. The culture and sensitivity study of the aspirate isolated Streptococcus pneumoniae.

Ultrasonography of the lumbar spine: sonoanatomy and practical applications

Ultrasonography of the bones and joints has gained considerable ground in the field of rheumatology over the past decade and is now used in everyday practice both for diagnostic purposes and to guide local injections. However, the use of ultrasonography is virtually confined to the peripheral joints, whereas spinal diseases make a major contribution to rheumatology practice. Studies have established that ultrasonography of the lumbar spine is feasible. Adequate equipment and familiarity with spinal sonoanatomy are required. In this update, we suggest starting with a systematic examination of the lumbar spine to assess the various anatomic structures, from the thoracolumbar fascia superficially to the posterior part of the vertebras at the deepest level. The ligaments, erector spinae muscles, facet joints, and transverse processes can be visualized. Ultrasonography can serve to guide injections into the facet joints, about the nerve roots, and into the iliolumbar ligaments; as well as to identify relevant landmarks before epidural injection. Although diagnostic applications are more limited at present, systematic studies of abnormal ultrasonography findings will allow evaluations of the potential usefulness of ultrasonography for diagnosing spinal disorders. The depth of the spinal structures limits the ability to obtain high-resolution images. However, future technical improvements in ultrasound transducers and machines, together with the growing number of physicians trained in ultrasonography, can be expected to benefit the development of spinal ultrasonography in the near future.

Persistent back pain in the absence of clear red flags

A 62-year-old woman with low back pain was eventually diagnosed with vertebral osteomyelitis after multiple visits to emergency, primary and specialty care. The absence of traditional 'red flags' from her history and examination serves as an important reminder that their absence does not necessarily reflect benign pathology.