Cerebrospinal fluid infection after lumbar nerve root steroid injection: a case report

Clinical features and outcome of vertebral osteomyelitis after spinal injection: is it worth the price?

PURPOSE

Spinal injections are increasingly used for back pain treatment. Vertebral osteomyelitis (VO) after spinal injection (SIVO) is rare, but patient characteristics and outcome have not been well characterized. The aim of this study was to assess patient characteristics of SIVO in comparison to patients with native vertebral osteomyelitis (NVO) and to determine predictors for 1-year survival.

METHODS

This is a single-center cohort study from a tertiary referral hospital. This is a retrospective analysis of Patients with VO who were prospectively enrolled into a spine registry from 2008 to 2019. Student's t-test, Kruskal-Wallis test or Chi-square test were applied for group comparisons. Survival analysis was performed using a log-rank test and a multivariable Cox regression model.

RESULTS

283 VO patients were enrolled in the study, of whom 44 (15.5%) had SIVO and 239 (84.5%) NVO. Patients with SIVO were significantly younger, had a lower Charlson comorbidity index and a shorter hospital stay compared to NVO. They also showed a higher rate of psoas abscesses and spinal empyema (38.6% [SIVO] vs. 20.9% [NVO]). Staphylococcus aureus (27%) and coagulase-negative staphylococci (CNS) (25%) were equally often detected in SIVO while S. aureus was more frequently than CNS in NVO (38.1% vs. 7.9%).Patients with SIVO (P = 0.04) had a higher 1-year survival rate (Fig. 1). After multivariate analysis, ASA score was associated with a lower 1-year survival in VO.

CONCLUSION

The results from this study emphasize unique clinical features of SIVO, which warrant that SIVO should be estimated as a separate entity of VO.

Characteristics of patients with meningitis after lumbar epidural steroid injection

To investigate the clinical, laboratory, and radiological features of meningitis after lumbar epidural steroid injection (M-ESI) without accompanying spinal infection, data of patients with meningitis admitted between January 2014 and December 2021 in a single center were retrospectively reviewed. Among them, patients with a recent history of lumbar ESI were identified, and their medical records were collected. Patients with concomitant infections other than meningitis, including spinal epidural abscess, were excluded. Seven patients with M-ESI were identified. All patients presented with headache and fever without focal neurological deficits, and headache developed shortly after a procedure (median, 4 hours). Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis (median, 6729/μL), elevated protein level (median, 379.1 mg/dL), decreased ratio of CSF glucose to serum glucose (median, 0.29), and elevated lactate level (median, 8.64 mmol/L). Serum level of C-reactive protein was elevated in 6, but serum procalcitonin level was within normal range. No causative pathogen was identified in the microbiological studies. The most frequent radiologic feature was sulcal hyperintensity on fluid-attenuated inversion recovery images (57%), followed by pneumocephalus (43%). Symptoms subsided in a short period (median, 1 day) after initiating treatment with antibiotics and adjuvant intravenous corticosteroids. None of the patients experienced neurological sequelae. Though the cardinal symptoms and CSF findings of M-ESI were comparable to those of bacterial meningitis, M-ESI seems to have distinctive characteristics regarding the clinical course, laboratory parameters, and pneumocephalus.

A rare case of acute meningitis shortly after lumbar selective nerve root block: a case report

A 57-year-old man underwent lumbar selective nerve root block (SNRB) for low back pain and lower radiating pain caused by left-sided L4 disc herniation. He presented to the emergency department with fever, headache and aggravated low back pain approximately 3 hours after the procedure. Infection was suspected; hence, blood tests, cerebrospinal fluid (CSF) tests, lumbar magnetic resonance imaging, and brain computed tomography were performed. Imaging findings were not suggestive of infection. The CSF was turbid and yellowish with pleiocytosis; however, the CSF culture was negative. Based on these findings, the patient was diagnosed with acute meningitis. Broad-spectrum antibiotics and steroid therapy were initiated considering the patient's age and general condition. From hospital day (HD) 2, fever and headache were reduced and disappeared completely by HD 5. At the last follow-up, 1 month after discharge, the patient had no symptoms. Acute meningitis is associated with a high mortality and neurologic deficits. Hence, timely tests, diagnosis, and treatment are critical for positive outcomes. Symptoms of meningitis following a nerve block generally occur within 24-48 hours after the procedure. This case is notable, as it involved a quicker and more sudden onset of symptoms; meningitis occurred only a few hours after lumbar selective nerve root block.

Psoas Abscess After Lumbar Facet Joint Injection: Case Report and Literature Review

Low back pain (LBP) is a common condition. It is estimated that 84% of adults will present LBP symptoms at some point in their lives. Rarely, however, is LPB an indication of a serious medical condition, requiring further investigation. The treatment of non-specific LBP is based on non-pharmacological strategies, e.g., non-steroidal anti-inflammatory drugs (NSAID) or skeletal muscle relaxants. The use of epidural steroid injection (ESI) or facet joint injections relieves pain originating from degenerative spine disorders or a disk herniation, thereby providing rapid pain improvement, despite considerable long-term outcomes. Although rare, ESI complications can occur, and infections are infrequently described. This paper describes a rare case of an abscess in the psoas muscle, secondary to facet joint lumbar block. We report a male aged between 30 and 40 years old with LBP, who was submitted to a facet joint and ESI. The procedure evolved into a spinal infection of the psoas muscle. In addition, we present a brief literature review on psoas infections after spinal injection. Infection post facet joint lumbar block is very rare, with few publications in the literature. Early detection and the aggressive broad-spectrum antibiotic course must be initiated until adequate cultures are obtained and antibiotics prolong to at least four weeks.

Best cut-off point of the cervical facet joint area as a new morphological measurement tool to predict cervical foraminal stenosis

Purpose: One of the main factor of cervical foraminal stenosis (CFS) is the hypertrophic change of the cervical facet joint. In order to analyze the connection between CFS and the facet joint hypertrophy, we devised a new morphological parameter, called the cervical facet joint cross-sectional area (CFJA). The CFJA has not yet been investigated for its association with CFS. We hypothesized that the CFJA is an important morphologic parameter in the diagnosis of CFS.

Patients and methods: All patients over 50 years of age were included. Data regarding the CFJA were collected from 160 subjects with CFS. A total of 162 control individuals underwent cervical spine magnetic resonance imaging (CMRI) as part of a routine medical examination. Axial T2-weighted CMRI images were acquired from all subjects. We used a picture archiving system to analyze the cross-sectional area of the bone margin of the cervical facet joint at the level of the most stenotic cervical spine in the axial plane.

Results: The average CFJA was 109.07±20.91 mm² in the control group, and 126.75±22.59 mm² in the CFS group. The CFS group was found to have significantly higher levels of the CFJA (p<0.001) than the control group. ROC curve estimation was used to verify the validity of the CFJA as a new predictor of CFS. In the CFS group, the best cut off-point was 113.14 mm², with sensitivity =70.6%, specificity =68.6%, and AUC =0.72 (95% CI, 0.66–0.77).

Conclusions: CFJA high values were closely associated with a possibility of CFS. We concluded CFJA is easy to use, fast, and useful new morphological parameter to predict CFS.