Download Vertebral Osteomyelitis with Paravertebral Abscess: A Case Report

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J Emerg Crit Care Med. Vol. 24, No. 3, 2013
Vertebral Osteomyelitis with Paravertebral Abscess:
A Case Report
Cho-Chao Feng
Vertebral osteomyelitis usually presents with clinical manifestations, laboratory data and
radiographic changes that are non-specific. This makes it difficult to diagnose during the early stages of
the disease and consequently this increases morbidity. As a result it is a challenging diagnosis to most
clinicians, especially the emergency physician. I report a case of vertebral osteomyelitis associated with
paravertebral abscess diagnosed at an emergency department. This patient presented with back pain only
and was discharged without complication after conservative treatment.
Key words: vertebral osteomyelitis, paravertebral abscess
Introduction
Ve r t e b r a l o s t e o m y e l i t i s ( V O ) w a s f i r s t
described in 1880 by Lannelongue (1) and since
then there have been numerous articles published
on the subject(2-7). It is usually caused by either
direct postoperative inoculation of an infectious
agent, by hematogenous spread of such an agent
from a distant infectious focus such as the urinary
tract infection (UTI) or by spread of a contiguous
infection from adjacent soft tissue(3,4). The disease’s
insidious clinical presentation, such as back pain,
together with a lack of specific laboratory and
radiographic findings, have contributed to delays
in diagnosis and an increase in comorbidity(4). The
most frequent comorbidities are septicemia (27%)
and endocarditis (9%)(5,6). Carlos et al. described a
complication rate for endocarditis of 30%(6). The
mortality rate of VO among hospitalized patients
ranges from 2.5% to 3.5% (5,6) . Another study
has suggested a fatality rate for VO of 17% (7).
Therefore, it is an important and challenging
diagnosis for most medical clinicians, especially
the emergency physician and this is especially true
when the general condition of patient is unstable
or there is poor ability to communicate with the
patient, such as when the patient is elderly or has
dementia. The vague chief complaints of patient
and non-specific clinical presentation of this disease
can also easily contribute to a misdiagnosis, which
may leads to medico-legal issues. Therefore I report
a case of vertebral osteomyelitis that was diagnosed
at an emergency department (ED) and where
the patient was discharged successfully without
complication.
Case Report
A 69-years-old well conscious and oriented
afebrile diabetic female patient presented at our
ED during the weekend. Generalized weakness for
a week without any other systemic symptoms and
Received: April 3, 2013 Accepted for publication: December 25, 2013
From the Emergency Department, Hsinchu Cathay General Hospital
Address reprint requests and correspondence: Dr. Cho-Chao Feng
Emergency Department, Hsinchu Cathay General Hospital
678 Section 2, Zhonghua Road, Hsinchu, Taiwan (R.O.C.)
Tel: (03)5278999 ext 1191 Fax: (03)5261499
E-mail: [email protected]
Vertebral osteomyelitis with paravertebral abscess
95
signs were complained of by the patient. Physical
examination revealed only a marked tenderness of
was discharged after 2 weeks hospitalization and
no recurrence has been found to have occurred on
regularly followed up at an orthopedic department.
The laboratory data was within normal limits except
Discussion
the back and the family stated that this had already
lasted for more than six months and had been
for the white blood cell count, which was 26920/
uL, a sugar level of 436 mg/dl and a CRP level
of 14.38 mg/dl. Increased soft tissue density and
vertebral spondylosis were noted when a thoracolumbar spine x-ray study was carried out (Fig. 1).
Based on this, a CT scan was arranged, and this
showed abnormal soft tissue with bone destruction
at T8-10 and osteomyelitis with abscess formation
(Fig. 2). A neurosurgeon was then consulted
for debridement but conservative treatment was
suggested. An MRI was arranged after admission to
the ward. This showed pyogenic osteomyelitis with
subligamentous spread together with paraspinal
abscess formation at T7-9. Blood culture revealed
Escherichia coli. A tuberculosis culture and acid
fast staining were negative. This patient was treated
intravenously with Ceftriaxone Sodium 2g q8h and
Metronidazole 500 mg q8h for 10 days. The patient
Fig. 1
follow-up.
Vertebral osteomyelitis accounts of 3% to
7% of all cases of osteomyelitis(2,8). The incidence
increases as the age of the patient increases(9), with
rates of 0.3/100000 (<20 years old), 3.5/100000 (5070 years old) and 6.5/100000 (>70 years old)(5).
The disease also affects intravenous drugs abusers
and other immune compromised patients such
as diabetics and cancer patients (10,11). The maleto-female sex ratio is about 1:1.5 (5, 12) . VO is
caused by hematogenous dissemination through
retrograde flow from the pelvic venous plexus to
the perivertebral plexus(8), by a distant infection
with an endogenous origin such as urinary tract
infection (UTI); alternatively, it may follow direct
inoculation from an exogenous origin such as a
fixation device after spinal surgery(9,4,3).
The most common infectious agents of
endogenous origin are Staphylococcus aureus,
The presence of increased soft tissue density (arrow) was
noted on the thoraco-lumbar spine x-ray study
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J Emerg Crit Care Med. Vol. 24, No. 3, 2013
Fig. 2 Abnormal soft tissue with bone destruction and abscess
formation is present in the paraverterbral space (arrow)
followed by E. coli. Coagulase-negative
Staphylococcus and Propiopinibacterium acnes
are common exogenous causative agents (9,5,11-13).
I n a d d i t i o n , P s e u d o m o n a s a e r u g i n o s a (15),
brucellosis(3,12,14) and tuberculosis(16) have also been
reported as being involved in cases of vertebral
osteomyelitis. Pathologically, the bacteria usually
lodge in the arteriolar network of the metaphyseal
region adjacent to the vertebral disc (8) . The
infection begins near the anterior longitudinal
ligament of vertebral bodies and then extends
into the subligamentous paravertebral area, the
epidural space and the contiguous vertebral bodies.
Among elderly patients, increases in the length
and degree of the arterioles within the cancellous
part of the vertebral bodies leads sluggish blood
flow, which then contributes to the infection(2). The
most common site of vertebral osteomyelitis is the
lumbar spine (58%), followed by the thoracic spine
(30%) and then the cervical spine. (11%)(10,12).
Clinical presentation is nonspecific. Back
pain is the most common manifestation and is
presented in 85 % of cases(12). In addition, localized
tenderness on percussion, muscle spasm and a
limited range of motion may also be present (16).
Occasionally a local mass, fluctuant mass or
kyphosis has been reported(2). Chang et al. reported
a VO case that presented with abdominal pain
only at the ED(17). Fever is present in only about
one third of VO patients(2,12,18). with some studies
showing about 23% to 30% of VO patients
presenting with fever(10,11). Fever presentation does
not seem to be related to the presence or absence
of paravertebral abscess formation. Baldwin et
al. reported four diabetic cases with vertebral
osteomyelitis that had paravertebral abscesses and
all were afebrile(19). McHenry et al. indicated that
vertebral osteomyelitis may be complicated by
epidural abscess in 17% of cases, by paravertebral
abscess in 26% of cases and by disk-space abscess
in 5 % of cases(7).
Approximately 15% to 48% of VO patients
may show an association with a neurological
deficit including sensory loss and various types
Vertebral osteomyelitis with paravertebral abscess
97
of myelopathy, such as quadriplegia and caudaequine syndrome(2,8,9,16). A review study suggested
example leukocytosis. Most studies suggest
that ESR can be used as a diagnostic marker
severity of the neurological deficit depends on the
site of vertebral involvement and when the spinal
leukocytosis and very high values for ESR and
CRP, may be used as diagnostic tools for VO(10).
that 36.4% of VO cases had severe neurological
deficits involving paraplegia or tetraplegia(6). The
epidural abscess developed(2,8,9,16). The longer the
diagnosis of VO is delayed, then the more frequent
becomes the presence of spinal deformity, which,
in turn, results in an increase in consequently
neurological deficit(10). The neurological deficit and
the frequency of motor dysfunction are closely
related to the vertebral level that has been infected.
These were found to be highest among patients with
infections of the cervical spine (44%), followed by
the thoracic spine (32%), the thoracolumbar spine
(25%) and the lumbar (17%) spine(7).
The relationship between the infectious agent
and the neurological deficit resulting from VO
remains controversial. Carlos et al. suggested that
VO caused by Staphylococcus aureus is associated
when a patient has pain and VO is clinically
suspected (2,17,19) . Carmero et al. suggested that
However, others have suggested that both ESR and
CRP are only useful during treatment follow-up and
in cases where there is postoperative spinal wound
infection(4,20). The case presented here did not have
her ESR level checked because CRP and ESR are
equally useful when detecting an infection and both
are known to increase when similar conditions are
present, such as infection, malignancy and tissue
trauma(21-24).
A plain x-ray film is not a useful diagnostic
tool for VO. This is because the disease usually
presents nonspecifically and lacks early specific
changes; these can include disc space narrowing,
uneven destruction of adjacent end-plates and
with more neurological deficits than other infected
reactive changes within the adjacent vertebral
body(2). Richard et al. suggested that disk narrowing
related vertebral osteomyelitis is associated more
often with neurological deficit complication than
following the onset of symptoms and is quite
frequent at 6-8 weeks into the illness (16). Such
agents (6) . However, another comparative study
of 219 VO cases concluded that tuberculosis
vertebral osteomyelitis caused by other bacteria(10).
The case in this article was afebrile and
presented with no related neurological clinical
manifestation. The diagnosis of VO may have
been delayed in the patient because she had been
treated with the long term use of oral analgesic
medication for control of back pain by an
orthopedic department and this may have masked
other symptoms such as fever. The back pain
had been misdiagnosed and treated as a chronic
symptom related to spondylosis. As a consequent,
other symptoms may have manifested themselves
but were neglected by the care giver.
Laboratory findings related to a diagnosis
of VO are non specific and lack sensitivity, for
is the earliest radiographic findings that can
be detected and may occur as early as 2 weeks
vertebral changes also may also be related to
alternative diagnoses, including bone metastasis
and osteoporotic changes(9). Hopkinson suggested
that 18% of disc narrowing events are completely
normal and that 41%, although abnormal, are agerelated findings only; these may be suggestive of
discitis. He also suggested that CT is generally
unhelpful(25). However, another study has suggested
that CT and MRI are able to show significantly
improved sensitivity and specificity compared
to plain radiography (12). The CT imaging of VO
usually reveals diffuse moth eaten or permeative
bone destruction that involves the intervertebral
disc as well as paravertebral osseous elements. In
addition, there can be some gas associated with
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J Emerg Crit Care Med. Vol. 24, No. 3, 2013
the bone and soft tissue, which was the situation
with the patient presented in this article(4). Today,
In addition, it can also be used for identification
of the causative organism by carrying out an open
make detailed assessments of bone destruction and
to detect the exact position of the sequestrum(12).
face many senile ED patients with a vague chief
complaint such as generalized weakness, poor
CT is the methodology of choice for the guidance
of needle biopsies(13). In addition, it is also used to
MRI has been recommended as a diagnostic
tool for vertebral osteomyelitis and shows high
sensitivity at the early stages of the disease;
this is because there is better definition of the
paravertebral and epidural space (13,25) , together
with a high diagnostic accuracy of about 90%(9).
Furthermore, the higher contrast resolution of MRI
is able to detect marrow infiltration and intradural
disease(4,12). The median time between the onset of
symptoms and performance of MRI has been found
to be 1.4 months(7). Unlike CT, MRI is the method
of choice for detecting early infection and is able
to fully evaluate the extent of the disease, including
how it affects the spine, which allows delineating
soft tissue involvement, investigating neural structure
involvement and visualizing the formed abscess(12).
The VO presented in this article showed
vertebral spondylosis without destruction and
was diagnosed incidentally by CT carried out at
the ED after some unrelated vertebral plain film
findings. An MRI was not arranged by the ED in
the case presented in this article because the patient
presented at a weekend. In Taiwan, MRI may not
be available in some tertiary hospitals and is mostly
can only be arranged during daytime working
hours. Therefore, as an emergency physician and
based on my experience in the presented case, I
would suggest a CT scan is still a useful differential
diagnostic tool for any ED patient who is clinically
suspected of having VO, either with or without
paravertebral abscess complications.
The mainstay therapeutic choice when treating
VO is conservative treatment. The goal of any
surgical treatment is usually to relieve radicular
neurological deficit and spinal cord compression(16).
biopsy and for the management of severe pain(26).
In conclusion, emergency physicians usually
appetite or generalized body pain/soreness. These
may not be accompanied by fever even if the
patient is severely infected, as was the case with
the patient presented in this article. Vertebral
osteomyelitis can only be ruled out by an astute
clinician after a complete history has been taken
and a full physical examination has been carried
out; these need to be correlated with appropriate
laboratory findings. Finally, in order to diagnose
vertebral osteomyelitis, the physician needs to get
to the bottom of the problem and establish the true
origin of the disease, as well as the underlying
cause of the patient’s clinical presentations. There
needs to be correlation between the patient’s
laboratory findings and their radiographic changes,
which are far more important than their MRI results
and their ESR level. In addition, an early CT scan
study should be arranged at ED for any patient who
is suspected of vertebral osteomyelitis, whether this
is complicated by paravertebral abscess or not.
References
1. Ralph ZK, Joseph BH. Pyogenic vertebral
osteomyelitis: diagnosis and management. Can
Med Assoc J 1984;130:1025-7.
2. Jan L. pyogenic vertebral osteomyelitis/disc
infection. Bailleiere’s. Clinical Rheumatology
1999;13:59-75.
3. Torda AJ, Gottlied T, Bradbury R. Pyogenic
vertebral osteomyelitis: analysis of 20 cases
and review. Clin Infect Dis 1995;20:320-8.
4. Jaramillo-de la Torre JJ, Bohinski RJ, Kuntz
C.Vertebral osteomyelitis. Neurosurg Clin Am
2006;17:339-51.
Vertebral osteomyelitis with paravertebral abscess
5. Grammatico L, Baron S, Rush E, et al.
Epidemiology of vertebral osteomyelitis (VO)
in France: analysis of hospital-discharge data
2002-2003. Epidemiol Infect 2008;136:653-60.
6. Carlos P, Benito A, Xaier F, et al. Spontaneous
pyogenic vertebral osteomyelitis and
endocarditis: Incidence, risk factors, and
outcome. Am J Med 2005;118:128.e17-24.
7. M c H e n r y M C, E a s l e y K A, L o c k e r G A.
Vertebral osteomyelitis: long-term outcome for
253 patients from 7 Cleveland-area hospitals.
Clin Infect Dis 2002;34:1342-50.
8. Govender S. Spinal infections. The Journal of
Bone and Joint Surgery 2005;87-B:1454-8.
9. Werner Z. Vertebral osteomyelitis. N Engl J
Med 2010;362:1022-9.
10. Colmenero JD, Jimenez-Mejias ME, Sanchez
–Lora FJ, et al. Pyogenic, tuberculous, and
brucellar vertebral osteomyelitis: a descriptive
and comparative study of 219 cases. Ann
Rheum Dis 1997;56:709-15.
11. Judith L, Martin M. Spinal osteomyelitis: a
review of 10 years’ experience. Orthopedics
1995;18:561-5.
12. Myolna E, Samarkos M, Kakalou E, et al.
Pyogenic vertebral osteomyelitis: a systemic
review of clinical characteristics. Semin
Arthritis Rheum 2008,39:10-7.
13. Nolla JM, Ariza J, Gomez-Vaquero C, et al.
Spontaneous pyogenic vertebral osteomyelitis
ub nondrug users. Semin Arthritis Rheum
2002;31:271-8.
14. Chua F. Clinical picture. Lancet 2001;357:168.
15. Wa n g C C . P s e u d o m o n a s a e r u g i n o s a
costovertebral arthritis in association with
spontaneous cervical spondylodiscitis and
epidural abscesses in the elderly. J Clin Gerontol
Geriatr 2012;3:82-6.
16. R i c h a r d K O, P a t r i c k W H, A r n o l d H M.
Pyogenic vertebral osteomyelitis in adults.
17.
18.
19.
20.
21.
22.
23.
24.
25.
99
Surg Neurol 1990;33:266-75.
C h a n g T C, H u a n g M N, C h e n J C, e t a l
Infectious spondylodiscitis with abdominal
pain in ED. Am J Emerg Med 2011;29:133.
e1-e3.
Priest DH, Peacock JE jr. Hematogenous
vertebral osteomyelitis due to Staphylococcus
aureus in the adult: clinical features and
t h e r a p e u t i c s o u t c o m e s. S o u t h M e d J
2005;98:854-62.
Baldwin N, Scott AR, Heller SR, et al.
Vertebral and paravertebral sepsis in diabetes:
an easily missed cause of backache. Diabetic
Medicine 1985;2:395-7.
Khan MH, Smith PN. Rao N, et al. Serum
C-reactive protein levels correlate with clinical
response in patients treated with antibiotics for
wound infections after spinal surgey. Spine J
2006;6:311-5.
D e o d h a r S D. C-r e a c t i v e p r o t e i n: t h e
best laboratory indicator available for
monitoring disease activity. Cleve Clin J Med
1989;56:126-30.
Kenny RA, Saunders AP, Coll A, Harrington
MG, et al. A comparison of the erythrocyte
sedimentation rate and serum C-reactive
protein concentration in elderly patients. Age
Ageing 1985;14:15-20.
Osei-Bimpong A, Meek JH, Lewis SM. ESR
or CRP? A comparison of their clinical utility.
Hematology 2007;12:353-7.
C o s t e n b a d e r K H, C h i b n i k L B, S c h u r
P H. D i s c o r d a n c e b e t w e e n e r y t h r o c y t e
sedimentation rate and C-reactive protein
measurements: clinical significance. Clin Exp
Rheumatol 2007;25:746-9.
Hopkinson N, Stevenson J, Benjamin S. A case
ascertainment study of septic discitis: clinical,
microbiology and radiological features. Q J
Med 2001;94:465-70.
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脊椎骨髓炎合併椎旁膿腫：個案報告
馮卓超
椎體骨髓炎通常是以非特異性的臨床表現、實驗數據和放射線的變化。因而難以早期診斷，因而使
得死亡率增加。所以，它對許多臨床醫師，特別是急診醫師而言是一個具有挑戰性的診斷。我要報告一
例在急診室診斷出合併有椎旁膿腫的椎體骨髓炎。病患僅以背部疼痛方式表現，經由保守治療後，在無
併發症狀況下出院。
關鍵詞： 脊椎骨髓炎，椎旁膿腫
收件：102年4月3日　接受刊載：102年12月25日
新竹國泰綜合醫院 急診科
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