Joint Bone Spine 73 (2006) 753–755 http://france.elsevier.com/direct/BONSOI/
Case report
Posterior spinal epidural abscess: an unusual complication of vertebroplasty Yetkin Söyüncü a,*, Hakan Özdemir a, Seçgin Söyüncü b, Zekiye Bigat c, Semih Gür a a
Department of orthopedics and traumatology, school of medicine, Akdeniz university, Dumlupınar street, Campus, 07070 Antalya, Turkey b Department of emergency medicine, school of medicine, Akdeniz university, Antalya, Turkey c Department of anesthesiology, school of medicine, Akdeniz university, Antalya, Turkey Received 22 October 2005; accepted 31 January 2006 Available online 25 April 2006
Abstract Objective: Complications after vertebroplasty are rare. There are few reported infectious complications requiring surgical management such as corpectomy with anterior reconstruction and posterior stabilization, although we have not seen any reports about epidural abscess in the literature. We present a patient in whom posterior epidural abscess developed after vertebroplasty in which drainage and antibiotherapy were required for treatment. Methods: A 70-year-old female with a painful T12 osteoporotic compression fracture underwent percutaneous vertebroplasty using polymethylmethacrylate without complication. One week after vertebroplasty, however, she had fever and increased back pain. On clinical examination, soft tissue abscess formation was determined at the vertebroplasty site. This was drained surgically and antibiotic treatment was started. At follow-up, she had progressive neurological deterioration (paraparetic) on the 18th day after abscess drainage. MRI of the thoracolombar spine revealed posterior spinal epidural abscess at the T11/12 level. Partial laminectomy and drainage were performed. She had complete neurological recovery in the follow-up period. Conclusion: An epidural abscess, which is an unusual complication of vertebroplasty, represents a medical and surgical emergency. Treatment is generally urgent surgical drainage combined with antibiotics. The patient should be evaluated in detail for systemic infectious disease and comorbid conditions before the vertebroplasty procedure. © 2006 Elsevier Masson SAS. All rights reserved. Keywords: Vertebroplasty; Infection; Epidural abscess; Osteoporosis
1. Introduction Vertebroplasty and kyphoplasty are relatively new techniques that are being used to treat painful vertebral compression fractures. Vertebroplasty is the percutaneous injection of a vertebral body with bone cement. Use of percutaneous vertebroplasty for the treatment of painful hemangiomas was first reported during the late 1980s [1]. Recently, its indication has been expanded to include osteoporotic compression fractures, traumatic compression fractures, and painful vertebral metastasis [2,3]. Infectious complications requiring surgical management after vertebroplasty in an osteoporotic patient have rarely * Corresponding author. Tel.: +90 242 22 74343/66249; fax: +90 242 22 74329. E-mail address:
[email protected] (Y. Söyüncü).
1297-319X/$ - see front matter © 2006 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2006.01.015
been reported in the literature. Only a few English-language articles were found in which postvertebroplasty infections were detailed [4–7] and only three reported cases of pyogenic spondylitis following vertebroplasty were identified [6,7]. We present a patient in whom posterior epidural abscess complicated with neurological deterioration developed after vertebroplasty in which surgical drainage and antibiotherapy were required for treatment. To the best of our knowledge, this is the first reported case of posterior epidural abscess without pyogenic spondylitis as a complication of vertebroplasty. 2. Case report A 70-year-old female with osteoporotic compression fracture of the 12th thoracic vertebral body confirmed by radiography was admitted to our hospital. She had a medical history for
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type II diabetes mellitus and hypertension, and these were brought under control by medicine. Neurological examination results were normal. CT imaging showed vertebral collapse without posterior cortical breakage, and MR imaging showed loss of normal signals from the marrow space of the 12th thoracic vertebrae. The pain, located at the thoracolumbar junction, had not been sufficiently relieved by rest, analgesics, nonsteroidal anti-inflammatory drugs and calcitonin therapy. Four weeks after injury, she underwent T12 vertebroplasty. At that time there were no radiological or laboratory signs of infection and malignancy. Percutaneous vertebroplasty was performed with the patient under general endotracheal anesthesia and in a prone position. One dose of cefazolin (1 g) was administered before the operation. Under fluoroscopic guidance an 11-gauge bone marrow biopsy needle was introduced through a posterior one side transpedicular approach into the vertebral body. Biopsy was taken from the vertebral body before the injection of the polymethylmethacrylate (PMMA) and did not show infection or malignancy. For the procedure, CMV 1 original® (bone cement powder—methylmethacrylate polymer 40 g, bone cement liquid methylmethacrylate monomer 20.72 g, and barium sulfate 5 g; Depuy, UK) was used without complication. The pain symptoms improved following the operation, and the patient was able to sit on and get out of bed using a walker. One week after vertebroplasty, however, she had increased back pain and a spiking fever. On clinical examination, abscess formation was determined at the soft tissue around the thoracolumbar area. At that time, the patient’s body temperature was 38.7 °C, and the white blood cell (WBC) count was 12,000 per mm3 with 85% segmented neutrophils. Her erythrocyte sedimentation rate was 95 mm/hour and C-reactive protein was (+++). The site was drained surgically and swabs were taken. These ultimately grew S. aureus which was sensitive to vancomycin, and antibiotic treatment was started. On the 18th day after abscess drainage, she had progressive neurological deterioration. Neurologically, she had 3/5 lower extremity weakness and a sensory level to pain and temperature of L 3. Anal tone was present and she did not require a urinary catheter. Her temperature was mildly elevated (38 °C). The WBC count was 12,300 per mm3 and the sedimentation rate was 100 mm/hour. She was immediately taken to the MR imaging unit. This revealed a posterior epidural abscess causing spinal cord compression at the T11–12 vertebral body level (Fig. S1; see the supplementary material associated with this article online). The patient was immediately taken to the operating room. Using a posterior approach, limited laminectomy was performed at T11/12. Liquid pus was encountered intraoperatively, and the epidural space was washed thoroughly with saline solution, purulent material was evacuated and the spinal cord was decompressed. Over the next few days, she had complete neurological recovery. Cultures of intraoperative swabs yielded S. aureus, and the patient was maintained on intravenous vancomycin therapy for 6 weeks. Postoperatively, the inflammatory markers (sedimentation and C-reactive protein) fell to normal. Repeated MR imaging showed resolution of the abscess (Fig. S2). Four months after surgery, the patient was able to walk unassisted. Twenty months after surgery, she had little
back pain and this did not prevent her daily activities, and stress radiographies did not show any instability. 3. Discussion The prevalence of vertebral compression fracture in women 50 years of age and older has been estimated at 26%. The prevalence increases with age, reaching 40% in 80-year-old woman [8]. Osteoporotic vertebral compression fractures are a common and significant public health problem. Recommended treatment of osteoporotic vertebral compression fractures commonly includes bedrest, bracing, and pain medications. Bedrest accelerates bone loss, however, and functional decline is common, and in many patients the pain is refractory to these measures. Operative stabilization is rarely employed because of its significant rate of morbidity and a high likelihood of instrumentation failure [9]. Vertebroplasty is relatively a new technique used to treat painful vertebral compression fracture [2,10]. The risk/benefit ratio appears to be favorable in carefully selected patients. The risks associated with the procedures are low but serious complications can occur. These complications include radiculopathy, paralysis, worsening pain, pulmonary emboli, bleeding, infection and rib fractures [11–13]. New vertebral compression fractures adjacent to those that have already been treated have been implicated, particularly when large amounts of cement have leaked into the adjacent disc spaces. Infectious complications are generally considered very rare [4– 7]. A Medline search revealed only four English-language papers concerning postvertebroplasty infection, thought none of these referred to the isolated posterior epidural abscess. The focus of this study is to present posterior epidural space infection without osteomyelitis complicated with neurological deterioration after vertebroplasty. We did not aim to present the treatment strategies for the spinal epidural abscess or results of the infection. Our case illustrates several points that differ from the cases presented in the literature. When we evaluated our patient she had neither a history of prior infection nor a distant focus of infection before the vertebroplasty. When we examined the literature we noted that Walker et al. and Yu et al. [6,7] reported previous infections before vertebroplasty. The patient described by Yu et al. had a urinary tract infection that was treated with intravenous antibiotic drugs before vertebroplasty. In Walker’s series, two patients also had previous infections. One of the patients had a pre-existing urinary tract infection as well as recent sepsis. She had received antibiotic medications for several weeks before vertebroplasty. The other patient had undergone previous discectomies for discitis. These infections resulted in the patients undergoing extensive anterior and posterior surgeries for debridement and stabilization. On the other hand, Kallmes et al. [4] reported iatrogenic Staphylococcus epidermiditis infection in one case. That patient was severely immunocompromised as a result of high dose steroid therapy, and infection was more likely secondary to the patient’s severely immunocompromised state. Comorbid conditions that may impair immunocompetence are commonly associated with spinal epidural abscess. Diabetes mellitus is the
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most frequent, but intravenous drug use, chronic renal failure, alcoholism, and cancer are also commonly associated [14–17]. Our patient was not immunocompromised, but diabetes mellitus may be the predisposing factor for the soft tissue infection and epidural abscess. The majority of epidural abscesses are from hematogenous spread, as well as being located posteriorly. In some cases (from 16% to more than 40%) the source of infection may not be identified [14,15]. In those cases in which a source can be determined, the skin and soft-tissue represent up to 25% of cases, whereas previous spinal surgery, osteomyelitis, spinal trauma, and the urinary and respiratory tracts are other common probable sources or associated conditions [14,15]. If the probable source of infection is the skin, or if there is associated blunt spinal trauma, S. aureus is essentially always the infectious organism [14]. In our case we did not determine infection of the posterior and anterior elements of the vertebrae either clinically or radiographically (MRI), so our theory was hematogenenous spread or secondary to soft tissue infection. In conclusion, an epidural abscess, which is an unusual complication of vertebroplasty, may represent a medical and surgical emergency. To prevent this serious complication, the patient should be evaluated in detail for systemic infectious disease and comorbid conditions before the vertebroplasty procedure. Sterile conditions and infection prophylaxis such as cement mixed with antibiotic drugs may be a solution in risky patients but it is not possible to say that preoperative antibiotic regimen is a suitable strategy in our case report. Although vertebroplasty is highly efficacious for pain relief and mobility, we should emphasize that the procedure is technically demanding and holds the potential for significant complications. The more randomized controlled trials are needed to compare the outcomes of vertebroplasty with those of more conservative therapies. Supplementary material Supplementary material (Fig. S1, S2) associated with this article can be found, in the online version, at http://www.sciencedirect.com, doi:10.1016/j.jbspin.2006.01.015.
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