Journal of Orthopaedic Association of South Indian States

CASE REPORT
Year
: 2021  |  Volume : 18  |  Issue : 1  |  Page : 24--27

Acute spondylodiscitis - A rare presentation of sacrocolpopexy complicated with chronic left iliac fossa discharging sinus


Suresh S Pillai1, Premdeep Dennison2, Usha Sreekumar3, Sailesh Aikot3, KV Deepa3,  
1 Department of Orthopaedics, BMH Spine Centre, Baby Memorial Hospital, Calicut, Kerala, India
2 Department of Orthopaedics, Gastro Surgery and Anaesthesia, Baby Memorial Hospital, Calicut, Kerala, India
3 Department of Gynaecology, Gastro Surgery and Anaesthesia, Baby Memorial Hospital, Calicut, Kerala, India

Correspondence Address:
Suresh S Pillai
Department of Orthopaedics, BMH Spine Centre, Baby Memorial Hospital, Calicut, Kerala
India

Abstract

Spondylodiscitis following sacrocolopopexy is a rare complication. Many cases of spondylodiscitis are preceded by infection elsewhere, most commonly the genitourinary tract. Inadvertent placement of bone anchors into the L5-S1 disc space likely results in an L5-S1 inflammatory process with infection often tracking along the suspension sutures attached to the bone anchors. Commonly onset of spondylodiscitis is in <1 year of index surgery (average 4 months) but is reported as late as 8 years. However, the patient presenting with chronic discharging sinus (6 years) and acute spondylodiscitis following sacrocolpopexy is not reported in the literature to the best of our knowledge. To report a case of lumbosacral (L5-S1) discitis in a patient who had a discharging sinus at the left iliac fossa following a sacral colpopexy procedure 6 years back. A 44-year-old female underwent laparoscopic sacral colpopexy for uterovaginal prolapse approximately 6 years back. Approximately 4 months after the surgery, she had abdominal pain and fever, followed by discharge from the left iliac fossa. She presented to the spine surgery outpatient department with severe back pain and difficulty in walking for the last 2 weeks. Magnetic resonance imaging revealed L5-S1 spondylodiscitis. She was managed collectively by a spine surgeon, gynecologist, and gastro surgeon. The principal aims of surgery are to debride infected disc tissue, which is avascular, and excision of the sinus tract along with the removal of the sling along with its anchor. To minimize L5-S1 spondylodiscitis during sacrocolpopexy, it is recommended to start the presacral dissection at the sacral promontory, which generally lies just below the steep lumbosacral angle.



How to cite this article:
Pillai SS, Dennison P, Sreekumar U, Aikot S, Deepa K V. Acute spondylodiscitis - A rare presentation of sacrocolpopexy complicated with chronic left iliac fossa discharging sinus.J Orthop Assoc South Indian States 2021;18:24-27


How to cite this URL:
Pillai SS, Dennison P, Sreekumar U, Aikot S, Deepa K V. Acute spondylodiscitis - A rare presentation of sacrocolpopexy complicated with chronic left iliac fossa discharging sinus. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 Jan 18 ];18:24-27
Available from: https://www.joasis.org/text.asp?2021/18/1/24/322299


Full Text



 Introduction



Pelvic organ prolapse is the descent of one or more of the pelvic organs (uterus, vagina, bladder, or bowel).[1] The “gold standard” procedure for vault prolapse is the sacral colpopexy that suspends the vaginal vault by reinforcing the anterior and posterior vaginal fibromuscularis with mesh secured to the anterior longitudinal sacral ligament on the height of the promontorium or at the sacral bone (S2).[2] Lumbosacral discitis is a rare complication following sacral colpopexy. We report a case of lumbosacral (L5-S1) discitis in a patient who had a discharging sinus at the left iliac fossa following a sacral colpopexy procedure 6 years back. There no similar case reported to the best of our knowledge.

 Case Report



A 44-years-old female, mother of a single child, presented with complaints of low back ache for the last 2 weeks. She had undergone laparoscopic sacral colpopexy for uterovaginal prolapse approximately 6 years back. Approximately 4 months after the surgery, she had abdominal pain and fever followed by discharge from the left iliac fossa. She was treated with antibiotics, and she responded to the treatment, and there was a temporary cessation of symptoms. She had persistent discharge from the left iliac fossa and on and exacerbation of abdominal pain for the last 6 years. She consulted different doctors for the same and was advised hysterectomy, for which she was not ready.

She presented to the spine surgery outpatient department with severe back pain and difficulty in walking for the last 2 weeks. On examination, she had a severe paraspinal spasm of the lumbar area and local tenderness over the lumbosacral junction. There was purulent discharge from the left iliac fossa which was kept bandaged and nursed herself for all these years. There is no history of diabetes mellitus or any immunosuppressive therapy. No other surgical history apart from the Sacro colpopexy. There are no signs of meningismus or motor or sensory deficit. Laboratory studies showed elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at 45 and 32.8, respectively. Her total leukocyte count was 7200 with neutrophil predominance 89%. Mantoux test for tuberculosis (TB) was negative.

The patient was evaluated with lumbar spine and pelvic magnetic resonance imaging (MRI) with and without contrast enhancement, which showed hypointense signals in the endplates of L5 and S1 and L5/S1 intervertebral disc on T1- and T2-weighted images and showing intense enhancement with contrast. Pre- and para-spinal soft tissues are normal. In the pelvis, collection is extending inferiorly around the left lateral aspect of the uterus and extending anteriorly on the left side of the urinary bladder up to the skin surface. Findings were suggestive of L5/S1 discitis and pelvic collection.

Gynecology, gastrosurgery, and infectious disease specialists were consulted. She was planned for laparotomy, hysterectomy with bilateral salpingo-oophorectomy, abscess drainage, and sinus tract excision in the supine position by a gynecologist and gastro surgeon. Under the same anesthesia, a minimally invasive L5/S1 discectomy was planned in the prone position. She underwent both procedures without any complications. The pus drained was sent for culture and sensitivity and TB-polymerase chain reaction (PCR). Removed uterus, ovaries, sinus tract, and the intervertebral disc were sent for histopathologic examination. Culture-yielded growth of Staphylococcus aureus sensitive to tetracyclin, clindamycin, linezolid, cefoxitin, cefalexin, cotrimoxazole, teicoplanin, rifampicin, and cloxacillin. Mycobacterium tuberculosis–PCR was negative. She was treated with intravenous antibiotics and changed to oral rifampicin and cloxacillin at discharge, which showed the maximum C/minimum inhibitory concentration values at 33 and 8, respectively. The patient improved symptomatically. Wounds healed, and the patient was comfortable at the time of discharge. She had good pain relief and was walking comfortably [Figure 1], [Figure 2], [Figure 3].{Figure 1}{Figure 2}{Figure 3}

 Discussion



Septic discitis is infection of the intervertebral disc space. However, the vertebral endplates are frequently involved, leading to infection of the vertebral body as well as the disc or spondylodiscitis. Many cases of spondylodiscitis are preceded by infection elsewhere, most commonly the genitourinary tract.[3] Inadvertent placement of bone anchors into the L5-S1 disc space likely results in an L5-S1 inflammatory process with infection often tracking along the suspension sutures attached to the bone anchors.[4]

Commonly onset of spondylodiscitis is in <1 year of index surgery (average 4 months) but is reported as late as 8 years.[5],[6],[7] However, the patient presenting with chronic discharging sinus (6 years) and acute spondylodiscitis following sacrocolpopexy is not reported in the literature to the best of our knowledge. Although the cause of discitis has not been proven, plausible etiologies include (1) direct penetration of the disc by sutures or metal tacks; (2) ascending bacterial infection from infected vaginal mesh; (3) hematogenous spread of organisms arising from sites such as the genitourinary system; or (4) a combination of these.[8]

MRI is the most sensitive (93%–96%) and specific (92.5%–97%) modality for early detection of spondylodiscitis.[3],[7],[9],[10] The inflammatory response to spondylodiscitis consists of edematous change within the bone marrow. This altered hydration state can be detected with MRI before bone destruction is manifest on X-rays or computed tomography.[3],[11] A rise in the ESR and CRP is seen in over 90% of patients.[3],[11],[12],[13] Leukocytosis occurs in <50%.[3],[12],[14],[15],[16]

A single organism is usually involved, and S. aureus is the most common organism isolated, implicated in 15%–84% of nontuberculous cases.[3],[9],[14] In patients with stable hemodynamics and normal neurologic examination, empiric antibiotic treatment should be held until a microbiologic diagnosis is established.[3],[17],[18] In our case, there was definite isolation and growth of the organism in both abdominal and disc samples (S. aureus).

The relative ability of different antibiotics to penetrate bone is well established, and a league table was produced by Grados et al. Fluoroquinolones, clindamycin, rifampicin, fusidic acid, and metronidazole all achieve excellent levels in bone. Beta lactam antibiotics and glycopeptides achieve moderate levels, whereas aminoglycosides diffuse into bone poorly.[3],[19] By contrast, the ability of antibiotics to penetrate disc tissue is less well established. Studies have correlated between ionic charge and penetration with negatively charged antibiotics such as penicillins penetrating much less well than positively charged drugs such as gentamicin. This relates to the nucleus pulposus being negatively charged. The message is Penicillins and cephalosporins do not penetrate the discs well, but clindamycin and aminoglycosides do. Quinolones and glycopeptides have intermediate penetration.[3],[20] Culture susceptible antibiotics should be continued for a minimum duration of 6 weeks.[17],[18] Grados et al. advocated an earlier switch to oral treatment, after 3 weeks of the intravenous route, or even after only 2 weeks if the CRP is normal at that time.[19] Drugs such as clindamycin, rifampicin, cotrimoxazole, fusidic acid, and fluoroquinolones have good intra-osseous penetration and oral bioavailability and when used in combination, may provide effective, early oral therapy, reducing the duration and cost of hospitalization and improving the patient comfort.[3],[21]

Surgery may be indicated for the resolution of significant spinal cord or radicular compression; prevention or correction of biomechanical instability and deformity; management of severe persistent pain; and drainage of abscesses. Some authors also advocate an open biopsy to identify the pathogen.[3] The principal aims of surgery is to debride infected disc tissue, which is avascular.[19] Spinal surgery can be done with debridement alone or with instrumentation, and ongoing infection is not a contraindication for spinal instrumentation.[17],[22]

To minimize L5-S1 spondylodiscitis during sacrocolpopexy, Good et al. recommend starting the presacral dissection at the sacral promontory, which generally lies just below the steep lumbosacral angle (average 60°). When the disc location is in question, avoid deep suture bites and metal fixation devices that penetrate the L5–S1 disc, which may increase the risk of infection. The ideal location for graft fixation is the anterior surface of S1, at or below the sacral promontory. With the endoscopic approach, a combination of Trendelenburg position and a 30° angle scope directed downward should improve visualization and allow precise needle placement.[8]

 Conclusion



Spondylodiscitis following sacrocolopopexy is a rare complication. A high index of suspicion should be present when evaluating a patient with significant back pain. A proper surgical history could be priceless. The physician should also look for signs of infection associated with surgery such as discharging sinus. Raised ESR and CRP could point to the diagnosis though leukocytosis is inconsistent. MRI remains the most sensitive and specific modality to confirm the diagnosis. Along with culture-specific antibiotic therapy, we recommend surgical removal of infected disc material and also removal of the infected material in abdomen and debridement. Inflammation scarring and adhesions can make surgery very risky with injury to bowel, ureters, and iliac vessels.

Although spondylodiscitis and osteomyelitis are uncommon, it should always be kept as a possible differential diagnosis in patients presenting with low backache after sacrocolpopexy. Rather than a chronic complaint, it could be a warning sign of a potentially serious complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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