extensive soft tissue defects accompanied by infectious spondylitis are rare clinically . in these cases , medical / surgical therapy that involves debridement of the dead tissue and treatment with antibiotics can take a long time to carry out and a considerable length of time may elapse before the patient recovers , with this lengthy period of recovery adversely influencing the clinical outcome of patients . in addition , management of massive soft tissue defects and chronic wounds are major challenges . various reports have proposed techniques of managing complex back wounds1,8,10 ) . published methods for treating the complex back wound of paraplegia patients it is even hard to find a case of a complex back wound of a paraplegic patient that is associated with a spinal infection in the literature . in this case , to treat the complex back wound that involved an extensive soft tissue defect associated with spinal infection , we tried a muscle flap technique that is mainly used in the plastic surgery field and not in neurosurgery in this hospital . the reverse latissimus dorsi muscle flap ( rldmf ) was our final choice for this patient . this muscle flap technique allowed us to fill up the extensive soft tissue defect , thereby reducing the dead space , and maintain the paraspinal vasculature . the objective of this report was to evaluate the efficacy of filling up the defect using rldmf in the treatment of severe infectious spondylitis . we observed that 6 months after the operation , the patient showed no sign of recurrence of infection and the back wounds had completely healed without any complication or sequela . a 68-year - old woman with a previous history of paraplegia after traumatic spinal epidural hemorrhage from a ruptured l3 arteriovenous fistula ( avf ) was admitted to our institute with high fever above 38 and severe back pain . about 10 days earlier , she suffered a superficial burn to her back and was admitted into the local hospital because of acute renal failure due to rhabdomyolysis . on neurologic examination , examination of the motor system revealed intact muscle strength in the upper extremity and flaccid paraplegia with areflexia . an examination of the sensory system revealed that all sensory modalities had decreased below the t10 dermatome level . an abdominal computed tomography scan demonstrated a suspicious pyogenic spondylitis of multiple lumbar spines with multiple perivertebral abscess formation and fluid collections around the pyriform muscles and parasacral area . a drainage catheter was inserted by a radiologist and the patient was admitted into the infectious diseases ward for antibiotic therapy . empirical antibiotic therapy with ampicillin and sulbactam drug fever developed after nafcillin was given , so the antibiotic was changed to cefazolin . this antibiotic was maintained until the culture of the draining catheter was identified . on culture of the draining catheter , after 14 days on that regimen , the antibiotic was changed to teicoplanin because the patient developed a skin rash . despite conservative therapy using the appropriate antibiotics for 3 months and surgical drainage we thought that the fluid collection in the dead space between the intra-/inter - muscular area and the scar of the previously embolized avf was the main source of infection recurrence ( fig . we believed that by filling the dead space , we would be able to control the spondylitis . first , we performed multiple posterior screw fixations from l1 to the sacrum with wide debridement of infected soft tissue and obliteration of dead space using rldmf ( fig . 2 ) . second , we performed anterior column reconstruction with an expandable mesh cage via an anterolateral reptroperitoneal approach to correct deformity and bone fusion . after the staged operation and antibiotic therapy , the multiple infectious spondylitis completely resolved without recurrence ( fig . conservative management of pyogenic spondylitis is the traditionally used approach5 ) . in certain pyogenic spondylitis cases , surgical treatment is strongly indicated , but invasive surgeries often cause various problems . when the patient 's general condition is poor , less invasive treatment is required . the standard management of infectious spondylodiscitis with spinal epidural abscess has been surgical debridement with or without operative stabilization , followed by prolonged antibiotic treatment7 ) . nevertheless traditional surgical treatment for pyogenic spondylitis has the disadvantage of increased morbidity caused by the extensive exposure of the wound in the presence of infection . percutaneous suction aspiration with drainage is another effective alternative for not only mild to moderate spondylodiscitis but also for early - stage pyogenic spondylodiscitis . nagata et al.12 ) , indicated that the main advantages of the technique were its reduced invasiveness compared with open surgery , and the almost immediate symptomatic relief it provided . indications for this technique are considered to include the following : 1 ) no improvement in the condition of the patient despite use of antibiotic agents and immobilization for at least 1 month ; 2 ) the presence of only a single affected intervertebral disc ; 3 ) the location of the involved vertebra in the lower thoracic or lumbar spine ; 4 ) the absence of any major neurological deficit ; and 5 ) the absence of radiographically documented marked destructive changes in the affected vertebral body . but this treatment is not indicated in severe pyogenic spondylodiscitis in which abscess formation or marked bone destruction or extensive soft tissue defect is associated with a potential risk of neurological complications , such as existed in our case . in addition , the procedure failed to improve symptoms in one patient in whom marked destructive changes were apparent on radiography , and open surgery involving an implantation was necessary in that case . in the presence of instrumentation , providing preemptive soft tissue reconstruction at the time of the initial spinal surgery can help minimize potentially serious wound complications . for management of wound complications that have developed , aggressive debridement and coverage with well - vascularized tissue can allow for expedient wound healing while maintaining stabilized instrumentation . in extensive soft tissue defects accompanied by infectious spondylitis , such as in our case , the conventional approach using serial wound debridement and antibiotic administration could take a considerable period to complete , and is usually only successful in cases of mild infections . in more severe cases of infection with an extensive soft tissue defect , marked skin and muscle reactive fibrosis adjacent to the wound makes using paraspinous muscle flaps to close the defect difficult , if dissection is possible in the first place . moreover , even if they can be dissected , they often are of insufficient volume to fill these wide and deep wounds . in this situation , pedicled latissimus dorsi muscle flaps have proven to be the most reliable method of treatment . generally , the muscles of the back can be classified into 3 groups : superficial , intermediate , and deep groups . the superficial muscles such as the latissimus dorsi muscle are often valuable sources for a secondary flap in paraspinous muscle reconstruction as soft tissue defects are usually deep and extensive or require a skin island4 ) . the pedicled latissimus dorsi flap proved to be a valuable and reliable tool to treat large and deep back wound infections with extensive soft tissue defects . it can be used as a musculocutaneous advancement or rotation flap when laterally based ( thoracodorsal vessels ) , or as a muscular turnover flap , when medially based ( paraspinous perforators ) . this versatility enabled the latissimus dorsi flap arc of rotation to reach midline spine defects from high thoracic through lower lumbar levels . and as the procedure is simple and the blood circulation stable during this operation , it is thought to be an effective reconstruction method for extensive soft tissue defects accompanied by infectious spondylitis . it is true that literature has been published on methods of operative defect closure in the case of complex back wounds . however , since the data available is limited and the numbers of cases are relatively small in these studies , any comparison between the use of the pedicled latissimus dorsi flap and other methods such as the use of free flaps2,6 ) , perforator flaps9 ) , or tissue expansion13 ) , combined methods3 ) , paraspinous muscle flaps10 ) and superior gluteal muscle flaps15 ) are precluded . use of the rldmf , which was attempted in our patient , is a reliable method of treatment of infectious spondylitis with an extensive soft tissue defect11 ) . we experienced good surgical and clinical outcome using rldmf in treating intractable spinal infection . hence , we recommend rldmf in the case of infectious spondylitis with an extensive soft tissue defect or dead space and uncontrolled recurrent spinal infection .