Thoracic Infectious Spondylitis After Surgical Treatments of Herniated Lumbar Intervertebral Disc
A 32-year-old Mongolian male developed lower back pains after a traffic accident and was diagnosed to have traumatic L3-4 and L4-5 herniation of intervertebral disc via magnetic resonance imaging (MRI) at a Mongolian orthopedic clinic. The patient had no past medical history of high blood pressure, diabetes, tuberculosis or hepatitis, and he was not a smoker. After a week, he had an operation on total laminectomy and discectomy at L3-4, L4-5 levels and posterior interbody fusions at L3-5 (). The patient had a fever 3 weeks after the surgery, and also developed bilateral lower extremities and external anal sphincter muscle weakness.\nTo investigate the causes of fever and neurological deficits, a lumbosacral MRI follow-up was performed but no definite abnormalities were found. Seven weeks after surgery, the patient was transferred to the department of neurosurgery at our medical institution for further evaluations and treatments. When performed a whole spine MRI, the T2 and T3 vertebral body destruction and compressive myelopathy were detected (, ). Anterior and posterior epidural mass formations caused the compressive myelopathy at T2 to T4 levels. In addition, the epidural mass was extended to bilateral T3-T4 neural foramen, thus, forming the paravertebral mass.\nBased on the laboratory studies, white blood cell (WBC) count resulted to 7,020/µL, the erythrocyte sedimentation rate (ESR) is at 54 mm/hr, and the C-reactive protein (CRP) level reached 0.87 mg/dL. The reported values represented increases from the normal ranges.\nUpon physical examinations, voluntary anal contracture was not checked. Therefore, a manual muscle testing in accordance to the Medical Research Council (MRC) scale was performed to the bilateral hip flexors and knee extensor which resulted in the MRC grade II. Bilateral ankle dorsiflexors, big toe extensors, and plantar flexors were checked as MRC grade I. Sensory deficit was noted below bilateral T9 dermatome. In addition, there were also no perianal and deep anal sensations. Both the left knee and ankle jerks were brisk. Babinski sign was bilaterally checked while the ankle clonus was not.\nOpen bone biopsy of thoracic vertebrae, blood culture, and antigen detection assays were performed to determine microorganisms. The specimens were sent for bacterial culture, acid-fast bacilli smear and culture, fungal culture and polymerase chain reaction for Mycobacterium tuberculosis. The results of the tests were all negative. Microscopic histological examinations of thoracic vertebrae biopsy revealed chronic spondylitis. T2 and T3 vertebrae showed hypercellular bone marrow tissues with bone desorptions and high cellularity with focal infiltrations of chronic inflammatory cells including plasma cells in normal marrow. An open biopsy of the soft tissues at the lumbar operative site was also performed which showed foreign body reactions with granulation tissues and fat necrosis.\nFor the treatment of compressive myelopathy, the patient had a decompression laminectomy at T2-T3 level. The patient was also treated by antibiotics. Nafcillin was applied for 11 days followed by cefadroxil for 5 weeks. The patient was then transferred to a rehabilitation medicine department when his neurological and medical conditions were stabilized.\nThe laboratory tests showed improvements after surgery and antibiotics treatments. Results were 5,900/µL, 14 mm/hr, and 0.38mg/dL, for the WBC count, ESR, and CRP level, respectively.\nAfter decompressions of laminectomy and antibiotics treatment, the weaknesses of bilateral lower extremities were improved. Bilateral hip flexor, bilateral knee extensors, and right ankle dorsiflexor were checked for MRC grade IV. Left ankle dorsiflexor, bilateral big toe extensors, and bilateral ankle plantar flexors were checked as grade III. Moreover, the voluntary anal contraction was mildly checked, and the perianal skin sense and deep anal sense were recovered. After positive examinations, the patient was discharged from the hospital with no additional complications.