Primary pyogenic spondylitis following kyphoplasty: a case report
© Schofer et al; licensee BioMed Central Ltd. 2011
Received: 14 March 2010
Accepted: 13 March 2011
Published: 13 March 2011
Only ten cases of primary pyogenic spondylitis following vertebroplasty have been reported in the literature. To the best of our knowledge, we present the first reported case of primary pyogenic spondylitis and spondylodiscitis caused by kyphoplasty.
A 72-year old Caucasian man with an osteoporotic compression fracture of the first lumbar vertebra after kyphoplasty developed sensory incomplete paraplegia below the first lumbar vertebra. This was caused by myelon compression following pyogenic spondylitis with a psoas abscess. Computed tomography guided aspiration of the abscess cavity yielded group C Streptococcus. The psoas abscess was percutaneously drained and laminectomy and posterior instrumentation with an internal fixator from the eleventh thoracic vertebra to the fourth lumbar vertebra was performed. In a second operation, corpectomy of the first lumbar vertebra with cement removal and fusion from the twelfth thoracic vertebra to the second lumbar vertebra with a titanium cage was performed. Six weeks postoperatively, the patient was pain free with no neurologic deficits or signs of infection.
Pyogenic spondylitis is an extremely rare complication after kyphoplasty. When these patients develop recurrent back pain postoperatively, the diagnosis of pyogenic spondylitis must be considered.
Vertebroplasty and kyphoplasty are discussed critically in the literature [1–6]. The overall risks of these procedures are low and more severe complications such as spinal cord compression or pulmonary embolism are very rare (0.01%-0.03%) after kyphoplasty . Older patients undergoing kyphoplasty may have risk factors for immunocompromise, such as diabetes or renal insufficiency. Until now, there have been no reported cases of primary pyogenic spondylitis or spondylodiscitis after kyphoplasty.
Re-exploration was recommended but was refused by the patient due to his poor general medical condition, although he was informed about the risk of a progression to complete paralysis. The patient underwent CT-guided aspiration and drainage of the psoas abscess. Cultures grew group C hemolytic Streptococcus. He was initially treated conservatively with a six-week course of cefuroxime and clindamycin. The abscess cavity was irrigated daily with normal saline until drain removal on post procedure day six.
Literature review of 10 reported cases of pyogenic spondylitis following vertebroplasty.
Affected vertebral body
Time from vertebroplasty until infection
Urinary tract infection
T11 and T12
Urinary tract infection, cholecystitis, meningitis, diabetes mellitus
Discectomy after spondylodiscitis T12/L1
L3 - L5
Liver cirrhosis, alcohol abuse
Serratia marcescens, Stenotrophmonas maltophilia, Burkholderia cepacia
Diabetes mellitus, decubital ulcus II
Immunosuppressive therapy, urinary tract infection
Diabetes mellitus, vertebroplasty T12
Drainage with subsequent vertebroplasty
There is no established evidence as to why more infectious complications have been observed in vertebroplasty versus kyphoplasty. However, the incidence of infectious complications may be attributable to comorbidities, suggesting that high-risk patients may need specific prophylactic antibiotic treatment in order to avoid pyogenic spondylitis. Before our patient's initial kyphoplasty, preoperative imaging and blood tests did not indicate an infectious source in the vertebral body; the bone cylinder biopsy did not show signs of malignancy or infection. Therefore, it is unlikely that an infection that caused the spondylitis was already present. Although the patient had a history of Parkinson's disease and coronary artery disease, these are not regarded as contraindications to kyphoplasty. However, postoperative morbidity may be increased with these comorbidities. One possible cause for an iatrogenic pyogenic infection could be contamination from skin flora . Pyogenic spondylitis and spondylodiscitis following spinal anesthesia have been reported and this may have been the case in our patient; if so, a single dose antibiotic prophylaxis with a first-generation cephalosporin may have been inadequate. To date, there are no official guidelines for antibiotic prophylaxis in spinal surgery.
The cement traditionally used in kyphoplasty does not contain antibiotics. However, the increasing use of antibiotic cement in endoprosthetic surgery is documented. The use of antibiotic cement must be evaluated bearing in mind a patient's individual risk factors, such as age and comorbidities. In immunocompromised patients, the use of antibiotic cement and prolonged perioperative antibiotic prophylaxis should be considered in order to avoid infectious complications. In our case, we propose that there may be a benefit from the use of antibiotic cement in spine augmentation. This area requires further investigation with controlled studies.
In addition, early and emergent spinal cord decompression of the spinal cord is the standard of care. Conservative treatment in this situation is not ideal but we were limited by the patient's refusal to proceed with our initial recommendations. In this case, the primary presenting symptom was recurrent severe back pain. Therefore, severe back pain after a pain-free interval following kyphoplasty must be investigated in order to rule out pyogenic spondylitis. Another diagnosis in the differential that should be considered in such a scenario, especially without adjacent segment fractures, is vertebral necrosis associated with cement injection.
Complications following kyphoplasty are rare, especially compared with the number of surgeries performed. In pyogenic spondylitis, treatment is laborious and extends over a long period, often involving multiple surgeries. In elderly patients and those with multiple comorbidities, pyogenic spondylitis can be life-threatening. Therefore, antibiotic prophylaxis is likely to be extremely important for the prevention of infectious complications following kyphoplasty in high-risk patients. In these patients, antibiotic cement should be considered.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
eleventh thoracic vertebra
twelfth thoracic vertebra
first lumbar vertebra
second lumbar vertebra
third lumbar vertebra
fourth lumbar vertebra
magnetic resonance imaging
visual analog scale.
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