Lumbar spine epidural abscess and facet joint septic arthritis in a pediatric patient.

Abstract

A 13-year-old girl presented with lower back pain that began 7 days earlier after a volleyball workout. She had no history of trauma or fever. On physical examination, a contraction of the left paravertebral muscles associated with pain on flexion-extension of the spine and a positive left Lasègue's sign were evident. She had no neurological deficits in the lower limbs. Chest and lumbosacral X-rays were unremarkable, and a laboratory investigation revealed neutrophilia and elevated C-reactive protein (75.7 mg/L; normal value < 5). Urine and blood cultures were carried out before starting ceftriaxone. She developed a fever (38.8 °C) 1 day after admission, and the blood culture was positive for methicillin-sensitive Staphylococcus aureus. A lumbosacral magnetic resonance imaging (MRI) scan was performed considering the clinical and microbiological evidence and suspecting an osteoarticular infection. The MRI revealed a small amount of interarticular fluid in the left L4-L5 hemivertebral region and a posterior spinal epidural abscess on the left side extending from L4 to L5-S1 (Fig. 1). The diagnosis was lumbar spine epidural abscess (SEA) and facet joint septic arthritis (SAFJ). As the girl did not present with neurological symptoms, no surgical treatment was indicated, and cefazolin was administered intravenously with rapid resolution of the fever and pain. She was discharged after 4 weeks of intravenous antimicrobial therapy, which was followed by 4 more weeks of oral antibiotic therapy with levofloxacin. The 3-month follow-up MRI showed complete regression of the epidural fluid and almost complete normalization of the signal abnormalities in the L4-L5 soft tissues (Fig. S1). Facet joint septic arthritis is a rare condition.1Mas-Atance J. Gil-García M.I. Jover-Sáenz A. Curià-Jové E. Jové-Talavera R. Charlez-Marco A. et al.Septi carthritis of a posteriorlumbarfacet joint in an infant: a case report.Spine (Phila Pa 1976). 2009; 34: E465-E468Crossref PubMed Scopus (10) Google Scholar Few pediatric cases have been described, mainly in immunosuppressed patients. The most commonly associated pathogen is S. aureus.2Cabet S. Perge K. Ouziel A. Vandergugten S. Guibaud L. Ferry T. et al.Septic arthritis of facet joint in children: a systematic review and a 10-year consecutive case series.Pediatr Infect Dis J. 2021; 40: 411-417Crossref PubMed Scopus (0) Google Scholar The mechanism of the spread of this infection is not understood, but contamination may originate from direct inoculation, contiguity, or hematogenous dissemination. In the present case, the patient had no history of lumbar or epidural injections, so the most likely origin was hematogenous dissemination. The coexistence of localized epidural, articular, and paravertebral abnormalities on an MRI examination acquired only a few days after symptom onset led us to speculate that the infection originated in the left L4-L5 zygoapophyseal joint and spread to contiguous tissues, both inside and outside the lumbar canal. The three most common presenting symptoms of spinal epidural abscess are back pain, fever, and neurological deficit; however, these symptoms do not always occur together, contributing to the delayed diagnosis, which is reported in 50%–75% of cases.3Reihsaus E. Waldbaur H. Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients.Neurosurg Rev. 2000; 23: 175-204Crossref PubMed Google Scholar Surgery is reserved for nonantibiotic responders or in cases of neurologic deficit. Lumbar SEA and SAFJ are clinical emergencies with significant morbidity and mortality, particularly when there is a delayed diagnosis. Therefore, early clinical suspicion, diagnosis, and treatment are essential to obtain a favorable outcome.4Davis D.P. Wold R.M. Patel R.J. Tran A.J. Tokhi R.N. Chan T.C. et al.The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess.J Emerg Med. 2004; 26: 285-291Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar The authors declares that there is no conflict of interest regarding the publication of this paper. The following is the supplementary data to this article: Download .docx (2.14 MB) Help with docx files Multimedia component 1