Strange and Dangerous Spinal Infections.

Abstract

Because of the spine’s important roles in mobility, flexibility, and protecting the central nervous system, the stakes are high for patients and orthopaedists when confronting spinal conditions. Infections of the spine are particularly challenging because they often present emergently, can be difficult to diagnose precisely, and can have catastrophic or fatal outcomes if not treated effectively. This month’s “Case Connections” discusses five cases of rare but serious spinal infections. Although these events occurred outside the United States, the causative infectious pathogens are “alive and well” in America. In the September 9, 2015 issue of JBJS Case Connector , Rosinsky et al. reported on a sixty-five-year-old man who presented with fever and intractable lumbar pain that radiated to his right leg. He was otherwise healthy and had no history of trauma, tuberculosis, or malignancy. A neurological exam revealed normal muscle strength and no sensory deficits in the upper or lower limbs. However, one day after presentation, his fever and levels of inflammatory mediators spiked. Blood cultures came back positive for methicillin-susceptible Staphylococcus aureus (MSSA), and a sagittal MRI scan showed a large lobulated epidural abscess at L4-S1, with paraspinal muscle extension and hyperintense signals of the meninges and proximal nerve roots (Fig. 1). Axial MRI revealed intradural extension of the abscess. Fig. 1 Sagittal MRI scan showing posterior and anterior epidural abscesses (dashed red arrows) and hyperintense signal suggesting inflammation of the meninges and nerve roots at L1-L3 (white arrow). Surgeons performed an L3-S1 laminectomy, during which they encountered frank pus around the S1 foramen, purulence in the paraspinal muscles, and multiple dural perforations. Surprisingly, they did not find a cerebrospinal fluid (CSF) leak, hypothesizing that the inflamed meninges and nerve roots acted as a plug that prevented CSF from leaking through the holes in the dura. The dura was friable around …