Spondylodiscitis is a rare disease which is generally seen after long-term epidural catheterization. However, spondylidiscitis developing after diagnostic lumbar puncture is very rare. Early diagnosis has a crucial role in the management of the disease and inclines the morbidity rates. However, the diagnosis is often delayed due to the rarity and insidious onset of the disease usually presenting with low back pain which has a high frequency in the society. If it is diagnosed early before development of an abscess requiring surgery or neurological deficit, it responds to antimicrobial therapy quite well. We report 66-year-old male case of spondylodiscitis developing after diagnostic lumbar puncture. The patient was treated with antimicrobial therapy. After antimicrobial therapy, findings of spondylodiscitis were completely resolved and no recurrence was seen in the period of 9-month followup.
Spondylodiscitis is characterized by vertebral osteomyelitis, spondylitis, and discitis. Diagnosis is made with the combination of clinical, radiological, and laboratory findings. Patients present with persistent low back pain, fever, or neurological findings [
66-years-old male patient was admitted with 3-month history of gait disturbance, urinary incontinence, and mental decline. In cranial CT and MRI scans normal pressure hydrocephalus was suspected, and diagnostic lumbar puncture was done three times every other day. Patient complained of low back pain after the third puncture. Systemic examination was unremarkable. There was no fever. Laboratory examination revealed elevated erythrocyte sedimentation rate (80 mm/h) and C-reactive protein level (3.6 mg/L) with 9.5
(A) Discitis and osteomyelitis are seen on this T2-weighted MR image of the lumbar spine which demonstrates infective destruction of the L4-5 disk space with the adjacent L4 and L5 vertebral bodies. (B) T2-weighted MR image of the lumbar spine demonstrates diskitis and osteomyelitis persisting despite 4-week treatment of ceftazidime and vancomycine. (C) Eight weeks after the treatment of teikoplanin. T2-weighted MR image of the lumbar spine demonstrates significant resolution in signs of discitis and osteomyelitis. (D) Nine months after the diagnosis. T2-weighted MR image of the lumbar spine demonstrates no recurrence of discitis or osteomyelitis.
Ceftazidime (6000 mg/day) and vancomycin (2000 mg/day) were given for 4 weeks. The blood and CSF cultures were negative. In lumbar MRI scan done after 4 weeks of ceftazidime and vancomycine treatment, signs of spondylodiscitis were persisting (Figure
Antimicrobial therapy was replaced by teikoplanin (200 mg/day). After 8-week treatment of teikoplanin, infection markers declined to normal ranges, and the patient improved clinically. Lumbar MRI scan revealed significant improvement in signs of spondylodiscitis (Figure
Iatrogenic spondylodiscitis may occur as complication of lumbar disc surgery, epidural catheterization, laser discectomy, percutaneous lumbar nucleotomy, lumbar puncture, and discography [
The diagnosis of spondylodiscitis is usually delayed due to high frequency of low back pain beside the rarity and insidious onset of the disease. When the diagnosis is delayed the mortality and morbidity increase [
Predisposing factors for spondylodiscitis are foci of local infections, remote infections, AIDS, alcohol use, chronic renal failure, diabetes mellitus, intravenous drug use, malignancy, history of spinal surgery, lumbar catheterization, lumbar puncture, and history of spinal trauma [
Spondylodiscitis usually presents with fever, low back pain, local tenderness, neurological deficit, or high infection markers [
MRI is the most commonly preferred imaging method with the 96% sensitivity and 93% specificity rates due to its superiority to show soft tissues, epidural area, and disc space [
Spondylodiscitis may result from hematogenous spread, direct inoculation, and inoculation from nearby infective tissues [
The interval between microbial inoculation and occurrence of clinical manifestations of spondylodiscitis is from 2 to 6 weeks [
Spondylodiscitis may be bacterial, fungal, parasitic, or mycobacterial [
Antimicrobial therapy is a very important issue in management of spondylodiscitis, whether or not surgical intervention is required. Successful results are achieved with appropriate antibiotics given in sufficient dose and duration. Pathogen-specific antibiotherapy should be given parenterally for 6–12 weeks [
In our case, spondylodiscitis may have been resulted from direct inoculation due to nonoptimized sterile conditions. For this reason, optimal sterile conditions should be accomplished especially when serial lumbar punctures will be performed. In any clinical suspect, spondylodiscitis should be diagnosed early, and treatment should begin as soon as possible considering satisfying response of spondylodiscitis to antimicrobial therapy in cases of early diagnosis.