Extension of lumbar spine infection into osteoarthritic hip through psoas abscess

We present a case of pyogenic lumbar discitis and septic hip arthritis, accompanied by a psoas abscess and pyogenic iliopsoas bursitis, for which the correct diagnosis was delayed. The patho-mechanism was speculated to be initial hematogenous infection in the lumbar spine that spread along the psoas muscle as a psoas abscess and then extended into the hip joint via the iliopsoas bursa. For an early correct diagnosis, clinicians should be aware that the lumbar spine and hip joint regions communicate through the psoas muscle space and iliopsoas bursa, making it possible for infection to spread.     

Vertebral osteomyelitis, epidural and psoas abscess after epidural catheter use

We report on a patient who developed persistent low back pain, pyrexia and neurological deficit soon after she underwent a laparotomy under combined general and epidural anaesthesia. The diagnosis of lumbar vertebral osteomyelitis, discitis, epidural and psoas abscesses was made one month later when she was referred to our institution. The patient was successfully treated with posterior decompression, drainage of the epidural abscess and fusion in combination with percutaneous, computed tomography-guided needle aspiration of the psoas abscesses.     

Psoas abscesses complicating colonic disease: imaging and therapy

Most surgeons think of psoas abscesses as a very rare condition related to tuberculosis of the spine, but in contemporary surgical practice they are more usually a complication of gastrointestinal disease. A case note study was undertaken on all patients treated for psoas abscess at two large hospitals in the mid-Trent region over a 2-year period. All seven patients presented with pyrexia, psoas spasm, a tender mass and leucocytosis. The diagnosis was made on abdominal radiographs in one patient, CT scan in three, MRI in two, and ultrasound in one. Aetiological factors included Crohn's disease in three, appendicitis in two, and sigmoid diverticulitis and metastatic colorectal carcinoma in one each. Six patients underwent transabdominal resection of the diseased bowel, retroperitoneal debridement and external drainage of the abscess cavity. Percutaneous drainage was performed in one. Two patients had more than one surgical exploration for complications. There were no deaths and the hospital stay ranged from 8-152 days. Psoas abscess can be a difficult and protracted problem. Bowel resection, thorough debridement, external drainage and concomitant antibiotics are essential for psoas abscesses complicating gastrointestinal disease. Defunctioning stomas may be necessary. However, in some cases a multidisciplinary approach may be required, as psoas abscesses can involve bone and joints.     

Psoasabszesse

BACKGROUND: A psoas abscess is a rarely encountered entity with various etiologies and nonspecific clinical presentation, frequently resulting in delayed diagnosis, increased morbidity, and prolonged or recurrent hospitalization. PATIENTS AND METHODS: Between January 1996 and January 2002 we treated ten patients (approximately 54.8, 5 males,5 females). These cases were analyzed retrospectively relative to a review of the literature. RESULTS: CT scanning was decisive in the final diagnosis of psoas abscess. Primary psoas abscess occurred in four cases and six patients had secondary abscesses. In all except one case, the psoas abscess was located on the right side. The causes of primary abscesses were retroperitoneal perforated appendicitis, paravertebral injections for lumboischialgia, Pott's disease, and repeated intravenous drug application in the groin. Five patients underwent retroperitoneal open drainage and four patients CT-guided drainage. One patient with retroperitoneal perforated appendicitis was treated by laparotomy. Staphylococcus aureus, Bacteroides fragilis, and Escherichia coli were the most common infective agents. There was no postoperative mortality and no cases of abscess recurred. CONCLUSIONS: CT scan is a diagnostic "gold standard" for psoas abscess. CT-guided drainage is the method of first choice, but is not possible in all cases. Open retroperitoneal drainage is a standard method of treatment. Postoperative antibiotic therapy is obligatory and should be adapted individually.     

Brucellar and tuberculous spondylitis. A comparative study of their clinical features

The clinical data from 19 patients with brucellar spondylitis and 15 with tuberculous spondylitis were compared. The former disease affects males whose occupations expose them to Brucella. The lumbar spine is usually involved and there are other symptoms of brucellosis. Tuberculous spondylitis is not usually accompanied by general symptoms. The dorsal spine is more frequently affected and may exhibit vertebral collapse and paraspinal abscesses. These differences permit a presumptive aetiological diagnosis, but the definitive diagnosis depends upon bacteriological tests.     

A rare radiological appearance of lumbar tuberculous vertebral osteomyelitis

Spinal tuberculosis (TB), or Pott disease, has classically been recognized as a source of spinal deformities in unindustrialized countries. However, in industrialized countries with more access to sensitive imaging studies, Pott disease may be identified earlier as vertebral osteomyelitis with local complications, such as psoas abscess. In industrialized countries, persons at risk for Pott disease include the immunosuppressed, African Americans and those with a history of prior exposure to TB (Maron et al. Spine 31(16):E561–E564, 2006). This report describes an unusual case with a very interesting radiological appearance of spinal TB. A 30-year-old man presented with dull, progressive back pain. Radiological control showed complete destruction of the L4 vertebral body and partial destruction of the L3, as well as extensive bilateral paraspinal soft tissue infection. The patient underwent open biopsy, complete abscess drainage, lumbar spine stabilization and antituberculous chemotherapy.     

Spinal epidural abscess in the lumbar spine after dental extraction in a 53-year-old man

Spinal epidural abscess is rare in patients following dental extraction. Only seven cases have been described in the literature. We report the first case of an epidural abscess in the lumbar spine following dental extraction, and present a review of the relevant literature. A 53-year-old man presented with low back pain 1 week following dental extraction, and imaging revealed the presence of a lumbar epidural abscess. He underwent surgical drainage by decompressive laminectomy with evacuation of pus and debridement of the infected bone, and he was treated with a prolonged course of intravenous antibiotics. The patient demonstrated no neurologic sequelae at the 6-month follow-up examination. A search of the relevant literature showed that, of the seven epidural abscesses that occurred following dental extractions, five were cervical and two were intracranial. An epidural abscess in the lumbar spine following dental extraction had not been reported. Thus, this is the first report of an epidural abscess in the lumbar spine following dental extraction. It is also the first case of epidural abscess following dental extraction that was determined to be caused by Streptococcus suis. Our findings indicate that epidural abscess must be considered as a diagnosis for all patients presenting with intractable low back pain, with or without fever and neurologic impairment, after a recent dental extraction. We conclude that appropriate imaging must be conducted for early diagnosis.     

Iliacus abscess: an entity to be differentiated from psoas abscess: a review of 15 cases

Conventional orthopaedic and surgical literature classifies an iliacus abscess and a psoas abscess as a single entity. Ten cases of iliacus abscesses and five cases of psoas abscesses treated over a 3-year period were retrospectively reviewed. The clinical features at presentation, the method of diagnosis and the complications were assessed. It was found that iliacus abscesses had a significantly higher rate of complications giving rise to prolonged morbidity. It was noted that three out of the ten cases of iliacus abscesses developed septic arthritis of the hip joint and two had associated sacro-iliac joint involvement, whilst the patients with the psoas abscesses developed no further complications due to the abscess. The regional anatomy of the iliacus muscle in relation to the hip and sacro-iliac joints was reviewed to obtain a better understanding of the clinical observations. The authors believe that the iliacus muscle is a separate structural entity enclosed in its own fascia although it is functionally classed along with the psoas muscle and it appears that the bulk of the iliac bursa, which communicates with the hip joint lies under the iliacus rather than the psoas muscle. The iliacus muscle also lies in close proximity to the sacro-iliac joints. As a result, the functional outcome of an iliacus abscess can be more damaging than a psoas abscess, resulting in a need for early diagnosis and aggressive treatment.     

Vertebral osteomyelitis and psoas abscess occurring after obstetric epidural anesthesia

BACKGROUND AND OBJECTIVES: Back pain and infectious complications occasionally occur after epidural anesthesia in obstetrics, and accurate diagnosis can be difficult. We report a patient who developed low back pain soon after obstetric epidural anesthesia and was diagnosed 6 months later with lumbar vertebral osteomyelitis, discitis, and a psoas abscess. CASE REPORT: A 34-year-old woman developed persistent low back pain after receiving epidural anesthesia for labor analgesia and cesarean delivery. After 6 months, a diagnosis of lumbar vertebral osteomyelitis, discitis, and psoas abscess was made, and surgery was performed. Because of the temporal and anatomical relationships between epidural catheterization and the development of symptoms, the preceding epidural anesthesia was initially suspected as a potential cause. However, because the posterior spinal elements were unaffected and the infectious agent was subsequently identified as tuberculous, the cause was eventually determined as unlikely to be related to the epidural procedure. CONCLUSION: Investigation of severe back pain after epidural anesthesia should include consideration of infectious causes, such as vertebral osteomyelitis and discitis, which may not be causally related to the epidural catheterization itself.     

Laparoscopic drainage of bilateral tuberculous psoas abscesses

Psoas abscess secondary to Mycobacterium tuberculosis infection is rare in industrialized countries. Standard treatment options for psoas abscess of any etiology include percutaneous drainage under radiographic guidance and surgery, which is reserved for failure of conservative therapy. A case of bilateral tuberculous psoas abscesses is reported and a surgical method of drainage utilizing a totally extraperitoneal laparoscopic approach is described.     

Salmonella osteomyelitis of multiple ribs and thoracic vertebra with large psoas muscle abscesses

Backgroud contextSalmonella vertebral osteomyelitis is a well-known complication of sickle cell disease. However, it has been infrequently reported in immunologically normal people or diabetic patients.PurposeTo report a case of Salmonella vertebral osteomyelitis in a diabetic patient with multiple rib infections, large bilateral psoas muscle abscesses, and pleural effusion.Study design/settingCase report.MethodsA case of Salmonella vertebral osteomyelitis is reported in a 42-year-old man with diabetes. The patient had multiple rib and T12 vertebral infections with pleural effusion and large bilateral psoas muscle abscesses. The adjacent discs were intact.ResultsDiagnosis was made by computed tomography–guided psoas muscle abscess drainage and aspirate culture. Appropriate antibiotic treatment resulted in a favorable outcome. The patient had mild back pain with a 38° residual kyphosis at his thoracolumbar junction after treatment.ConclusionsVertebral osteomyelitis caused by Salmonella is uncommon in diabetic patients. Salmonella can cause multiple bone infections and large abscesses of psoas muscles in patients without sickle cell disease. Correct diagnosis can be confirmed by blood, biopsy, or abscess culture. Appropriate antibiotic treatment was effective.     

前路病灶清除椎管减压及一期椎间植骨内固定治疗胸、腰椎结核

目的 分析前路病灶清除椎管减压一期椎间植骨内固定治疗胸腰椎结核的疗效。方法 回顾2002年3月以后的病例中对17例胸腰段、腰椎结核病者,行前路病灶清除椎管减压一期椎间植骨钛质钉-板、钉-棒系统内固定治疗。本组患者术前均有椎旁或腰大肌脓肿,椎体破坏塌陷,椎管内占位,脊柱畸形,不同程度神经功能受损。结果 术中无脊髓、神经及大血管损伤;术后随访1～3年,脊髓神经功能恢复良好。椎间植骨全部融合,脊柱畸形被矫正,无病灶复发。结论 前路病灶清除椎管减压一期椎间植骨内固治疗胸、腰椎结核具有安全．疗效可靠、恢复快,卧床时间短,护理简单等优点。     

Primary Psoas Abscess. Report of Three Cases

Abstract

Background: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections.

Early diagnosis and appropriate management are therefore challenging aspects for physicians. Patients and methods: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36–51 years were admitted with fever, abdominal pain and a palpable tender mass.

Results: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor.

Conclusions: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.     

ACUTE OSTEOMYELITIS OF THE SPINE WITH PARAPLEGIA

A case is reported of acute osteomyelitis of the lumbar spine presenting with a psoas abscess which extended into the epidural space mimicking an epidural abscess. The patient also had severe septicaemia and a complete cauda equina lesion. The septicaemia was controlled by draining the abscess by an anterior approach to the lumbar spine. Decompression of the cord was achieved by removing the sequestrated discs, the necrotic body of the fourth lumbar vertebra and draining the epidural abscess by opening the posterior longitudinal ligament.     

Multifocal extensive spinal tuberculosis (Pott's disease) involving cervical, thoracic and lumbar vertebrae

An unusual case is reported of a 53-year-old woman presenting with spinal tuberculosis involving cervical, thoracic and lumbar vertebrae. The patient originally presented with progressive quadriparesis, fever, night sweats and weight loss. Imaging studies demonstrated vertebral body destruction with and without paraspinal and/or intraspinal abscess in cervical, thoracic and lumbar regions. The laboratory studies confirmed the diagnosis of Pott's disease and the patient was placed on anti-tuberculosis chemotherapy. The anterior approach was used for removal of the infected necrotic material, bone grafting and instrumentation, in both cervical and thoracic vertebrae. The postoperative course was uneventful and the patient made an excellent neurological recovery. The present report is of the first published case of an extensive spinal tuberculosis involving cervical, thoracic and lumbar spine.     

Unilateral psoas abscess following posterior transpedicular stabilization of the lumbar spine

A case of unilateral psoas abscess in a 58-year-old patient, shortly after posterior lower spine stabilization and fusion for spinal stenosis using transpedicular spine fixation is reported. The diagnosis was delayed because the patient’s symptoms were referred to the thigh and the plain roentgenograms were negative for pathology. The technetium scintigram and computed tomography (CT) helped localization, diagnosis and treatment of the psoas abscess. Percutaneous CT-guided drainage was followed by recurrence of the abscess, and open surgical evacuation was performed successfully in combination with antibiotic treatment for 8 weeks. Psoas abscess should always be suspected when recurrent pain is associated with fever and elevated erythrocyte sedimentation rate after instrumentation of the lumbar spine. Hardware of a low profile and volume should be used to decrease dead space in the fusion area, and the volume of bone substitutes should be limited for the same reason. Received: 28 January 2000 Revised: 17 May 2000 Accepted: 22 May 2000     

Cervical spinal epidural abscesses. A report on five cases.

The authors report a series of five cases of non tuberculous cervical spinal epidural abscesses. There were neither patients suffering from immunodeficiency syndromes nor drug addicts; all the patients were in their seventh decade; two patients were affected by diabetes mellitus refractory to medical treatment. Retropharyngeal abscess was the main etiological risk factor (two cases); Staphylococcus aureus was cultured in two cases. Gadolinium MRI was necessary for a preoperative diagnosis, planning surgical approach and postoperative prognosis. Surgical debridement was performed via an anterior approach in those cases where the collection was located lower than C4 and did not span more than three vertebral segments; posterior approach, via a laminectomy, was performed in a case of C1-C2 location of the lesion and in a case of involvement of the whole cervical spine. Surgical results were poor in those patients affected by diabetes mellitus, a lesion involving the high cervical segments (higher than C4) or a lesion spanning more than three levels. Medical treatment with MRI follow-up was not undertaken in any of the patients and we opted for surgical drainage in all the cases due to the possibility of a sudden neurological deterioration, caused both by spinal cord mechanical compression and vascular compromission.     

后路脊柱固定联合双侧经腹膜外病灶清除术治疗腰骶椎结核

目的探讨后路脊柱固定联合双侧经腹膜外病灶清除术治疗腰骶椎结核的临床疗效。方法2000年3月-2005年2月，采用后路脊柱固定、双侧经腹膜外病灶清除术治疗16例椎体结核患者。男11例，女5例；年龄21～56岁。结核部位：L3 4例，L4 6例，L5 4例，S1 2例。其中累及3个椎体1例，跳跃病变1例。病程6个月～6年，平均13个月。16例血沉平均40mm／h；14例WBC正常，2例稍高。X线片检查示5例椎间隙破坏变窄，7例出现病椎压缩，1例相邻2个椎体破坏严重，残余骨质嵌插重叠；16例均可见双侧腰大肌脓肿。16例CT扫描可见椎体骨质破坏、脓肿形成及数量不等的死骨。11例MRI显示椎体破坏、脓肿形成并流注到腰大肌内。患者术后进行常规抗痨治疗。结果1例术后1个月切口裂开，经对症处理后愈合；余患者切口均Ⅰ期愈合。患者获随访2～5年，平均29个月。术后即出现双大腿麻木3例，足背伸无力1例，大小便失禁1例，未作特殊处理，2周后均恢复正常；1例出现腹股沟斜疝，未作处理：6例出现视物模糊、眼睛干涩等：2例出现听力障碍，调整用药后恢复；1例再次出现低热、腰痛，卧床3个月并调整延长应用抗痨药物后痊愈。余患者均无复发。血沉均恢复正常，随访末期X线片示腰椎、腰骶椎获骨性融合13例，后凸畸形1例，椎体间形成骨桥2例。结论一次手术完成后路脊柱固定、双侧经腹膜外病灶清除术治疗腰骶椎结核有较高的安全性、可行性，可减少手术次数、缩短治疗周期、降低治疗费用、提高治疗效果。     

Paraplegia caused by spinal infection after acupuncture

STUDY DESIGN: Case report of a 64-year-old man with psoas abscesses, epidural abscess and spondylitis after acupuncture. OBJECTIVE: To report a case of paraplegia caused by spinal infection after acupuncture. SETTING: Seoul, Korea. CASE REPORT: A 64-year-old man came to an emergency room because of severe back pain. At 3 days prior to visit, the patient received acupuncture therapy to the low back with a needle about 10 cm in length because of back pain. Pain was aggravated gradually for 3 days. Escherichia coli sepsis developed with altered mentality during admission. At hospital day 9, he regained his consciousness and was found to have paraplegia. Abdominal computerized tomography (CT) and lumbar spine magnetic resonance imaging (MRI) revealed abscesses of bilateral psoas muscles and spondylitis with epidural abscess. After conservative management with intravenous administration of antibiotics, infection was controlled but the patient remained paraplegic (ASIA scale C L1 level) without neurological recovery. CONCLUSION: Paraplegia might result from complications of an acupuncture therapy.     

Tuberculous aneurysms of the abdominal aorta

Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare and life-threatening disease. We report a single-center experience of three patients treated with a combination of surgical aortic replacement and prolonged antituberculosis therapy. The first case is a 34-year-old woman with a suprarenal abdominal aortic aneurysm, the second case is a 77-year-old man with an infrarenal abdominal aortic aneurysm and a right psoas abscess, the third case is a 37-year-old woman with an infrarenal abdominal aortic aneurysm. All patients had a favorable outcome with a mean follow-up of 6.2 years (range, 6 months-10 years). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.