A 39-year-old female patient presented to external consult after presenting on May 2021, a fall from her height secondary to a syncopal episode, as well as anomic aphasia, dizziness, and short-term memory loss. She presented again on August 2021, after another syncopal episode, as well as the gradual loss of sensibility and strength in all 4 extremities, and intense pain located in the cervical and thoracic regions.
During the physical examination, the patient remained alert, orientated, and cooperative, with oxygen saturation of 88%, a rhythmic heartbeat, globally diminished sensibility (1/2 ASIA), and strength (3/5 ASIA) in the upper extremities. A 3 cm diameter flyctena was documented on the medial aspect of the left heel, as well as spontaneous and involuntary movements of the left leg. A patient with a history of urinary tract infection was treated with ciprofloxacin for three weeks. Laboratories were obtained, showing chronic anemia grade 2 (WHO), platelets 515 K/muL and leucocytes 6 K/muL.
A series of X-rays and MRI were performed (Figure 1), which demonstrated multiple erosive and expansive lesions in the intervertebral discs and endplates in all segments of the spine, the most important being at the cervical region (C3-C7), with destruction and collapse of C6 and an abscess compressing the spinal cord. At the thoracic region (T6-T7), there was noted another abscess with significant compression of the spinal cord as a well as endplate and disc destruction, and at the thoracolumbar junction (T12-L1), an early process of spondylodiscitis was noted, with the erosion of the disc and endplates and an abscess in the medullary canal.
On November 2021, the patient was admitted for surgery under the diagnosis of spondylodiscitis to stop the progression of the severe neurological deficit. A staged surgical approach was preferred over a single surgical approach for two main reasons: first, the patient presented with suboptimal health status and second, it was the surgical team's choice of approach.
Based on physical exploration and neurological deficit, the first surgery was conducted in the most symptomatic region, the thoracic spine. A lateral retropleural thoracic approach was conducted, an osteotomy of the rib was performed, and selective lung intubation was needed to deflate it during the procedure. Affected levels (T6-T7) were identified and before I&D, multiple samples were obtained for cultures and histopathological study. Debridement included a corpectomy of T6, stability of the spine was achieved by placement of a titanium cage filled with allograft and matrix, and fixation was done with lateral T5-T7 screws and rod. A chest tube was placed and maintained for the next 72 hours, and broad-spectrum antibiotic therapy was initiated with vancomycin and meropenem awaiting culture results (Figure 2).
The biopsy sample demonstrated extensive fibrosis with a mixed inflammatory infiltrate and fragments of bone and cartilage with reactive-looking atypia. Under PAS and Ziehl-Neelsen stains, no microorganisms were identified. The cultures isolated Escherichia coli extended-spectrum beta-lactamases (ESBL) and Gram-positive cocci Staphylococcus aureus. Rose bengal and GeneXpert MTB/RIF (mycobacterium tuberculosis/rifampin) studies were negative for tuberculosis and brucellosis (Figure 3). The patient was discharged home after clinical improvement of pain and function, and infectology indicated a 6-week oral antibiotic course at home with ertapenem, trimethoprim/sulfamethoxazole, and doxycycline.
A second surgical intervention was scheduled on January 2022 after the patient presented with deterioration of sensibility and strength in the upper extremities. The cervical spine X-rays showed progression of the collapse and deformity noted in the previous MRI. An anterior cervical approach (Smith-Robinson) on the right side was performed, I&D of the prevertebral and medullary canal was carried out and multilevel discectomies were done in levels C3-C4 and C6-C7 and replaced with PEEK cages with matrix, and fusion and stabilization were maintained with an anterior 64 mm titanium plate and locked screws (Figure 4). After the surgical procedure, the patient reported minimal neck pain but right leg pain persisted, mobilization outside of bed with assistance was allowed, and the patient was discharged home with antibiotic and analgesic treatment with neurological rehabilitation for 3 months.
In April 2022, during follow-up, low back pain while walking and intractable pain in the right leg continued despite rehabilitation and analgesic medication. The patient was readmitted and scheduled for surgery, a direct posterior thoracolumbar approach was carried out at T12-L1 for I&D, discectomy, foraminal decompression, and fixation with transpedicular screws and rods. Evolution at 24 and 36 hours post-op showed pain decline and increased strength in the lower extremities (Figure 5). The patient was discharged home to continue with rehabilitation therapy in an ambulatory center.