Keywords: Infective discitis, laparoscopic sacrocolpopexy, postoperative complications

Study Design: A case report of infective lumbar discitis following laparoscopic sacrocolpopexy. Objectives: To improve awareness of the possibility of surgical procedures for genital prolapse causing discitis by presenting a case history. Background: Infective lumbar discitis following laparoscopic sacrocolpopexy is very rare. Methods: Case history of a 63 year old lady who developed infective L5- S1 discitis three weeks following a laparoscopic sacrocolpopexy. Conclusion: Discitis following a laparoscopic sacrocolpopexy procedure is a very rare but significant complication

J.R.Coll.Surg.Edinb., 47, October 2002, 709-710 

INTRODUCTION

Infective lumbar discitis has been described following haematogenous spread or following direct instrumentation of the disc space.^1,2 There are some isolated reports of discitis following urinary tract infections or urological instrumentation.³ Discitis following laparoscopic gynaecological procedures remains rare. It is important, therefore, that this condition is recognized and treated quickly and effectively. Here we present a case history to illustrate these aspects.

CASE REPORT

A 63 year old lady presented to the gynaecology outpatients three weeks following a laparoscopic sacrocolpopexy. She gave a three day history of severe low backache and stiffness associated with a moderate degree of fever.

The laparoscopic sacrocolpopexy had been carried out under antibiotic prophylaxis (single dose of 1.2 grams of intravenous co-amoxiclav). The procedure involved stapling of the vaginal vault to the sacral promontory with the aid of a prolene mesh^® (15 x 15 cm, Ethicon) and titanium staples. No problems were encountered during the procedure. Postoperatively there was a minor wound infection at one of the port sites, which resolved following a course of oral flucloxacillin prescribed by the general practitioner.

At presentation, the patient was comfortable at rest, though complaining of considerable pain on standing up; she had a pyrexia of 38.2^ºC and was tachycardic (100 beats per minute). Inspection of the back was unremarkable. There was no local tenderness and neurological examination was normal. No abnormality was detected on systemic examination.

Laboratory examination revealed a normal full blood count and a raised erythrocyte sedimentation rate of 79 mm/hour.

C-Reactive protein (CRP) was elevated at 45. Blood cultures were positive for beta haemolytic streptococcus. The patient was commenced on a course of 750 mg of intravenous cefuroxime, three times daily, and 500 mg of intravenous metronidazole, three times daily, which was changed to 1.2 grams of benzyl penicillin, four times daily, based on the sensitivity results. Further imaging was arranged.

Plain radiographs of the lumbosacral spine, though normal initially, showed narrowing of the disc space at L5-S1 level. (Figure 1) An ultrasound scan of the pelvis performed three days after presentation showed no obvious fluid collection in the pelvis. Technitium bone scintigraphy was performed as an initial investigation due to the lack of adequate localization of pathology on clinical examination. It showed an increased uptake at L5-S 1 level (Figure 2). A magnetic resonance imaging (MRI) scan was performed one week following presentation and showed gross loss of height of the disc at the L5-S 1 level, with abnormal signal changes on the adjacent vertebral bodies, but with no evidence of nerve root compression (Figure 3).

The patient was continued on intravenous benzyl penicillin for two weeks. The inflammatory markers showed a steady decline and the patient was discharged home on oral antibiotics with a lumbosacral spinal support. The patient was followedup on an outpatient basis and her antibiotics were discontinued after two months. At that time her erythrocyte sedimentation rate (ESR) was 29 mm/hour and the CRP was less than 1 units. She continues to be well and without any significant symptoms apart from some low back stiffness, eight months after the presentation.

DISCUSSION

Infective discitis in adults is thought to occur following direct spread through instrumentation as in surgery for disc disease, discography. It can also occur via haematogenous spread in which case discitis follows vertebral end plate infection and its consequent collapse. It is known to occur more frequently in immunocompromised patients. Infective discitis has been described following a variety of surgical procedures not involving direct instrumentation of the disc space - procedures on the urinary tract being the most commonly reported. Infective discitis following surgery for genital prolapse is exceptionally rare. The mode of spread of infection remains unclear. The possible modes involve spread by direct contiguity, spread through Beatsons’s plexus of veins and haematogenous spread.

The aids to the diagnosis include markers of infection such as ESR and CRP.⁴ Bone scintigraphy can be used in cases where the exact site of pathology is not evident from clinical examination or radiographs. Although very sensitive, it is not specific for infection. Magnetic resonance imaging is considered the best radiological investigation.⁵ Plain radiographs are known to be normal except in the late stages. There is a definite role for a diagnostic biopsy though positive blood cultures, in the absence of signs of any other focus of infection, may obviate the need for a diagnostic biopsy and culture.

Early recognition and treatment prevents the onset of neurological deficit, which presents usually after spread to the epidural space or following collapse of vertebral bodies.¹ There seems to be a lack of consensus on the type of antibiotic agents, their duration and method of administration. A commonly used regimen is to treat patients with antibiotics based on positive culture and sensitivity results till the inflammatory markers return to normal.

Figure 1: Lateral view of lumbosacral spine taken 12 weeks after presentation. The titanium clips can be seen anterior to the disc space.

Figure 2: Technitium bone scan performed at 1 week following presentation showing increased uptake at L5 S1 level.

Figure 3: MRI scan, sagittal view of lumbosacral spine showing signal change at L5 S1 level.

CONCLUSION

Infective discitis following laparoscopic sacrocolpopexy, a commonly performed procedure, is a possible complication which, if recognized promptly, can be effectively treated and potentially serious sequelae prevented.

REFERENCES

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3. Ponte CD and McDonald M. Septic discitis resulting from escherichia coli urosepsis. J Fam Pract 1992; June 34: 767-771
4. Carragee EJ, Kim D, van der Vlugt T, Vittum D. The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine 1997; 22: 2089-2093
5. Maiuri F, Iaconetta G, Gallicchino B, Manto A, Briganti F. Spondylodiscitis-clinical and magnetic resonance diagnosis. Spine 1997; 22: 1741-1746
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Copyright: 4 August 2002

Correspondence: B. Kapoor, 29 Melrose Avenue, Stone, Staffordshire, ST15 8SU, UK