Spondylodiscitis with epidural and bilateral psoas abscesses

Case contributed by Siobhan Lee

Presentation

Acute lower back pain, worsening over 1 week. Normal lower limb neurological examination.

Patient Data

Age: 65 years
Gender: Male

MRI demonstrates L4/L5 intervertebral disc irregularity and height loss, bone marrow edema and enhancement, in keeping with spondylodiscitis.

Large epidural multiloculated collection in the dorsal spinal canal and extending from mid L1 level to S1. Anterior and lateral loculations at L4/L5 level. 

Severe spinal canal stenosis from L2-L5, with compression of the cauda equina nerve roots. Enhancement along the exiting nerve roots with possible loculated collection along the right exiting S1 nerve root.

Extensive edema and enhancement throughout the paravertebral soft tissues. Bilateral multiloculated psoas abscesses, right > left.

CT guided psoas drainage

ct

CT guided insertion of right psoas 10Fr pigtail drainage catheter. No periprocedural complications.

Case Discussion

The patient had a history of fall 7 weeks prior to presentation, with L5 vertebral fracture. Subsequent outpatient CT (not available) for investigation of increasing pain demonstrated L4/L5 endplate erosions with paravertebral mass, suspicious for spondylodiscitis. The patient was referred to ED, and shortly after became febrile and with CRP >200, WCC 13. Blood cultures grew Steptococcus anginosus (milleri)

His neurological examination remained reassuring, so the decision was made to manage non-operatively. The psoas aspirate sent for culture grew Streptococcus anginosus. Approx 100 mL of purulent material drained over the next 48 hours, with gradually reducing output. The drain was removed after 10 days. The patient responded to drainage of the psoas abscess and antibiotics and was discharged home to complete a 6 week course of IV antibiotics.

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