Presentation
Severe lower back pain for several weeks, not responding to analgesia
Patient Data
At the L1-L2 intervertebral disc unit, there are erosions involving the inferior endplate of L1 and superior endplate of L2 with disc height loss and mild L1 vertebral body height loss/compression. Focal kyphosis is seen as a result. Findings are in keeping with spondylodiscitis.
There is paravertebral and psoas muscle soft tissue thickening and inflammatory changes suggestive of phlegmon with a very small fluid collection extending into the adjacent left psoas muscle. No epidural collection is noted.
Case Discussion
The diagnosis was confirmed with subsequent MRI and blood cultures (enterococcus). The patient was known for hepatocellular carcinoma being treated with transarterial chemoembolization.
Spondylodiskitis is osteomyelitis of the vertebral bodies and intervertebral diskitis secondary to an infectious process. Hematogenous spread of pathogens is the most common route of seeding. It leads to erosions, destruction and compression fractures with resulting spinal instability, deformity and risk of cord compression. The infection can breach the bone and spread into surrounding soft tissues, causing paravertebral or psoas abscesses, and track into the central canal, forming an epidural abscess.
The predominant pyogenic pathogen is S. Aureus with a distant focus of infection being identified in almost 50% of cases. Hematogenous bacterial spondylodiskitis can affect any part of the spine but the lumbar spine is the most commonly affected, as in this case.
Although CT is good at delineating bone abnormalities including early endplate erosions, MR is considered the modality of choice for assessment of spondylodiskitis and its associated complications.
Case co-author: Rehana Jaffer, MD, FRCPC
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