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Korean J Anesthesiol > Volume 71(2); 2018 > Article
Asakura: Just think about pyogenic spondylodiscitis before performing the epidural steroid injection for low back pain
An epidural steroid injection (ESI) is a commonly performed procedure to relieve low back pain (LBP) [1]. The underlying pathological condition of LBP encompasses a wide spectrum of diseases, and the clinical diagnosis requires a complex decision-making process. Among which, pyogenic spondylodiscitis entails major morbidity and mortality, and is an absolute contraindication for ESI [2]. The major clinical symptom of pyogenic spondylodiscitis is the pain, particularly LBP, with a prevalence >90% in patients [3]. Therefore, we preclude the presence of pyogenic discitis before performing an ESI.
To evaluate and understand more fully the clinical manifestations of pyogenic spondylodiscitis, we extracted all medical charts of patients in our facility diagnosed as such, based on International Classification of Diseases-10 coding, after Institutional Review Board approval was obtained. The following variables were reviewed retrospectively from the medical charts: age, sex, clinical manifestations, white blood cell (WBC) count, C-reactive protein (CRP), magnetic resonance imaging (MRI) findings, blood culture, and fluoroscopy-guided biopsy and tissue culture of infected discs.
We identified 26 patients during the 10-year period from 2006 to 2015. The following patients were excluded from the analysis: those who had already been diagnosed with pyogenic spondylodiscitis (recurrent cases) and those who had developed pyogenic spondylodiscitis following any spinal surgery (surgical site infection cases). Accordingly, 18 “de novo” cases were analyzed. The detailed characteristics of the patients are summarized in Table 1.
The chief complaint of 14 of the 18 patients was LBP. A WBC count ≧ 11,000 /μl was observed in six individuals and WBC counts were < 9,600 /μl in nine cases. Similarly, CRP level was < 3 mg/dl in six cases. In contrast, MRI findings suggesting the presence of pyogenic spondylodiscitis (T1 low/T2 high/fast imaging employing steady-state acquisition high) were detected in all cases. Fluoroscopy-guided biopsy and tissue culture of infected discs were carried out in 12 cases, and pathogenic microbes were detected in four cases. Only two cases were positive for blood culture. In all cases, the inflammation resolved without any neurological complications following administration of an appropriate antibiotic, and no surgical procedures were required. Notably, ESI had been performed for LBP before any diagnostic procedures had been performed either at the other department or at other facilities in eight of the 18 cases.
In conclusion, LBP is a common chief complaint of spinal infection. Blood examinations, such as WBC count and CRP, are of limited value, whereas the sensitivity of MRI findings is high. Fluoroscopy-guided biopsy and tissue culture of the infected disc (s) provide good clues for the diagnosis and treatment of pyogenic spondylodiscitis, but the sensitivity of a blood culture is not sufficient. Diagnostic procedures to identify the etiology of the corresponding LBP must be carried out before performing any interventional procedures, including ESI for LBP.

Table 1.
Clinical Manifestations and Characteristics of the Patients with Pyogenic Spondylodiscitis
Sex Age Chief complaint(s) Infected discs and vertebrates WBC count C-reactive protein MRI findings Biopsy of infected discs Therapy and clinical outcome Prediagnostic block therapy
Female 54 LBP L4, L5 5200 0.05 Yes Yes Conservative No
Female 84 LBP L3 6300 0.1 Yes No Conservative Yes
Male 59 LBP L4, L5 7100 1.5 Yes Yes Conservative No
Female 69 Backache Th7, Th8 7200 1.3 Yes No Conservative No
Male 55 LBP L4, L5, S 7200 7.1 Yes Yes Conservative Yes
Male 72 LBP L4, L5 8100 7.0 Yes Yes Conservative Yes
Male 73 LBP L3 8300 4.8 Yes No Conservative Yes
Female 75 LBP L4, L5 9100 5.3 Yes Yes Conservative Yes
Female 83 LBP L5 9600 11.7 Yes Yes Conservative No
Male 79 Fever Th11, 12 10000 1.6 Yes No Conservative Yes
Male 50 Cervical pain C6, 7 10000 3.1 Yes No Conservative No
Male 72 LBP Th12, L1 10300 3.1 Yes Yes Conservative No
Female 73 LBP L2, 3 11000 25.8 Yes Yes Conservative No
Male 74 LBP L3, 4 12400 13.3 Yes Yes Conservative No
Male 88 LBP L4 12500 6.5 Yes No Conservative No
Male 61 LBP L1, L5, S1 13600 2.3 Yes Yes Conservative Yes
Female 83 Fever Th11-L1 14300 7.4 Yes Yes Conservative No
Female 55 LBP L4, 5 15800 24.4 Yes Yes Conservative Yes

References

1. Cohen SP, Hanling S, Bicket MC, White RL, Veizi E, Kurihara C, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015; 350: h1748.
crossref pmid pmc
2. Skaf GS, Domloj NT, Fehlings MG, Bouclaous CH, Sabbagh AS, Kanafani ZA, et al. Pyogenic spondylodiscitis: an overview. J Infect Public Health 2010; 3: 5–16.
crossref pmid
3. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979; 1: 754–76.
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