Emphysematous osteomyelitis of the spine: a case report and case based review of the literature

Abstract

Background/objective: Emphysematous osteomyelitis (EO) of the spine is an uncommon type of osteomyelitis characterized by intraosseous gas-formation in the vertebrae. The objective of this report is to present a rare case of spine EO in a patient with emphysematous cystitis. A case-based review of the literature on spinal EO was also performed as an update to the relevant literature of this rare infection.

Case description/methods: A 55-year-old female with diabetes mellitus and peripheral vascular disease (PVD) presented to our institution with recurrent falls, fatigue, and low back pain. Computed tomography (CT) and magnetic resonance imaging (MRI) scans confirmed emphysematous cystitis and EO at L4. Given the diffuse involvement, surgical intervention was deferred for IV antibiotic therapy. A case-based review was also conducted by searching the SCOPUS and PubMed databases for the following terms: "emphysematous osteomyelitis", "gas", and "spine". Only publications in English were included in this review.

Key content/findings: Urine/blood cultures identified Klebsiella pneumoniae. After initial improvement with six weeks of broad-spectrum antibiotics, the patient re-presented with recurrent fevers and fatigue. Despite maximal medical therapy, the patient expired 2 months later due to multi-organ system failure. Including the present report, only 29 cases of spine EO have been described in the literature. Patients almost consistently presented with fever, elevated inflammatory markers, and localized pain. Most cases of spinal EO (89.7%) were monomicrobial. Escherichia coli (37.9%) and Klebsiella pneumoniae (27.6%) were the most causative organisms identified. Medical treatment universally consisted of broad-spectrum IV antibiotics prior to tailoring. Debridement and decompression, with or without fusion, were the main operative procedures performed for spine EO. Outcomes following spinal EO are varied with a 44.4% mortality rate.

Conclusions: We present a case of EO of the spine and concomitant emphysematous cystitis with Klebsiella pneumoniae and a case-based review of the literature. Appropriate work up for this rare infection should include inflammatory markers, cultures, and CT/MRI imaging. Treatment consists of IV antibiotics with anaerobic and gram-negative coverage. However, treatment guidelines and operative indications for spinal emphysematous osteomyelitis remain unclear.

Keywords: Emphysematous; case report; osteomyelitis; review; spine.

Figure 1

Radiographs of the lumbosacral spine. (A) Anteroposterior views of the lumbosacral spine. (B) Lateral views of the lumbosacral spine that demonstrate superior endplate depression at the L4 vertebrae. Black arrows highlight linear densities suspicious for retroperitoneal gas and gas forming infection.

Figure 2

Computed tomography scans of the abdomen/pelvis with contrast shown on bone window. (A) Sagittal views of the abdomen/pelvis. (B) Coronal views of the abdomen/pelvis. Black arrows highlight confirmation of gas on CT imaging in the bilateral iliopsoas muscles, throughout the bladder wall, L4 vertebral body, and L3-L4/L4-L5 intervertebral discs. CT, computed tomography.

Figure 3

Magnetic resonance imaging sagittal cuts of the lumbar spine with/without contrast. Demonstrates hyperintense signal in the L4 lumbar vertebral body and the anterior/posterior spinal elements correlating with the affected areas noted on computed tomography.

Figure 4

Timeline of antibiotic treatments and dosages with significant events denoted to help give a visual representation of the patient’s hospital course; ICU, intensive care unit.

Figure 5

Flowchart demonstrating overview of article selection process.