Dural perforation and life-threatening central nervous system complications associated with septic arthritis of the lumbar facet joint: illustrative case

Abstract

Background: Septic arthritis of the lumbar facet joint (SALFJ) is a rare condition that can lead to serious complications. The authors present an uncommon case in which SALFJ resulted in bacterial meningitis (BM) with hydrocephalus and pyogenic ventriculitis, causing a disturbance of consciousness. Reports describing perforation of the dura mater by an epidural abscess are rare, and the present case offers valuable insights into the management of complex and severe complications arising from SALFJ.

Observations: A 54-year-old woman presented with impaired consciousness and paraplegia. The patient was eventually diagnosed with SALFJ at the left L3-4 facet joint complicated by BM, hydrocephalus, pyogenic ventriculitis, and acute transverse myelitis. Surgery confirmed a dural perforation, enabling direct invasion of the abscess into the central nervous system (CNS). Surgical interventions, including debridement, dural reconstruction, and local antibiotic perfusion, along with systemic antibiotics, significantly improved the patient's condition.

Lessons: This case highlights the potential for an epidural abscess of the SALFJ to directly perforate the dura mater, causing severe CNS complications. This emphasizes the importance of prompt diagnosis and appropriate surgical intervention in managing such complex cases. Timely lumbar surgery, combined with targeted antibiotic therapy, can be life-saving in this rare but critical scenario. https://thejns.org/doi/10.3171/CASE24621.

Keywords: acute transverse myelitis; bacterial meningitis; dural perforation; epidural abscess; pyogenic ventriculitis; septic arthritis of the lumbar facet joint.

FIG. 1.

A: CT scan showing enlargement of the lateral ventricles, loss of gray–white matter differentiation, and effacement of the cortical sulci, indicating hydrocephalus and brain edema. B: Diffusion-weighted MRI scan revealing a high signal on the overall surface of the brain, indicating meningitis. The lesion had high signal intensity (white arrowhead), revealing ventriculitis.

FIG. 2.

A: Contrast-enhanced CT scan revealed a low-density area around the left L3–4 facet joint (black arrowheads). B: Neither erosive nor degenerative bone changes were observed at the same level as in panel A. C: Sagittal STIR image showed an epidural abscess with high signal intensity compressing the dural sac and a disruption of the dura mater at the level of L3–4. D: Axial STIR image revealed that the abscess from the left L3–4 facet joint spread both anteriorly and posteriorly and communicated with the intradural space.

FIG. 3.

Cervical (A) and thoracic (B) vertebrae on T2-weighted MRI revealed an extensive high signal lesion primarily below the T3 level in the sagittal plane, indicating LETM.

FIG. 4.

A: Paraspinal muscle abscess on the left side. B: Cloudy CSF mixed with the contents of the abscess exuded from the interlaminar space at the left side of L3–4. C: Thickened inflamed dura mater was observed, and a hole was identified after an L3 laminectomy. The black arrowhead indicates the hole from which the CSF and the abscess leaked. The white arrowhead indicates the intact dura mater. D: The arachnoid mater appeared to be intact, and the cauda equina (black arrowhead) was identified across the hole.