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Case report

Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management Chengjian He, Tao Wang, Yifeng Gu, Qinghua Tian, Bi Zhou, Chungen Wu

Department of Diagnostic and Interventional Radiology, Shanghai Jiaotong University Affiliated Sixth People’s Hospital, Shanghai, China Correspondence to Dr Chungen Wu, Department of Diagnostic and Interventional Radiology, Shanghai Jiaotong University Affiliated Sixth People’s Hospital, No 600, Yishan Road, Xuhui District, Shanghai City, Shanghai 200233, China; [email protected] Received 18 November 2014 Accepted 18 February 2015 Published Online First 20 March 2015

To cite: He C, Wang T, Gu Y, et al. Acupunct Med 2015;33:154–157.

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ABSTRACT Background We report, for the first time, a case of pyogenic spondylodiscitis combined with vertebral osteomyelitis and bilateral psoas abscesses after acupuncture. Case history A 60-year-old man was diagnosed with rectal cancer, and radical rectectomy and permanent colostomy were carried out. However, 3 years after the surgery the patient complained of pain in the lower back, and the symptoms worsened after seven sessions of acupuncture. Technetium 99m-labelled methylene diphosphonate (99mTc-MDP) bone scintigraphy (BS) revealed abnormal uptake of 99mTc-MDP in the L4 and L5 vertebrae. He was admitted to our hospital because of suspected bone metastases from rectal cancer. He was diagnosed with infection based on a history of acupuncture and the findings of enhanced MRI and CT. Percutaneous lumbar discectomy (PLD), external drainage and irrigation using antibiotics were carried out to treat the L4−5 disc. Pathological analyses and bacterial culture of the resected disc confirmed infection with group C streptococcus. Postoperative antibiotic treatment resulted in significant pain relief on the third day and gradual complete relief. Considerable improvement was seen on CT and MRI at follow-up. Conclusions We consider it highly likely that this patient’s infection was caused by acupuncture. In patients with malignancy, abnormal uptake of 99m Tc-MDP in BS may signify bone metastasis but can also be observed in bone infections. PLD can be used to resect diseased discs to relieve pain quickly and to prevent herniation of lumbar discs. After PLD, external drainage can be employed for

abscess drainage, decompression and perfusion of antibiotics. PLD may serve as an alternative to open surgery for pyogenic spondylodiscitis.

INTRODUCTION Acupuncture is a traditional Chinese treatment that is gaining worldwide popularity. In general, it is regarded to be a safe procedure but has been associated with serious complications. Here we describe an unusual patient with rectal cancer who had pyogenic spondylodiscitis combined with vertebral osteomyelitis and bilateral psoas abscesses induced by acupuncture, initially misdiagnosed as bone metastases. He was treated successfully by percutaneous lumbar discectomy (PLD), external drainage, irrigation with antibiotics and postoperative antibiotics. CASE REPORT Patient characteristics and diagnosis

A 60-year-old man was diagnosed with rectal cancer in 2010 and radical rectectomy was performed. In 2011 a permanent colostomy was carried out to overcome intestinal obstruction. In May 2013 the patient complained of pain in the lower back, which was diagnosed as herniation of a lumbar disc. The symptoms worsened after seven sessions of acupuncture. In September 2013, imaging with technetium 99m-labelled methylene diphosphonate (99mTc-MDP) using bone scintigraphy (BS) revealed abnormal uptake of 99mTc-MDP in the

He C, et al. Acupunct Med 2015;33:154–157. doi:10.1136/acupmed-2014-010717

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Case report L4 and L5 vertebrae. In October 2013 he was referred to our hospital with a suspected diagnosis of bone metastases from rectal cancer. He presented with soreness in the lower back and fluctuating fever. The details of the acupuncture were provided by the patient, his family and his acupuncturist: seven sessions of acupuncture were performed in the lower back around the L4−5 disc. Disinfection of skin and hand washing was performed before each acupuncture treatment but the acupuncturist did not wear a mask or gloves. The depth of the needles was 3–4 cm and the needles were disposable.

(figure 2B). The disc was sent for bacterial culture, antibiotic susceptibility, determination of tuberculosis DNA and pathological examination. Findings

The resected disc looked like ‘white mince’ and was very different from the nucleus of a healthy lumbar disc. Pathological examination revealed chronic purulent inflammation and proliferation of granulation tissue in the resected tissue; the culture was positive and group C streptococcus was isolated. Pathological examination and bacterial culture confirmed pyogenic spondylodiscitis.

Investigations

As suggested by the medical history, enhanced MRI (figure 1A,B) and CT (figure 1C, D) were carried out. Sagittal MRI of the lumbar vertebrae showed that the middle and lower segments of L4, middle and upper segments of L5 and the L4−5 disc were hypointense on T1-weighted images and slightly hyperintense on T2-weighted images. Also, the discs were herniated and the intervertebral space narrowed. All images were enhanced unequally on enhanced MRI. Axial-enhanced MRI showed an abnormal signal at the bilateral inner portion of the psoas abscess. Sagittal CT of the lumbar vertebrae demonstrated bone destruction with osteosclerotic rims in the middle and lower segments of L4 as well as the middle and higher segments of L5. The soft tissue around the lesions was swollen. Laboratory evaluation revealed a white blood cell count of 8500/mm3 with 81.6% neutrophils. Based on the overall findings, infection caused by acupuncture was suspected.

Antibiotic therapy and recovery

Cefoxitin sodium (chosen because of its broad-spectrum antimicrobial activity and ability to penetrate bone and intervertebral discs) was administered prophylactically via the intravenous route from the time infection was first suspected and continued until the results of bacterial culture were obtained. The culture result showed that the pathogen was sensitive to levofloxacin, so levofloxacin in sodium chloride injection was used for irrigation through the drainage tube. The tube was removed 2 weeks after PLD. Intravenous levofloxacin was continued for 2 weeks following the procedure. The patient was discharged from hospital and instructed to take oral antibiotics for a further 4 weeks with bed rest for ≥4 weeks. The pain was signficantly relieved within 3 days after the procedure and then gradually resolved. Soreness in the lower back had disappeared 3 months after treatment. MRI of the lumbar vertebrae at 2-month follow-up was similar to preoperative MRI, and there was clear improvement at 8-month follow-up (figure 1E, F).

Interventional management

The PLD procedure was undertaken under local anaesthesia. The patient was placed in the prone position on the operating table. A small dermatotomy incision was made with a scalpel blade. C-arm fluoroscopy was used in the anteroposterior and lateral planes to localise the level of discitis and to direct placement of a 14G needle and a guidewire onto the disc surface. After guiding pin punctures and passing into the disc space, a small stab incision was made and a dilator cannula was inserted over the guiding pin until it reached the annulus. Dilation of the tract was done using a sequential working cannula, and a trepan was inserted through the last working cannula (5 mm indiameter). PLD was undertaken with a marrow nucleus rongeur inserted through the working cannula. The target disc was withdrawn by PLD as much as possible (figure 2A). After PLD, cefoxitin sodium was irrigated. Another guidewire was then introduced into the disc space. A silica gel drainage tube with several side apertures was inserted into the debrided disc space over the guidewire and connected to a negative pressure vacuum drainage bag

The patient had back pain before consulting the acupuncturist, which worsened after the acupuncture. The L4−5 disc was hypovascular so the response to bacterial infection was slow. Furthermore, the patient had cancer and so had low immunity. Pyogenic spondylodiscitis was highly unlikely to be a delayed side effect of surgery and colostomy for the following reasons: (1) based on the MRI and CT findings, the infection originated in the L4−5 disc and spread to the middle and lower segments of L4, the middle and higher segments of L5 and the bilateral inner portion of the psoas, but the site of the colostomy was not close to the L4−5 disc; (2) the sites of surgery and colostomy were separated from the L4−5 disc by the peritoneum and the anterior longitudinal ligament; (3) the odds that pyogenic spondylodiscitis without peritonitis was caused by the surgery and colostomy are very low. In addition, the likelihood that the infection was spread in the bloodstream is very small because: (1) there needs to be infection before it is spread in

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Causal relationship

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Case report

Figure 1 Imaging examination before and after the procedure. (A) Middle and lower segments of L4, middle and higher segments of L5 and the L4−5 disc were all unequally enhanced on enhanced imaging examination scans. (B) Axial-enhanced MRI images showing an abnormal signal at the bilateral inner side of the psoas. (C) Sagittal CT of the lumbar vertebrae showing bone destruction of the middle and lower segments of L4 and the middle and higher segments of L5 with osteosclerotic rims. (D) Axial CT images showing swelling of the soft tissue around the lesion. (E) Sagittal T1-weighted MRI images at 8-month follow-up. (F) Sagittal T2-weighted MRI images at 8-month follow-up.

the bloodstream (eg, oral infection or bacteraemia) but the patient did not have any sign of infection 6 months before his back pain; and (2) bacteria always spread to organs with abundant vascularity such as the lung and liver, but not to hypovascular organs such as the L4−5 disc. For all these reasons, we consider that the likelihood of infection by inoculation from the acupuncture needle is high. DISCUSSION Some of the complications associated with acupuncture include pneumothorax1 and spinal cord injury as well as infection, which includes transmission of the hepatitis B virus,2 3 HIV4 and bacteria.5–8

Many factors can increase the risk of bacterial infection after acupuncture, one of which is a history of cancer (which is often associated with a weakened immune system). Pyogenic spondylodiscitis is a rare disease that can occur after spinal surgery and in those with a weakened immune system, and often causes considerable pain. Early diagnosis and treatment are crucial in its management. In our case, conservative treatment alone using antibiotics (orally and intravenously) was effective against vertebral osteomyelitis and bilateral psoas abscesses, but not against pyogenic spondylodiscitis because the poor blood supply to the hypovascular disc prevents a sufficiently high concentration of antibiotic. Open surgery is not recommended in patients with infections

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He C, et al. Acupunct Med 2015;33:154–157. doi:10.1136/acupmed-2014-010717

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Case report combined with vertebral osteomyelitis and bilateral psoas abscesses after acupuncture treatment. Malignancy must be considered seriously before using acupuncture. In patients with malignancy, abnormal 99m Tc uptake using BS may signify bone metastasis but it can also be observed in bone infections. PLD can be used to resect diseased discs to relieve pain quickly and prevent herniation of lumbar discs. Also, infected tissues can be debrided to obtain specimens for pathological examination and bacterial culture. After PLD, external drainage can be used for abscess drainage, decompression and perfusion of antibiotics. As a minimally invasive procedure, the novel intervention described here seemed to be highly effective in easing pain, eliminating inflammation and improving the quality of life of our patient. PLD may serve as an alternative to open surgery for pyogenic spondylodiscitis. Competing interests None. Figure 2 Interventional procedure. (A) The target disc was withdrawn by percutaneous lumbar discectomy as much as possible. (B) After completion of the discectomy, a silica gel drainage tube with many side apertures was inserted into the debrided disc space over the guidewire and connected to a negative pressure vacuum drainage bag. Injection of levofloxacin in sodium chloride (to which the pathogen was sensitive, according to the culture result) was used for irrigation through the drainage tube.

such as vertebral osteomyelitis because of the risk of infection spread. PLD is a new minimally invasive procedure for treating diseases affecting lumbar discs. The goal of the procedure is decompression of the spinal nerve root by percutaneous removal of the nucleus pulposus under local anaesthesia. In our case, PLD combined with external drainage and irrigation with antibiotics (a novel procedure) was undertaken to treat pyogenic spondylodiscitis. We obtained a good outcome in our patient, suggesting that PLD could be an alternative to open surgery for pyogenic spondylodiscitis.

Contributors Interventional procedure: CW, CH, TW, YG, QT. Analysing imaging examination: CW, CH, BZ. Writing and contributing: CW, CH. Patient consent Obtained. Ethics approval Ethical approval was obtained from the medical ethics committee. Provenance and peer review Not commissioned; internally peer reviewed.

REFERENCES

CONCLUSIONS We describe, for the first time, a patient with rectal cancer who developed pyogenic spondylodiscitis

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He C, et al. Acupunct Med 2015;33:154–157. doi:10.1136/acupmed-2014-010717

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Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management Chengjian He, Tao Wang, Yifeng Gu, Qinghua Tian, Bi Zhou and Chungen Wu Acupunct Med 2015 33: 154-157 originally published online March 20, 2015

doi: 10.1136/acupmed-2014-010717 Updated information and services can be found at: http://aim.bmj.com/content/33/2/154

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Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management.

We report, for the first time, a case of pyogenic spondylodiscitis combined with vertebral osteomyelitis and bilateral psoas abscesses after acupunctu...
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