Adjacent Segment Infection after Lumbar Fusion: A Case Report and the Literature Review

May 23, 2020

Case Reports

. 2020 Jan 20;2020:2163909.

doi: 10.1155/2020/2163909.

eCollection 2020.

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Free PMC article

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Case Reports

Wenlong Wang et al.

Case Rep Orthop.

2020.

Free PMC article

Abstract

Introduction:

Adjacent segment infective spondylodiscitis is a rare type of surgical spinal infection after lumbar fusion with few reports. We report a further case of adjacent segment infection after three-level lumbar fusion managed successfully with anti-infective therapy and revision surgery. Case Description. A clinical case of a 69-year-old female with multilevel lumbar degenerative disease received three-level fusion. The leading preoperative symptoms were relieved after decompression surgery. However, severe back pain recurred and prompted her to be rehospitalized 2 months later. The signal of spondylitis and discitis at the adjacent segment was detected by magnetic resonance imaging (MRI). No bacteria were identified despite blood cultures being taken before antibiotic treatment. After a long-term anti-infective therapy with vancomycin, the patient gained symptom relief and was discharged home. However, the patient complained of severe back pain again after long-term oral antibiotic treatment and was rehospitalized 6 months after surgery. The computed tomography (CT) scan showed obvious bony endplate destruction at the adjacent segment space. The patient received a debridement operation and autologous iliac bone graft. The infective inflammatory markers were controlled, and the infective space achieved fusion finally.

Conclusion:

Adjacent segment space infection is a rare reported complication that occurs after spinal fusion surgery. Conservative antibiotic therapy may not control the infection completely, and disc space debridement and autologous iliac bone graft can achieve ultimate fusion and a satisfactory outcome.

Conflict of interest statement

All authors declare that they have no conflicts of interest.

Figures

**Figure 1**

Flexion and extension lateral lumbar X-ray radiograph demonstrating segmental dynamic instability at L2-3 and L3-4 (a). Sagittal lumbar CT showing intervertebral space collapse and osteophyte at L4-5 and “gas sign” at L3-4 and L4-5 discs (b). Sagittal and axial T2-weighted lumbar MRI revealing serious central canal stenosis at L3-4, lumbar disc herniation and right lateral recess stenosis at L4-5, and moderate canal stenosis in L2-3 (c).

**Figure 2**

Postoperative anterior-posterior and lateral lumbar radiographs (a). Anterior-posterior and lateral lumbar radiographs of one-month follow-up (b).

**Figure 3**

Lateral lumbar radiograph of second hospitalization showing no significant changes at the adjacent L1-2 segment comparing with one-month follow-up (a). Sagittal MRI T2-weighted and short-tau inversion recovery (STIR) images of second hospitalization showing inflammatory edema signal in intervertebral disc and bone marrow below the endplates of L1-2 (b).

**Figure 4**

Main blood inflammatory indexes ranged from second admission to last out-patient review. WBC: white blood cell count; NEU: neutrophile granulocyte percentage; CRP: C-reactive protein; ESR erythrocyte sedimentation rate.

**Figure 5**

Lateral lumbar radiograph of third hospitalization showing the destructive endplates at the L1-2 space (a). Sagittal CT of third hospitalization showing spondylodiscitis and destruction of bony endplates at the L1-2 segment (b). Sagittal MR T2-weighted imaging of third hospitalization revealing spondylodiscitis at the L1-2 segment (c).

**Figure 6**

Main blood inflammatory indexes ranging from third hospitalization to recent out-patient review. WBC: white blood cell count; NEU: neutrophile granulocyte percentage; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate.

**Figure 7**

Sagittal lumbar CT after two-week anti-infective therapy (a). Sagittal lumbar CT after one-month anti-infective therapy showing little changes at the L1-2 space comparing with previous lumbar CTs during third hospitalization (b).

**Figure 8**

Anterior-posterior and lateral lumbar radiographs 1 week after revision. The upper instrumented level was extended to L1 (a). Sagittal lumbar CT 1 week after revision. The infective tissues at the L1-2 space were debrided and then an iliac crest autograft was implanted (b). Sagittal lumbar CT 6 weeks after revision. The surgical space tended to fuse with well-placed instruments (c). Sagittal lumbar CT 6 months after revision showed satisfactory fusion sign in the infective space (d).

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