Anesth Analg 2002;94:415-416
© 2002 International Anesthesia Research Society
OBSTETRIC ANESTHESIA
Discitis Associated with Pregnancy and Spinal Anesthesia
Zahid H. Bajwa, MD,
Charles Ho, MD,
Artem Grush, MD,
Jonathan Kleefield, MD, and
Carol A. Warfield, MD
Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachussetts
Address correspondence and reprint requests to Carol A. Warfield, MD, Anesthetist-in-Chief, Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215. Address e-mail to carol_ warfield{at}caregroup.harvard.edu
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Abstract
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Discitis (inflammation of the intervertebral disk) most commonly develops as a rare complication of bacterial infection or chemical or mechanical irritation during spine surgery (1) with a postoperative incidence of 1%–2.8% (2). It is also a complication of discography—the intradiscal injection of saline or contrast material (3). The incidence of postdiscography discitis is 1%–4% (3); no cases have been reported when prophylactic antibiotics have been used, supporting the theory of bacterial contamination (3). Although it is controversial whether discitis can be caused by an aseptic or infectious process, recent data suggest that persistent discitis is almost always bacterial (4). Honan et al. (5) reported 16 cases of spontaneous discitis and reviewed another 52 patients from the literature. In their series, patients tended to have one or more comorbid conditions, such as diabetes, vertebral fracture, or a preexisting spine injury. Spontaneous discitis has also been associated with advanced age, IV drug abuse, IV access contamination, urinary tract infection, and immunocompromised states (5,6). No cases of infectious discitis associated with pregnancy and spinal anesthesia have been reported in the English literature.
Discitis presents as spasmodic pain in the back that may be referred to the hips or groin (7). The pain may radiate to the lower extremities. The erythrocyte sedimentation rate is usually increased. Radiological changes in discitis include narrowing of the intervertebral disk space, vertebral sclerosis, and erosion of the end plates. The best diagnostic measure may be magnetic resonance imaging (MRI) or a combination of bone and gallium scanning (2). The mainstay for discitis treatment is pain control and antibiotics; surgical intervention is usually not required. Complications of discitis include intervertebral fusion, epidural abscess, and paralysis.
IMPLICATIONS: This is a case report of a disk infection (discitis) caused by the bacteria, Streptococcus bovis after spinal anesthesia for cesarean delivery. S. bovis rarely causes discitis, and spinal anesthesia for labor and delivery has not been reported as a cause of discitis.
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Case Report
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A 41-yr-old woman was scheduled for cesarean delivery because of nonreassuring fetal heart tracing. Her medical history was significant for well-controlled mild asthma and inactive genital herpes simplex. She had a 20-yr history of intermittent low back pain that occurred approximately four times per year in the lumbar area with no radiation. The patient had seen a chiropractor in the past but had not sought any other medical assessment or treatment. She reported an ampicillin allergy associated with rash. She denied using illicit drugs.
Spinal anesthesia was performed by a CA-3 resident wearing cap and mask. The aseptic technique included twice cleaning the area with single-use povidone preparation sticks; the area was allowed to air dry. A 24-gauge Sprotte needle was positioned on the first attempt through an introducer with a single puncture of the dura at the L3-4 interspace via a midline approach. The cerebrospinal fluid was clear and 1.5 mL of bupivacaine 0.75%, 25 µg of fentanyl, and 0.2 mg of preservative-free morphine (Astramorph; Astra Zeneca LP, Wilmington, DE) were injected. An anesthetic level to T4 was quickly achieved, and a healthy infant was delivered via uncomplicated cesarean delivery. The patient received 1 g of IV cefazolin during the cesarean delivery on request of the obstetrician, had an uneventful hospital course, and was discharged on the fourth postpartum day.
Retrospectively, the patient recalled the presence of new low back pain of variable intensity at the time of discharge, but she attributed this to spinal anesthesia and did not notify the anesthesia or obstetric teams. On the eighth postpartum day, she presented to the emergency room with severe, nonradicular low back pain worsened by sitting, standing, or turning in bed.
On initial examination, she was afebrile with no erythema or exudate at the spinal puncture site. She had exquisite lumbar paraspinous tenderness at the L4-5 level bilaterally, and a normal neurological examination. A presumptive diagnosis of musculoskeletal back pain was made. She was hospitalized and treated with systemic opioids, muscle relaxants, bed rest, hot packs to the affected area, and physical therapy.
When there was no improvement by the third hospital day, MRI of the lumbar spine was performed, revealing high T2 signals involving an irregularly marginated L4-5 disk with L4 and L5 bone marrow edema. Subsequent Gadolinium enhanced scan demonstrated subtle, linear enhancement of the disk margins increasing the suspicion of infection. No epidural or paraspinal abscess was delineated. The suspicion of discitis with adjacent osteomyelitis was raised on the basis of MRI findings and a sedimentation rate of 115 despite a white blood cell count of 5200 and negative serial blood cultures.
A computed tomography-guided disk biopsy was performed which confirmed the presence of Streptococcus bovis in the vertebral end plates and the disk. The Streptococcus was resistant to gentamicin but sensitive to penicillin and vancomycin. Bacterial discitis/osteomyelitis was treated with vancomycin 1 g IV every 12 h for a 6 wk course, analgesics, and bed rest. She was pain free by the end of the second week of hospitalization. Because she did not develop signs or symptoms of neural compression, further surgical intervention was not recommended.
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Discussion
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Compared to postoperative discitis, where the infecting organism is most frequently Staphylococcus aureus or epidermidis, spontaneous discitis has been attributed to a wide variety of Gram-positive and Gram-negative bacteria, or fungi (3).
S. bovis is a nonenterococcal group D streptococcal bacterium that is usually found in ruminant animals such as cattle. It has been identified as the infectious agent in endocarditis, discitis, vertebral osteomyelitis, and splenic abscess (8–10). There is a high correlation between endocarditis and underlying gastrointestinal malignancy (8–10). Patients diagnosed with S. bovis bacteremia should be investigated for gastrointestinal malignancy, as the gastrointestinal tract is the usual port of entry.
The etiology of S. bovis discitis in this patient is unclear. Preexisting disk disease could have been a predisposing factor to the development of discitis. It is possible that this was a case of spontaneous discitis with hematogenous spread of pathogen from a colonic or urinary origin, and not related to spinal anesthesia. The S. bovis could have been an unusual skin contaminant that was carried to the epidural space and disk via the spinal needle. As for the differing level of the discitis (L4-5) in relationship to the spinal puncture (L3-4), because spinal puncture is routinely performed based on anatomic landmarks without radiographic confirmation, one interspace could have been mistaken for the other (11). There was no evidence of gastrointestinal malignancy at the time of presentation.
In summary, even in the absence of neurological deficits, one should consider the possibility of discitis in a patient with worsening low back pain who does not respond to conservative treatment after spinal anesthesia.
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References
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Marsal S, Castro-Guardiola A, Clemente C, et al. Streptococcus bovis endocarditis presenting as acute spondylodiscitis. Br J Rheumatol 1994; 33: 403–8.[Free Full Text]
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Matsumura M, Araki T, Yokogawa A. Streptococcus bovis discitis and possible endocarditis. Intern Med 2000; 39: 677.[ISI][Medline]
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Accepted for publication September 19, 2001.
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Abstract
Case Report
