A 62 year old man presented to our clinic with history of severe low backache over the last 3 months. He gives history of being treated for Early Carcinoma of Sigmoid colon immediately prior to the onset of backache. He had underwent laparoscopic resection of the tumour and subsequent anastomosis of the large intestine. The histopathology showed good tumour clearance. Initial workup for metastasis was negative. He developed anastomotic leak and an enterocutaneous fistula and was reoperated via a laparotomy. Defunctioning colostomy was done. When he presented to us, he had a colostomy bag and his sinus had healed. The backpain was intense when he attempted to move about. Resting in bed gave him some relief. His examination was negative except for paraspinal muscle spasm He had no neurological deficit.
His Erythrocyte Sedimentation rate was 116 mm/first hour. Radiographs of the Lumbosacral spine showed sclerosis of the L2,3 endplates. MRI showed spondylodiskitis of L2,3 vertebrae and L1,2 vertebrae(Figs. ,,,). The involvement of L2,3 was more with early changes in L1,2 disc space. The patient had been on long duration of antibiotics following the abdominal surgery.
sagittal T1 MRI showing diskitis and vertebral signal changes suggestive of osteomyelitis
sagittal T2 MRI showing diskitis and vertebral signal changes suggestive of osteomyelitis
Axial T1 contrast showing the above lesions
Axial T2 MRI images showing the above lesions
Considering the MRI picture, an anterior debridement and biopsy via a retroperitoneal approach was thought of. But due to the colostomy wound and the laparotomy wound, the chance of contaminating the surgical wound was high. Also the possibility of peritoneal adhesions make anterior dissection difficult. Hence the lesion was approached via a posterior route. L2 laminectomy was performed, L2,3 disc space curetted out and sent for histopathology and culture. The spine was stabilized from L1 to L4 via pedicle screw instrumentation. Instrumentation in infected spine is now very well recognized as a therapeutic option to provide mechanical stability [1
Cultures for bacteria including mycobacterium were negative. Myco 3 PCR for Tuberculosis was negative. Fungal Culture grown on Saborauds Tween 80 corn meal agar showed yeast cells of Candida tropicalis. The organism was sensitive to Fluconazole and resistant to Amphotericin B.
Patient was started on Fluconazole – 400 mg intravenously for two weeks and then orally for a period of 10 weeks. Patient was gradually mobilized. His ESR dropped 40 mm/first hour and he had good symptomatic relief. He later underwent colostomy closure uneventfully and is back to normal activities.