PMC7201821_01
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).
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The flexion and extension lateral lumbar radiographs showed segmental dynamic instability at L2-3 and L3-4 (Figure 1(a)). Sagittal computed tomography (CT) showed multilevel disc degeneration, severe osteophyte at L4-5, and L3 spondylolisthesis relative to upper and lower vertebra (Figure 1(b)). Magnetic resonance imaging (MRI) revealed serious central stenosis at L3-4 and lumbar disc herniation and right lateral recess stenosis at L4-5 (Figure 1(c)).
Postoperative anterior-posterior and lateral lumbar radiographs (a). Anterior-posterior and lateral lumbar radiographs of one-month follow-up (b).
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The postoperative and one-month follow-up's lumbar radiographs showed no abnormal findings (Figure 2).
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).
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The spondylodiscitis signal of adjacent segment in lumbar MRI further confirmed our hypothesis of infection of the lumbar spine (Figure 3(b)).
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.
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The blood laboratory tests were done periodically, and the main inflammatory index changing curves are shown in Figure 4.
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).
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Moreover, the radiographic images revealed serious spondylodiscitis and bony endplate destruction at the adjacent L1-2 segment (Figure 5).
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.
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After five-week continuous anti-infective therapy, the main blood inflammatory indexes dropped to the normal level (Figure 6), with slight residual symptom. The patient had satisfactory symptom relief and significant inflammatory indexes decreased (Figure 6). The inflammatory indexes almost dropped to normal (Figure 6).
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).
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However, the spondylodiscitis and bony endplate destruction at the L1-2 space had little changes (Figure 7).
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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And the upper instrumented level was extended to L1 (Figures 8(a) and 8(b)). The six-week follow-up's CT scan showed that the destructive space was closed to fusion (Figure 8(c)).