PMC9124486_01
X-ray images showed a wedge-shaped change of the L4 vertebra (A and B). T1WI of MRI demonstrated hypointense signal (red arrow) and a clear horizontal fracture line of the L4 vertebra (C), T2WI showed mixed intensity signals (red arrow) of the L4 vertebra (D), and FS-T2WI showed hyperintense signal (red arrow) and clear horizontal fracture line of L4 vertebra, quasi-circular areas of high-intensity signal around L5 vertebra was due to MRI artifact (E).
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X-ray showed a wedge-shaped change of the L4 vertebra (Figure 1A and B). Magnetic resonance imaging (MRI) demonstrated hypointense signal of L4 vertebra with a clear horizontal fracture line on T1-weighted imaging (T1WI), mixed intensity signal of L4 vertebra on T2-weighted imaging (T2WI), hyperintense signal, and a clear horizontal fracture line of L4 vertebra on Fat-suppressed T2-weighted images (FS-T2WI), quasi-circular areas of high-intensity signal around L5 was due to MRI artifact (Figure 1C-E).
X-ray following vertebroplasty showed uniform distribution of bone cement in L4 vertebra (A and B). X-ray before revision surgery showed narrow intervertebral disc space at L3/4 and L4/5 with marked osteophyte formation at L3, L4, and L5 vertebra (C and D). X-ray immediately after revision surgery showed the placement of instrumentation (E and F). At 12 months after discharge, the X-ray showed no abnormal changes in instrumentation position (G and H).
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Her lumbosacral pain was relieved, and the spinal X-ray showed bone cement of L4 vertebra was uniformly dispersed when discharged from hospital three days following operation (Figure 2A and B). X-ray, computerized tomography (CT) scan, and MRI of the spine were performed to determine the spinal segment affected. X-ray showed narrow intervertebral disc spaces at L3/4 and L4/5, and the osteophyte at the vertebra edge of L3-L5 proliferated obviously (Figure 2C and D). X-ray showed postoperative changes of instrumentation placement (Figure 2E and F). X-ray showed no abnormal changes in spinal instrumentation placement (Figure 2G and H); CT scan and MRI also demonstrated no abnormity (Figure 6A-H).
CT before revision surgery showed multiple bone destructive changes (red arrow) of L4 and L5 vertebra (A-D). MRI before revision surgery showed intraspinal and paravertebral abscess formation (blue arrow) of the L4 vertebra, hypointense signal (red circle) on T1WI of L3, L4, and L5 vertebra, mixed-signal intensity (red circle) on T2WI, and hyperintense signal (red circle) on FS-T2WI (E-H).
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CT scan showed multiple destructive changes at L4 and L5 vertebra with paravertebral and intraspinal abscess formation around L4 vertebra (Figure 3A-D). MRI revealed hypointense signal of L3-L5 vertebra on T1WI of which T2WI demonstrated mixed intensity signal and FS-T2WI showed hyperintense signal (Figure 3E-H) consistent with infectious spondylitis with intraspinal abscess.
Intraoperative purulent fluid is seen during revision surgery (A). Disc tissue and little bone cement from L3/4 and L4/5 levels were collected during revision surgery (B).
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When empiric antibiotics were ineffective for two weeks, posterior focus debridement with decompression, fusion and internal fixation was performed, and large amounts of intraspinal and paraspinal purulent fluid were apparent during the procedure (Figure 4A), of which real-time polymerase chain reaction (Real-time PCR) test revealed Brucella melitensis (B. melitensis). The postoperative pathological results of the intervertebral disc of L3/4 and L4/5 (Figure 4B) demonstrated that organisms consistent with Brucella were present by Giemsa staining and Mycobacterium tuberculosis was not present by negative acid-fast staining (Figure 5A and B).
In postoperative pathology, Brucella (red circle) was positive for Giemsa staining while Mycobacterium tuberculosis was negative for acid-fast staining of the intervertebral disc of L3/4 and L4/5 (A and B).
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The postoperative pathological results of the intervertebral disc of L3/4 and L4/5 (Figure 4B) demonstrated that organisms consistent with Brucella were present by Giemsa staining and Mycobacterium tuberculosis was not present by negative acid-fast staining (Figure 5A and B).
No abnormalities on CT and MRI 12 months after discharge (A-H).
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X-ray showed no abnormal changes in spinal instrumentation placement (Figure 2G and H); CT scan and MRI also demonstrated no abnormity (Figure 6A-H).