One of the major risks of having spine surgery is the development of an infection. Discitis is an uncommon infection of the spinal disc that can occur after spinal surgery. Because of its rarity, discitis is often not on the minds of doctors. In this world of rushed, inattentive doctors, a person with an infection of the spine can be dismissed as a "common back pain" case when in fact discitis is the culprit.
A 58 year old woman who had years of lumbar pain came to me one and a half years following a complicated lumbar fusion; the surgery was complicated by the fact that the surgeon had to operate twice in order to get the hardware placed correctly. Unfortunately, the surgery did not cure her pain; and she came to me for pain management.
Two months into her treatment with me, she had a severe episode of low back pain after shoveling snow. She went to her primary doctor with not only complaints of worsening back pain, but she also had a fever and an upset stomach. That doctor ordered some labs (routine chemistry panel) which were all normal. The patient was told that she had the stomach flu and was sent on her way.
Shortly, thereafter, the woman urgently came to me with ongoing, severe lumbar pain and confusion. The fever had resolved, but her legs were developing weakness. When I examined her, she had extremely painful neurotension signs (straight leg raise) and a low back that was so sensitive that she nearly hit the ceiling when I gently touched her. Because of the sudden, severity of the low back pain with a recent fever, I suspected an infection, possibly discitis. Sure enough, her C-reactive protein (a sensitive inflammatory marker) was extremely elevated with an elevated level of white blood cells (infection fighters). While awaiting the results of blood cultures, I immediately started her on an antibiotic.
Two day later, on a Sunday morning, the lab called to confirm me that she indeed had a massive Staph (Staphlylococcus Aureus) infection. She was immediately admitted to the hospital with not only an infection in her spine causing meningitis; she also had a heart infection. Eventually, her low back hardware was removed and she completed two months of intravenous antibiotics.
Now, she is doing very well. She has very good control of her lumbar pain with use of a long-acting morphine. Although she no longer shovels snow, she enjoys agility competitions with her dogs and working in her garden. To me she says, "I am eternally grateful to you for saving my life".
Was this a case of post-surgical discitis? Even though the surgery took place nearly two years prior to the incident, the hardware in her spine could have harbored the bacteria for that period of time. The fact that her original surgery was complicated and required a re-operation certainly made her at very high risk for developing an infection. Such a sudden decline in her condition should have shouted, "Watch Out!" to any clinician, yet she was originally dismissed by her primary doctor. Often times, back pain patients are not taken seriously enough.
Even though discitis is an uncommon problem, it is a real post-operative complication which presents as low back pain worsening within 8 weeks of surgery (or maybe longer?). Maybe this patient had discitis immediately post-operatively that flew under the radar until the infection spread throughout the entire body. Sometimes infections are difficult to detect in the early stages. Sometimes the doctor's job is to stay vigilant until the disease rears its ugly head. Like in this case, infections like discitis can get ugly. The most common organism causing discitis is Staphylococcus Aureus (a common bacteria). The diagnosis is based on laboratory findings showing signs of infection. A CT scan or MRI can show total disc destruction and bone erosion from the infection. Ultimately, a disc biopsy may be required to determine which bug is causing the infection. Treatment usually entails removal of all the offending hardware where bacteria like to hide and intravenous antibiotics for six to eight weeks. The laboratory (C-reactive protein) values will then normalize as the infection is successfully treated.
I bring this case to your attention because badness can happen after spinal surgery. We all need to be attentive to the hoof beats of trouble. Typically, these hoof beats are common "horses", but sometimes the hoof beats are of those uncommon "zebras" like spinal discitis.
Published On: June 16, 2009