A 79-year-old man presented with a 1-month history of constant lower back pain (LBP) radiating to the right thigh. The pain had been increasing over time. Movements aggravated the symptoms. The patient reported 10 out of 10 points in the visual analog scale. He was afebrile but reported intermittent chills at night. There was no history of recent gastrointestinal procedures, dental diseases/procedures, oncological diseases, immunodeficiency, diabetes, or intravenous drug use.\nOn examination, the lumbar paravertebral muscles were tender, hip flexion on the right side revealed slightly paresis (M4/5), and minimal movement of the spine or the limbs was accompanied by severe pain.\nOn admission, the inflammation markers were elevated (C-reactive protein [CRP] 54,4 mg/l, white blood cells [WBC] count = 13,6 G/l, platelet count = 344 G/l). X-ray and a ct-scan of the lumbar spine revealed destruction of the intervertebral space L3/4 and the corresponding endplates. Because of the bony destruction, the L4-body presented an anterior wedging. The standing X-ray revealed a segmental kyphosis as a result of the wedge deformity of L4-body and the collapsed disc space L3/4 []. Blood cultures taken on admission were negative. During the next 12 h, the pain got worse, and the patient developed urinary retention, which required a bladder catheterization. MRI-scan of the lumbar spine 12 h after admission revealed an advanced spondylodiscitis L3/4 with a liquefied disc, blurred endplates, and a collection of two abscesses in the right psoas muscle. Furthermore, a diffuse signal enhancement in both psoas muscles and the autochthone muscles from L3 to S1 [] was shown. A ct-guided fine needle biopsy was performed, and the empiric intravenous antibiotic therapy with amoxicillin/clavulanate 2.2 g 4 times daily intravenously (iv.) was initiated. As the results of the biopsy did not show any growth of bacteria amoxicillin/clavulanate was stopped. After an antibiotic-free interval of 5 days (9 days after the CT-guided biopsy), an open transpedicular biopsy was performed. On the same day, iv. amoxicillin/clavulanate was resumed. The bacteriological examinations on aerobic/anaerobic cultures showed no results. The eubacterial PCR (16S rDNA-sequencing) revealed V. parvula as the causing pathogen. The antibiotic therapy was switched to ceftriaxone 2 g iv. and metronidazole 500 mg i.v. A CT of the abdomen was performed on day 21, which showed increasing abscess collection in the right psoas major of 4.1 × 4.6 cm [] but no signs of intraabdominal malignancy. A drain was inserted into the right psoas muscle, and the abscess formation was subsequently drained for 4 days.\nAbnormal high calcium levels revealed an incidental parathyroid adenoma, which had to be removed surgically. Because of the additional surgery, the patient was discharged on day 27. On day 39, the patient presented himself in good health and pain-free to our outpatient clinic. Inflammation markers had normalized (CRP 2 mg/l, normal WBC count). A small residual abscess collection in the right psoas muscle was discovered on CT scan. The CT-scans and the standing X-rays of the lumbar spine showed no instability of the spine without any progression of the kyphotic deformity L3/L4. The antibiotics were switched to amoxicillin/clavulanate 1 g po 3 times daily for another 2 weeks, completing 6 weeks of the antibiotic treatment altogether. The patient presented himself to the last follow-up at day 95 in perfect shape, without any symptoms, and further changes in the lumbar spine X-rays [].\nThere was no external immobilization of the spine during the whole duration of the treatment.
A 76-year-old male diagnosed with Veillonella bacteremia presented with a sudden onset of back pain, fever, and chills of four days duration. Although the fever and chills had since subsided, the back pain continued to persist and was exacerbated with positional change. CT scans revealed a psoas abscess with extradural extension, along with indications of lumbar osteomyelitis. MRI scans were unable to be obtained owing to the patient’s pacemaker. Due to medication allergies and growing sensitivity to the infection, the patient was transferred to MICU for a short period to be desensitized to ampicillin-sulbactam. Interventional Radiology then placed a retroperitoneal drain for the psoas abscess as well as a PICC line for IV antibiotic administration at home.\nDuring the following week, the Neurosurgery service performed laminectomy at levels L4-S1. Bilateral medial facetectomies and foraminotomies were also performed at L4-L5 and L5-S1 to fully decompress the exiting nerve root and thecal sac. Significant facet arthropathy was noted. The extradural abscess, which was revealed to be a large synovial cyst with no pus, was resected. Cultures were taken and sent for laboratory analysis, revealing the presence of Veillonella species. Post-operatively, CT scans indicated a resolving abscess. The patient was discharged and instructed to complete his course of ampicillin-sulbactam at home and switch to metronidazole and levofloxacin for a total six-week course of antibiotics.\nThe patient re-presented to the hospital 18 days after the neurosurgical operation complaining of worsening back pain radiating into his posterior buttocks that began 10 days after the operation. CT scans revealed considerable interval decrease in the psoas abscess but extensive osseous destruction in the L5-S1 region, anterior to the laminectomy sites, thereby advancing concerns of osteomyelitis. CT scans revealed trace retrolisthesis of L2 on L3 and L3 on L4, as well as grade 1 anterolisthesis of L4 on L5. There was multilevel disc height loss, most severe at L3-L4 and L5-S1, and persistent narrowing of the thecal sac. Fluid was observed posterior to the surgical site along with phlegmonous changes extending from L4-S1. A small abscess was also seen in the S1 prevertebral soft tissues. Interval erosions of the L5 and S1 endplates were noted, compatible with discitis. All of these findings were consistent with progressive osteomyelitis. Furthermore, bone and tissue cultures revealed continued Veillonella infection, perhaps due to a combination of both insufficient debridement as well as inadequate duration of antibiotic treatment. The patient was instructed to begin IV vancomycin in addition to metronidazole and levofloxacin for an additional 6 weeks.\nThe patient presented to the office 25 days later with unbearable, radiating lower back pain forcing him to use a wheelchair to move about. CT scans indicated progressive destructive changes of the L5-S1 vertebral body endplates. Two presacral abscesses measuring 4 mm and 7 mm were identified anterior to S1; additional microabscesses were found in the prevertebral phlegmon at the L5 level. A larger abscess measuring 15 mm was identified dorsal to the thecal sac at the previous L5 laminectomy site, leading to a narrowing of the dural sac. Progressive destruction of the vertebral bodies was noted with fragmentation of the inferior endplate of L5 and superior endplate of S1. Reflexes were absent bilaterally in the lower limbs and there was decreased sensation to light touch. Tissue cultures taken from the affected vertebrae were all negative at this time, and given the patient’s debilitated status, reconstructive spine surgery was indicated.\nPreoperative X-ray revealed spondylolisthesis of L5 on S1, and a CT myelogram showed severe multilevel spinal stenosis from L2 to S1. Therefore, the patient underwent a L2-S1 lumbar laminectomy with posterior segmental instrumentation and posterolateral arthrodesis from the L2 to the ilium using pedicle screws and iliac bolts bilaterally. Decompression of spinal nerves was achieved by posterior lumbar laminectomy, bilateral medial facetectomies, and bilateral foraminotomies at all spinal levels between L2 and S1. Given the patient’s history of infection, an allograft was used to form a final instrumented fusion mass. (Figs. , , , and ).\nThe patient recovered well after surgery. Final blood and tissue cultures were all negative. CT scans indicated resolution of the remaining abscesses. He was discharged and instructed to complete the previously prescribed course of antibiotics and follow-up with rehabilitation facilities. After 12 months of rehabilitation therapy, the patient regained a majority of mobility and ambulated with cane. However, at the 12 month follow up visit, he complained of groin pain. Additional physical therapy including aqua therapy was ordered and followed. At the 18 month follow up visit, the patient is noted to be doing quite well with occasional back discomfort and continues to ambulate with a cane.