A 79 years old man reported intense lumbar and lower limbs pain and impairment of the inferior limbs.
A 79 years old man reported intense lumbar and lower limbs pain and impairment of the inferior limbs. The first clinical suspicion was acute lumbar pain secondary to disk herniation. MRI esamination of the lumbar spine,with T1w (fig.2) and T2w axial and sagittal SE/TSE sequences ,followed by STIR fat-suppressed sequences showed signal alterations in L1 and L2 bone,and disk space with increment of the intensity of signal at T2w and STIR images ( fig.1,3) suggesting intense oedema and lytic bone involvement . Extensive fluid areas in the discal space and in the medullary bone of L1,and high intensity of signal in the anterior epidural space of L1-L2 were also present. After iv.contrast medium administration ( fig.4),MRI showed an intense enhancement of the spongio-medullary residual portions of L1 and L2,indicating medullary infiammation,of the meningeal structures of the anterior epidural space and the radicular pocket of L1 and L2, and of the posterior epidural recess;oedema of the isthmi and the near peduncolar structures was also observed. The patient underwent CT to estimate integrity of the posterior wall of L1 and L2,and to study the pattern of bone lytic involvement and of calcification of the fluid collection in the destroyed disk space. It documented the extension of the osteolytic erosion of trabecular and cortical bone of L1 and L2 vertebral bodies,in regard also of the anterior and the lateral walls in relationship to the fuse shaped inflammatory process (fig.5,6,7,8). The posterior wall turned out extremely thin. Microcalcifications were observed inside the necrotic lesion.
The spondylodiscitis is an inflammation of vertebres (the spondylitis) and intervertebral discs (discitis) which can be caused by inflammatory diseases (rheumatoid arthritis, psoriasic arthritis) or infections (tuberculosis). The diagnosis should have to consider these two great possibilities and oriented on specific immunological and microbiological examinations. In some cases it is necessary a biopsy that is positive in approximately 53% of the cases. The therapy must be oriented on the basis of the cause of spondylodiscitis; in the inflammatory autoimmune cases, it is based on antinflammatory therapy; when infection occurs, the most frequent bacteria involved is Staphilococcus Aureus (42-84% of the cases),and therapy is based on antibiotics. If there is a progression of the infection, it is observed a progressive destruction of the vertebres and at the end a pathological fracture; also the intervertebral disc is usually involved by the infection becoming a center of collection of pus that may progress and form an abscess in the tissues around the vertebres. If the infection is not controlled, this abscess can progress along the vertebral column or could penetrate in the vertebral duct and infect the contained nervous structures. It is in fact very important to make diagnosis of spondylodiscitis in time, before the alterations of the vertebral bodies and intervertebral discs and of the meninges make more difficult an effective therapeutic approach. The MR is considered the most sensitive diagnostic technique in estimating both the infective breeding grounds inside the intervertebral discs and the complications, such as the paravertebral abscess, the epidural abscess and the interest of the meninges.The high resolution of space and contrast, the high sensibility and specificity in the study of the oedema of the bone and the surrounding structures, make MRI more effective in differential diagnosis with osteomyelitis, discal degeneration and tumors. In our case, the use of fat-suppressed and post-contrast fat-saturation images, allowed a correct estimation of the extension of fluid areas in the discal space and in the medullary bone, the pathological involvement of the meninges in the anterior epidural space and of the epidural recesses, and of the structures of radicular pockets; the medullary oedema of the isthmus and of the near structures was also observed. CT was the choice for guidance in percutaneous biopsy, and for the drainage of abscesses inside the disc and paravertebral abscesses, and offers precious informations on the bony interest sometimes not evident on MRI scans. In our case, in fact, we could observe the microcalcifications inside the necrotic mass much more effectively on CT images.
Spondylodiscitis and infiltration of the meninges by Staphilococcus Aureus
Based on the provided lumbar MRI and CT images, the following key radiological features are observed:
Considering the patient’s age, clinical symptoms (severe back pain, restricted lower limb movement, etc.), and MRI/CT findings of vertebral and intervertebral disc lesions, the following causes are possible:
In summary:
The most likely diagnosis is infectious spondylitis/pyogenic spondylitis (septic vertebral-disc inflammation, collectively referred to as “spinal infection” or “myelitis”). However, if tuberculosis or other rare pathogens are suspected, or an autoimmune inflammatory etiology is possible, further confirmation is needed through blood tests (e.g., inflammatory markers, microbiological cultures), immunological studies, and biopsy of the vertebra/disc if necessary.
Treatment Principles:
Rehabilitation/Exercise Prescription (FITT-VP Principle):
For patients with severe osteoporosis or compromised cardiopulmonary function, enhanced supervision and protective measures are necessary, such as wearing a lumbar support brace, avoiding “unstable” movements, and closely monitoring vital signs and spinal load during exercise.
This analysis report is based solely on the provided clinical information and imaging findings, and is intended for academic and clinical reference only. It does not replace in-person consultation or professional medical advice. If you have any concerns or experience physical discomfort, please consult a specialist and undergo appropriate examinations and treatment.
Spondylodiscitis and infiltration of the meninges by Staphilococcus Aureus
