Mahesh et al., J Spine 2016, 5:4 DOI: 10.4172/2165-7939.1000320 Case Report Open Access Volume 5 • Issue 4 • 1000320 J Spine, an open access journal ISSN: 2165-7939 Emphysematous Osteomyelitis - A Rare Cause of Gas in Spine - A Case Report Mahesh BH, Upendra BN, Vijay S*, Arun Kumar GC and Srinivas Reddy Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Millers road, Vasanthnagar, Bangalore, Karnataka, India Abstract Emphysematous osteomyelitis is rare condition characterised by the presence of intraosseous gas. About 25 such cases have been reported in the literature with only 10 cases involving spine. These infections are commonly seen in elderly morbid patients and are highly fatal. We report a 65 year old female patient with history of sudden onset of back pain and weakness of both the lower limbs with radiological images revealing the features of emphysematous osteomyelitis of L5 vertebra, which was treated with surgical decompression and stabilisation, and post-operative antibiotics. We also review literature to describe the clinical and radiological features for diagnosis and the treatment options available for such infections. *Corresponding author: Vijay S, Spine Surgeon, Jain Institute of Spine Care and Research, Bhagwan Mahaveer Jain Hospital, Millers road, Vasanthnagar, Bangalore, Karnataka, India-560052, Tel: 9886271303; E-mail vijays_sdumc@yahoo.co.in Received June 10, 2016; Accepted July 13, 2016; Published July 15, 2016 Citation: Mahesh BH, Upendra BN, Vijay S, Arun Kumar GC, Reddy S (2016) Emphysematous Osteomyelitis - A Rare Cause of Gas in Spine - A Case Report. J Spine 5: 320. doi:10.4172/2165-7939.1000320 Copyright: © 2016 Mahesh BH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Emphysematous osteomyelitis; Gas in spine; Surgical decompression Introduction Emphysematous osteomyelitis is the infection of bone caused by gas forming microorganisms [1]. It’s a rare condition with only about 25 cases reported in the literature and only 10 involving spine [2]. Tese infections are highly fatal with the reported mortality of about 32%. Early diagnosis is essential for initiating appropriate treatment and reducing the mortality. Te presence of gas as a sign of infection was frst described by Ram et al. in 1981 [3] and is pathagnomic of infection in the appendicular skeleton [1]. However, the diagnosis of emphysematous osteomyelitis involving spine is difcult as the presence of gas within the intradiscal or intraosseous space would more commonly indicate a non-infectious process like degeneration, osteonecrosis or osteitis deformans [1,2]. We describe one such rare case diagnosed early and treated successfully with timely surgical intervention and appropriate post-operative antibiotics. We also review literature and describe clinical and radiological features that would help in diferentiating emphysematous osteomyelitis of spine from other non-infectious gas forming conditions. Case Report A 65 year old female patient presented with history of severe low back pain since 12 days with sudden onset of weakness of both lower limbs and inability to walk with bladder retention and bowel involvement since 4 days. Pain was continuous, associated with high grade fever and chills. She was a known hypertensive and a case of rheumatoid arthritis being treated with analgesics and steroids. On examination tenderness was found at lower lumbar spine, bilateral feet were fail with decreased sensations and absent ankle jerk. Per rectal examination revealed decreased perianal sensations with lax anal tone and absent anal wink. Her blood investigations revealed Hemoglobin of 9, total leukocyte count of 14,000/cm 2 of which 86% were neutrophils. Her blood urea and serum creatinine were 63 mg/ dl and 1.9 mg/dl. MRI and CT scans showed multilevel stenosis with altered signal intensity within the body of L5 and with epidural abcess with gas within the body of L5 vertebra, epidural space and in the psoas muscle (Figure 1). Based on the clinical, biochemical and radiological features she was diagnosed with L5 infective spondylitis and degenerative scoliosis, L2-L3, L3-L4, L4-L5, L5-S1 Lumbar canal stenosis, bilateral foot drop and cauda equina syndrome with chronic drug induced renal failure. In presence of dense neurological defcits with source of infection from L5 body and MRI showing signifcant stenosis, surgical decompression, debridement and stabilisation was contemplated. Afer stabilization of general condition, she underwent L1-ilium Pedicle screw instrumentation, L2, L3, L4, L5 Laminectomy and decompression of dura and bilateral roots, transpedicular biopsy of L5 vertebral body with posteriolateral fusion under Spinal anaesthesia. Post-operative X images showed satisfactory scoliosis correction, posterolateral bone grafing and laminectomy (Figure 2). Intraoperatively samples from L5 vertebral body were sent for histopathalogical examination which showed granulation tissue with neutrophils, necrotic bone, air bubble, sof tissue necrosis and Grams stain smear showed Gram negative bacilli with infammatory granulation tissue (Figure 3). Post operatively her general condition improved, renal parameters, total leucocyte and neutrophilic counts returned to normal. She was mobilized on wheel chair and catherization was continued. Culture grew E-coli and biopsy was reported as non-tuberculous osteomyelitis. She was started on Injection Magnex, Meropenam and clindamycin, based on culture and sensitivity reports. A week later, she developed repeated fever spikes with discharge from the wound, for which wound lavage was done. Post lavage her fever reduced and dressing remained dry and she was discharged parenteral antibiotics were continued for 6 weeks which was changed to oral antibiotics for next weeks. At 6 months follow up her pain had reduced, she was able to walk with support, regained bladder control and her motor power recovered partially in right ankle. Laboratory reports and imaging studies revealed resolution of infection. ESR was 16 mm/hr and CRP was negative, CT and MRI scans showed resolustion of gas shadows and epidural abcess (Figure 4). However L5 vertebral body showed increased collapse with caudal migration of lef connecting rod for which she is under observation and advised revision if becomes symptomatic. Discussion Intravertebral or intraosseous gas in the spine is termed as vacuum phenomenon and was frst described by Magnusson in 1937 [4]. It J o u r n a l o f S p i n e ISSN: 2165-7939 Journal of Spine