SURGERY

Gas Forming Infection of the Spine: a Case Report

Yossi Smorgick1 & Eran Beit Ner1 & Tal Granek2 & Ayana Dvir3 & Sigal Tal2 & Ariela Levcovich4& Yoram Anekstein1

Accepted: 25 May 2020# Springer Nature Switzerland AG 2020

AbstractGas-forming infection is a rapidly progressive and life-threatening soft tissue infection. Gas-forming infection with spinemanifestations is extremely rare and can be a result of several entities including necrotizing fasciitis (NF) and emphysematousosteomyelitis.We present a case of a 68-year-old man who presented with a 1 week back pain and fever. His lab results supporteda high-intensity inflammation process. Due to a positive urinalysis, he was treated for a urinary tract infection as the suspectedorigin to his symptoms. Shortly following admission, the patient’s condition declined. Following an orthopedic surgeon consul-tation, a CT scan of the lumbar spine was obtained and demonstrated gas-forming infection process that involved the spine,epidural space, and surrounding muscles. The patient underwent several surgical procedures in attempt to reduce the infectedtissues and the local pressure. Despite aggressive debridement of the spine and maximal medical therapy, the patient passed awaydue to multisystem organ failure. Spine involvement in gas-forming infection is a rare entity with very poor prognosis, requiringearly and aggressive surgical treatment. A multidisciplinary approach is necessary for management. Nevertheless, even withproper and optimal management, multisystem failure and mortality still may occur.

Keywords Spine . Gas forming infection . Irrigation and debridement . Necrotizing fasciitis . Emphysematous osteomyelitis

Introduction

Gas-forming infections (GFI) are rapidly progressive, life-threatening medical conditions [1, 2]. Involvement of thespine in these types of infection is extremely rare but can befatal. As opposed to gas formation or identification within theextra-axial bone which is commonly related to infection [3],identification of intraosseous gas in the spine is usually a

reassuring marker and do not necessitate further intervention[4]. It is most commonly a result of a degenerative process,trauma, post procedural, etc. [5, 6]. Most of these entities arethe result of penetration of discal nitrogen gas (i.e., Schmorl’snode) or nitrogen gas accompanying osteonecrosis (i.e.Kummel’s disease). In the absence of the conditions men-tioned above, a clinical image of general illness, fever whichaccompanied by formation\identification of intraosseous gasis suggestive of GFI.

Entities such as necrotizing fasciitis (NF) and emphy-sematous osteomyelitis (EOM) which represent the GFIare more often seen in the extremities and with much lessfrequent involvement of the axial skeleton. NF is an in-fection of the deep soft tissues which often results insevere signs of sepsis [2, 7, 8] and is commonly seen inthe extremities, and less frequently in the abdomen or theperineum. NF involving the spine is extremely rare, withonly two-cases ever reported in the literature [9–11].EOM is a gas-forming infection which primarily involv-ing the extra-axial bone [1, 12], of usually monomicrobialgas-producing organism [12]. Hematogenous dissemina-tion is the most common route of spread of infection[13]. Nevertheless, there have been other reports of lesscommon routes for infection spread including extensionof intraabdominal infection, post intraabdominal or spinal

This article is part of the Topical Collection on Surgery

* Eran Beit Nereranbnster@gmail.com

1 Department of Orthopedic Surgery and the Spine Unit, YitzhakShamir Medical Center, Zerifin, Israel, affiliated to the SacklerFaculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

2 Department of Radiology, Yitzhak Shamir Medical Center, Zerifin,Israel, affiliated to the Sackler Faculty of Medicine, Tel-AvivUniversity, Tel-Aviv, Israel

3 Intensive Care Unit, Yitzhak Shamir Medical Center, Zerifin, Israel,affiliated to the Sackler Faculty of Medicine, Tel-Aviv University,Tel-Aviv, Israel

4 Infectious Diseases Unit, Yitzhak Shamir Medical Center, Zerifin,Israel, affiliated to the Sackler Faculty of Medicine, Tel-AvivUniversity, Tel-Aviv, Israel

https://doi.org/10.1007/s42399-020-00337-6

/ Published online: 5 June 2020

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surgery, and direct inoculation from skin or soft tissueinfection [14].

Due to its progressive nature, in many of the cases it is hard todifferentiate between the primary source of infection.Nevertheless, in both entities early diagnosis, emergency surgicaldebridement, and broad-spectrum antibiotics are crucial. [1, 9].

We present a recent case of gas-forming infection involv-ing the spine.

Case Presentation

A 68-year-old man with a medical history of type 2 diabetesmellitus (age of onset was unknown), recent onset atrial fibril-lation, and occasional episodes of urinary retention was ad-mitted with complaints of dysuria and fever. No documenta-tion of prostate pathology was found. Neither history of to-bacco use nor excessive alcohol consumption was recorded onadmission. He reported a back pain that began a week beforebut had no neurological complaints.

His vital signs were a temperature of 38.1° C, blood pressureof 134/89 mmHg, and a heart rate of 155 beats-per-minute.

Laboratory tests showed a white blood cell count (WBC) of23,400 cells/μL and C-reactive protein level (CRP) of289 mg/L (normal values < 5 mg/L). His hemoglobin (Hb)was 12.1 g/dL and the platelet count (PLT) was 107 K/μL.Serum creatine kinase (CK) and serum glucose level were65 U/L (normal values for males, 55–170 units/L) and466 mg/dL, respectively. His urinalysis tested positive forleukocytes and his chest X-rays did not show any pathology.

Blood and urine cultures were obtained. Suspecting a uri-nary tract infection, the patient was treated empirically with adaily dose of 2 g IV (intravenous) ceftriaxone. He was alsotreated with IV insulin and verapamil and was hospitalized inthe internal medicine department. Shortly following admis-sion, the patient became lethargic. Antibiotic regimen waschanged to daily dose of 1 g IV vancomycin and 500/500 mg of IV imipenem/cilastatin every 6 h (total daily doseof 2 g). Following an orthopedic surgeon consultation, a CTscan of the lumbar spine was obtained.

CT scan revealed widespread subcutaneous emphysema,with extension into the epidural space in the entire lumbar spine.Moreover, it showed involvement of the L4, L5 vertebral bodiesas well as the disc at that height. The emphysema alsoencompassed both iliopsoas muscles and the right gluteus mus-cle. Inguinal and prevertebral involvements were also noted(Fig. 1a‑c). A subsequent total-body CT showed the continua-tion of the epidural emphysema into the thoracic spine up to T8.

Due to suspected gas-producing bacterial infection, the pa-tient was immediately (within 24 h from emergency roomadmission) taken to the operating room for irrigation and de-bridement of infected tissues. Debridement of the paraspinalmuscles on both sides from L1 to the sacrum and the right

gluteus muscle was performed, followed by laminectomy ofL1, L2, L3, L4, and L5, which exposed pus in the spinal canalin all operated segments. A discectomy at the L4‑L5 level wascompleted, and the spinal canal was irrigated up to L8 using asmall feeding tube.

After the surgery, the patient was then transferred to theintensive care unit for his postoperative care. On day two afterhis initial admission, Methicillin-sensitive Staphylococcusaureus (MSSA) growth was reported in blood cultures, whilegram stain from pus taken during surgery showed gram-positive cocci. Antibiotic regimen was then changed and in-cluded daily dose of 1 g IV vancomycin, two daily doses of2 g IV cefazolin (total 4 g), and 3 daily doses of 900 mg IVclindamycin (total daily dose of 2.7 g).

Throughout his hospitalization in the ICU, the patient wasunder high dosage of vasopressors including IV drip of0.65 mcg/kg/min and later 0.2 mcg/kg/min IV adrenaline and1.75 mcg/kg/h IV glypressin. Under this supportive treatment,blood pressures were kept within normal limits. However, sincethe patient’s condition continued to deteriorate, the patient wasagain operated on postoperative day 1 for additional debride-ment and irrigation of both iliopsoas muscles.

Despite maximal medical and surgical therapy, the patientpassed away due to multisystem organ failure 5 days after hisinitial presentation at the emergency department. All bloodand pus cultures grew MSSA.

Discussion

GFI involving the spine is extremely rare, with only two cases ofNF and less than 20 cases of EOM previously reported in themedical literature [10–12]. As opposed to spondylodiscitis andspinal epidural abscesses, in which MRI is the preferred diag-nostic technique for precise anatomical localization and surgicalplanning [15], in the case of spinal GFI, an MRI exam is far tootime-consuming and may delay surgical management. In thecase of EOM, CT holds a crucial role in early diagnosis of thisentity. As plain X-rays might not identify small amounts ofintraosseous gas within the vertebrae, performing early CT atadmission in patients presenting with general illness, fever andback pain may provide a clue to early diagnosis [16]. In the tworeported cases of spinal NF in the literature, as well as our case,surgeons decided against a preoperative MRI.

Clinical presentation of GFI is often challenging, as it isdifficult to differentiate from simple infections. Suspicionshould be raised in rapidly deteriorating patients with organsystem failure [17, 18]. Another important factor that must beassessed is the patient’s background and comorbidities asthese infections, both outside the spine as well as within, tendto be more common in immunocompromised individuals,with diabetes mellitus as the most significantly comorbidityreported [1, 19].

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When the diagnosis of GFI is suspected, CT findings ofbone involvement, subcutaneous emphysema or emphysemain the spinal canal should establish it. When assessing thespine, we advise to assess all aspects of it as it might help usseeing the whole picture. For example, a more localized pic-ture, with no extent of gas beyond vertebral bodies and discs,plus adjacent degenerative disc manifestations and vertebralbody height loss might imply on more degenerative/post trau-matic processes, respectively. As opposed to the later, pene-trating processes with gas extending into the soft tissues ismore specific for infection.

In the presented case, the appearance of gas along theparaspinal musculature and in the epidural fat from L1 toL5, as well as throughout the L4, L5 vertebral bodies,established the diagnosis and further demonstrated the aggres-sive nature of the infection.

Even though themanagement protocol in both entities consistAbx and surgical debridement, there is still a need for definingthe entity of the infection. The differences in causing organismand the differences in the deterioration rate might help us inchanging the treatment approach, either for the chosen Abx orfor the aggressiveness the surgical treatment. Due to the clinicalpresentation as well as for the repetitiveMSSA positive cultures,this patient was considered to be having NF involving the spine.Giuliano et al. [20] described two microbiologic profiles of NF.Type I describes polymicrobial infections, frequently consistingof anaerobes. Type II infections are monomicrobial and typicallyinvolve Group A Streptococcus or, less commonly,Staphylococcus aureus. Although we did not have the pathologyto prove it, we believe that the presented case demonstratesmonomicrobial infection (type II NF) with MSSA.

Conclusion

Spine involvement in gas-forming infection is a rare conditionwith extremely poor prognosis. It is a surgical emergency

which requires early and aggressive surgical treatment.Multiple teams from different specialties are crucial for propercase management. Diagnosis of this aggressive infection re-quires a high level of suspicion as this is a rare condition withpossible life-threatening outcomes. An early diagnosis is cru-cial for optimal management. Nevertheless, even with propercare, multisystem failure still may occur.

Compliance with Ethical Standards

Conflict of Interest All authors declare that they have no conflict ofinterest relevant to this case or paper.

Other disclosures are provided on the disclosure form.

Informed Consent We did not acquire an informed consent from thepatient’s next in kin. The given information is anonymized, and the sub-mission does not include images or other information that may identifythe deceased. We believe that it is very important to share information ofthe presented case of such a rare disease with very poor prognosis withour colleagues, in order to contribute to our joint understanding of thisdisease. Due to its clinical importance, our IRB\Ethics committee hasdiscussed the case and gave a waiver for the need of a formal reviewwhich is attached with the cover letter.

Abbreviations GFI, gas-forming infection; NF, necrotizing fasciitis;EOM, emphysematous osteomyelitis; WBC, white blood cell count;CRP, C-reactive protein level; Hb, hemoglobin; PLT, platelet count;CK, serum creatine kinase; CT, computed tomography; MRI, magneticresonance imaging

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