Challenges in Diagnosis and Management of Spondylodiscitis of L-5/S-1 Due to Propionibacterium acnes in a Patient with a Twenty-Year History of Tetraplegia

Objectives: To present novel strategies in the diagnosis and management of spondylodiscitis in a patient with tetraplegia. Case Presentation: A 44-year-old man presented with increased spasms despite having a SynchroMed II Medtronic for intrathecal infusion of baclofen. The C-reactive protein level was raised. Infection was suspected, but there were no localising signs. Positron Emission Tomography (PET) was performed to identify the focus of infection. PET showed an increased Fluorodeoxyglucose uptake in the L-5 vertebral body and the associated ill-defined soft tissue anteriorly. There was significant erosion and destruction of the S-1 vertebra. Magnetic Resonance Imaging of the lumbo-sacral spine revealed destruction and collapse of the S-1 vertebral body and a 6 cm × 2 cm anterior paravertebral abscess collection. This patient was managed in his home. Intravenous administration of 1 g of Ertapenem daily was provided by community nurses for eight weeks. Blood tests were performed in the community setting, and the patient was monitored by spinal unit doctors. Results: Follow-up CT revealed abnormal soft tissue, expanding and replacing the S-1 vertebral body, with appearances in keeping with an infective process. Using CT guidance and the Madison bone biopsy kit, multiple cores were obtained from the left sacral bone. Four of the five specimens showed no growth after extended incubation. Propionibacterium acnes were isolated after 10 days of incubation from the tissue from the sacral bone biopsy only. A shared decision was made towards active surveillance. Follow-up CT of the abdomen showed a stable appearance of the lumbar and sacral spine. Conclusions: A complex case of spondylodiscitis can be diagnosed and managed while the patient stays mainly in their home, avoiding prolonged admission to the spinal unit, in alignment with the “hospital to community” aspect of the National Health Service’s 10-year Health Plan for England. A diagnostic pathway with PET-CT as the first approach proved useful when the site of infection was unclear. Active surveillance obviated the need for extended periods of antibiotic therapy, which could have led to complications such as antibiotic-induced toxicity and microbial resistance to antibiotics.