Abstract ID: A28
Abstract Title: Paraspinal Abscess Complicated by Endocarditis Following a Facet Joint Injection
Authors: Hoelzer B1, Weingarten T2
Mayo Clinic Colleg of Medicine Rochester Mn USA1, Mayo Clinic Colleg of Medicine Rochester Mn USA2, Mayo Clinic Colleg of Medicine Rochester Mn USA3, Mayo Clinic Colleg of Medicine Rochester Mn USA4
Poster Type: Poster
ABSTRACT BODY
CASE REPORT
A 68-year-old male presented for evaluation of recurrent low back pain. A previous MRI demonstrated degenerative facet changes. 8 months prior a left L5-S1 facet intraarticular injection had been performed. On this presentation the exam was unremarkable except tenderness over the right L5-S1 level. He underwent a fluoroscopically guided contrast-confirmed right L5-S1 facet joint injection and infiltration of the L5-S1 intraspinal ligament. The procedure was carried out under aseptic conditions with Povidone-iodine skin preparation and sterile drapes. A 22-gauge 3.5" spinal needle was placed into the facet joint, and 1 ml of 0.5% bupivacaine and 20 mg of triamcinolone injected. The intraspinous ligament was infiltrated using a 25 gauge needle with 5 ml of 0.5% bupivacaine and 20 mg of triamcinolone. 2 weeks later while lifting heavy objects, the patient developed acute left-sided low back pain radiating to his left calf. These symptoms were similar to those experienced 8 months prior. The exam demonstrated left sided lumbosacral tenderness but was otherwise unremarkable. Fluoroscopically guided contrast-confirmed left L5-S1 facet joint and epidural steroid injections were performed. A 22-gauge 3.5" spinal needle was placed in the left L5-S1 facet and 5 ml of 0.5% bupivacaine containing 20 mg triamcinolone was injected with 2 ml intraarticular and 3 ml periarticular. A 22-gauge 3.5" spinal needle was placed into the L5-S1 epidural space by loss of resistance technique to air and 1 ml of 0.5% bupivacaine and 40 mg triamcinolone injected. 8 hours after the injection, the patient became febrile (39 degrees) and then developed malaise, myalgias, lower extremity edema, blisters on his forehead, and worsening back and leg pain. He was admitted to an internal medicine service. Exam revealed punctate, petechial lesions on the soft palate, painful erythematous and purpuric lesions on the legs, and non-painful macular lesions on the hands. Laboratory studies revealed a leukocytosis of 24.4 x10 (9) /L, a prolonged ESR of 74.4mm/1h, and MSSA on blood cultures. Roth's spots, heart murmur or valvular vegetation on TEE were not demonstrated. A diagnosis of infective endocarditis (IE) by Duke’s criteria was made. A MRI revealed a right paraspinal abscess that tracked to the right L5-S1 facet. An Indium-111 tagged white blood cell scan revealed uptake limited to the right L5-S1 facet joint. Aspiration of the abscess grew MSSA. The patient completed a 6 week course of nafcillin with full recovery.
DISCUSSION
This is the first description of the development of IE following a facet injection. 5 previous descriptions of iatrogenic infection following facet injection are reported, all which resulted in local spread (i.e., epidural space). Similarities between those and our case include weeks-long delay for symptom onset, worsening back pain as the initial symptom, and a prolonged ESR. It is unclear why this case resulted in IE. The time course suggests that the first injection was responsible for the facet abscess. The second injection may have disturbed the abscess resulting in a bacteremia and the rapid clinical deterioration. Infectious complications should be considered for pain recalcitrant to spine injections.
ATTACHED FILES
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Reg Anesth Pain Med 2005; 30(3):A28