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Psoas Abscess and Sacroiliac Osteomyelitis Following Dilatation and Evacuation: Unusual Causes of Lumbar Radiculopathy after Spinal Anesthesia
Abstract Number: S 75
Abstract Type: Case Report/Case Series
A 37 year old female, G5P2112 at 17 weeks 3 days gestation presented to the hospital for premature
spontaneous rupture of membranes and was diagnosed with intrauterine fetal death. She underwent dilatation and evacuation(D&E) with an atraumatic L4/L5 level subarachnoid block. Surgery was uneventful and she was discharged home on the same day. On postoperative day (POD) 1, she complained of intermittent fever, and severe back pain which radiated to the right buttock, medial thigh and foot. On examination, lower back tenderness with paresthesia at right-sided L2 and L3 dermatomes and reduced strength of right lower extremity was elicited. Total white count was 11.6 mmol/L and body temperature was 102.3°F. MRI showed asymmetric thickening and enhancement along the course of iliacus and piriformis muscles with a small amount of fluid in the sacroiliac joint. At this point, the patient was treated empirically with antibiotics and physical therapy. She was transferred to inpatient rehabilitation center for further physical therapy and pain control on POD 12.
Two weeks later, she was readmitted for persistent back pain radiating to the right lower extremity. MRI revealed an organized fluid collection on the right iliacus muscle which was drained percutaneously with aspiration of purulent material. Microbiological culture yielded Methicillin Sensitive Staphylococcus aureus. Since she continued to have severe back pain and marked limitation of ambulation, She was discharged to inpatient rehabilitation center for physical therapy and continued antibiotics.
Follow-up MRI preformed in 8 weeks revealed evolution of the initial iliopsoas abscess into sacroiliac osteomyelitis. The patient underwent percutaneous bone biopsy and completed 6 weeks of IV antibiotic treatment for osteomyelitis.
Discussion: Pyogenic infection following dilatation and evacuation is rare and may pose a diagnostic dilemma. In our patient, improper positioning and possible nerve root injury was considered as causes of back and lower extremity pain before imaging demonstrated an infective etiology. Clinically unapparent uterine perforation during D&E and transient bacteremia has been proposed as a likely initiator of pathogenesis. There is insufficient data to recommend routine prophylactic antibiotic preoperative to prevent this serious complication. We recommend serial imaging studies of the pelvis to accurately diagnose the condition early in the clinical course.
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