Bostelmann et al.

Journal of Medical Case Reports (2016) 10:349

DOI 10.1186/s13256-016-1125-y

CASE REPORT Open Access

First report on treating spontaneous

infectious spondylodiscitis of lumbar spine
with posterior debridement, posterior
instrumentation and an injectable calcium
sulfate/hydroxyapatite composite eluting
gentamicin: a case report
Richard Bostelmann1*, Hans Jakob Steiger1 and Armin O. Scholz2

Abstract
Background: Spontaneous infectious spondylodiscitis is a rare, but serious disease with the risk of progressive
neurological impairment. The surgical approach to spontaneous infectious spondylodiscitis is in most cases an
anterior debridement and fusion, often in staged surgeries. Here we report a case of single-stage posterior
debridement and posterior instrumented fusion in combination with an injectable calcium sulfate/hydroxyapatite
composite eluting gentamicin.
Case presentation: A 59-year-old Caucasian man presented with a 6-week history of lumbar pain without sensory
or motor disorders of his lower extremities. A magnetic resonance imaging scan of his lumbar spine in T2-weighted
sequences showed a high signal of the intervertebral disc L4/L5 and in T1-weighted sequences an epidural abscess
at the posterior wall of L4. Additional computed tomography imaging revealed osteolytic destruction of the
base plate of L4 and the upper plate of L5. Antibiotic therapy was started with intravenous ciprofloxacin and
clindamycin. We performed a posterior debridement via a minimally invasive approach, a posterior percutaneous
stabilization using transpedicular screw-rod instrumentation and filled the intervertebral space with an injectable
calcium sulfate/hydroxyapatite composite which elutes a high concentration of gentamicin. The patient’s lower
back pain improved quickly after surgery and no recurrence of infection has been noticed during the 1-year
follow-up. Computed tomography at 11 months shows complete bony fusion of L4 and L5.
Conclusions: An injectable calcium sulfate/hydroxyapatite composite releasing a high level of gentamicin can
support the surgical treatment of spondylodiscitis in combination with posterior debridement and transpedicular
screw-rod instrumentation.
Keywords: Spondylodiscitis, Surgical treatment, Posterior instrumentation, Local antibiotic, Injectable calcium
sulfate/hydroxyapatite, Gentamicin, Vertebral osteomyelitis, Case report

* Correspondence: Richard.Bostelmann@med.uni-duesseldorf.de
1
Department of Neurosurgery, University Hospital of Düsseldorf, Düsseldorf
40225, Germany
Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bostelmann et al. Journal of Medical Case Reports (2016) 10:349 Page 2 of 5

Background spine in T2-weighted sequences showed a high signal of

Infectious spondylodiscitis is usually secondary to spinal the intervertebral disc L4/L5 and in T1-weighted se-
surgery. Spontaneous infectious spondylodiscitis (SIS), quences an epidural abscess at the posterior wall of L4
caused by the hematogenous spread of bacteria, is a rela- (Fig. 2). Additional computed tomography (CT) imaging
tively rare disease. However, a rise in the incidence of revealed osteolytic destruction of the base plate L4 and
SIS has recently been noticed due to increasing life ex- the upper plate L5 (Fig. 3). Antibiotic therapy had been
pectancy, use of endovascular devices, diabetes mellitus, started with intravenous ciprofloxacin and clindamycin.
and HIV [1, 2]. Because of the progressive bone destruction of the base
Conservative treatment of SIS is effective in most pa- plate L4 and upper plate L5, we performed a posterior de-
tients [3], but surgical treatment is advocated in cases of bridement via a minimally invasive dorsolateral approach,
poor response to conservative treatment, progressive a posterior percutaneous stabilization using transpedicular
neurologic impairment, spinal instability, or progressive screw-rod instrumentation and filled the intervertebral
bone alteration [4–6]. Anterior debridement and fusion space with an injectable BGS, which elutes a high concen-
[7], mostly in a staged approach [8] are usually sug- tration of gentamicin (CERAMENT™ G, Bonesupport,
gested. Here we report a case in which an injectable, Lund, Sweden) after removing the pathological disc tissue.
antibiotic-eluting bone graft substitute (BGS) was used For posterior monosegmental instrumentation the Viper®
to facilitate fusion in single-stage posterior debridement 2 system (DePuy Synthes, Umkirch, Germany) with four
and posterior instrumentation. polyaxial screws (6 × 45 mm each) and two rods (40 mm
each) were used. The epidural abscess was not evacuated,
Case presentation since it did not compress the cauda equine.
A 59-year-old Caucasian man presented at our university A biopsy of the intervertebral disk was sent for micro-
hospital with a 6-week history of lumbar pain without sen- biological evaluation, but a causative bacteria could not be
sory or motor disorders of his lower extremities. The pain detected. Our patient’s lower back pain improved quickly
had not responded to the common conservative treatment after surgery. A postoperative CT scan on day 3 confirmed
of lower back pain [nonsteroidal anti-inflammatory drugs the correct positioning of the transpedicular screw-rod in-
(NSAIDs), physiotherapy, etc.] [9]. Our patient had a his- strumentation (Fig. 4). The antibiotic-eluting BGS is
tory of diabetes mellitus (noninsulin-dependent) but was clearly visible in the intervertebral space (especially on the
otherwise healthy. A physical examination showed pres- sagittal reconstruction, Fig. 4). Ciprofloxacin and clinda-
sure pain and tapping tenderness at the lower lumbar mycin were continued for 4 weeks intravenously, followed
spine. In blood biochemistry, an elevated C-reactive pro- by 4 weeks of oral administration. The surgical incision
tein (CRP: 27 mg/L) and a normal white blood cell count healed ad primam intentionem without prolonged wound
(WBC: 6.8 * 109/L) were found. Plain radiographs of the drainage. At discharge from hospital 4 weeks after surgery
lower spine revealed a narrowing of the intervertebral our patient was ambulatory, and CRP (0.8 mg/L) and
space between L4 and L5 with irregularity of the endplates WBC (8.1 * 109/L) levels were in the normal range.
(Fig. 1). Magnetic resonance imaging (MRI) of the lumbar No recurrence of infection was noticed during the
1-year follow-up. Our patient was generally well without
restrictions in his daily activities and able to work in his
previous job. He complained about mild pain from the left
lower spine to the left dorsal leg from time to time. He
was able to walk without pain for 45 minutes. Radiography
and CT of his lower spine during follow-up examination
at 11 months show complete bony fusion of L4 and L5
(Figs. 5 and 6).

Discussion
To the best of our knowledge, this is the first case where
an injectable, gentamicin-eluting BGS was used to facili-
tate fusion in the treatment of SIS. The presentation of
our patient was quite typical for a SIS: mean age about
50 years [10], back pain not responding to nonsurgical
treatment [11], and elevation of inflammatory markers
Fig. 1 a and b Preoperative radiograph of the lumbar spine anterior (CRP) [10]. The preferred diagnostic tool is an MRI
and lateral on 6 Jan 2016: narrowing of the intervertebral space L4
scan, with 76% definite and 20% possible diagnosis of
and L5 with osseous destruction of base plate L4 and upper plate L5
SIS, if the patient presents with symptoms that have
Bostelmann et al. Journal of Medical Case Reports (2016) 10:349 Page 3 of 5

Fig. 2 a and b Preoperative magnetic resonance imaging of the lumbar spine on 30 Dec 2014 T1- (right) and T2- (left) weighted sequences: note
the enhanced signal of the intervertebral disk L4/L5 and the epidural abscess at the posterior wall of L4

Fig. 3 a, b and c Preoperative computed tomography scan of the lumbar spine on 6 Jan 2015 (axial (left), coronary (middle) and sagittal (right)
reconstructions): significant bone osteolysis and erosion of base plate L4 and upper plate L5

Fig. 4 a, b and c: Postoperative computed tomography scan on 9 Jan 2015 (axial (left), coronary (middle) and sagittal (right) reconstructions):
correct position of transpedicular screw-rod instrumentation. Intervertebral space was filled with the antibiotic-eluting bone graft substitute, which
contains a radio contrast agent (Iohexol) with good visibility (especially on sagittal reconstruction)
Bostelmann et al. Journal of Medical Case Reports (2016) 10:349 Page 4 of 5

considered to be the “gold standard” in spine reconstruc-

tion [7, 16]. However, some well-recognized complications
associated with graft harvesting from the iliac crest includ-
ing pain at the donor site, nerve injury, hematoma, infec-
tion, and pelvis fracture have to be taken into account
[16–19]. These risks could be avoided with the use of a
synthetic BGS. Usually, the use of a synthetic BGS is not
indicated in septic or post-septic sites due to the risk of a
foreign body contamination as a trigger of recurring in-
fection. Therefore, the combination of a calcium sulfate/
hydroxyapatite composite with local antibiotic gentamicin
(CERAMENT™ G, Bonesupport, Lund, Sweden) seemed
to be a reasonable alternative. So far, the applied BGS in
our case has been used in bone reconstruction after osteo-
myelitis [20], but not in spine surgery. The composite
enabled us to combine posterior debridement, posterior
stabilization, and filling of the intervertebral space in a
one-stage procedure. Antibiotics were administered for
4 weeks intravenously, followed by a 4-week course of oral
administration, as suggested by Zhang et al. [10].
The administration of local anti-infective substances is
Fig. 5 a and b Follow-up radiograph of the lumbar spine anterior- becoming more popular in the treatment of SIS.
posterior and lateral at 11 months on 7 Dec 2015: unchanged Other groups have used antibiotic bone cement beads
position of the posterior instrumentation. Bony fusion of L4 and L5 [21], a combination of antibiotic-impregnated BGS and
autograft [22] or bioactive glass S53P4 [23]. In our
lasted longer than 2 weeks [12]. Operative treatment of opinion, the advantage of the injectable calcium sulfate/
SIS is indicated in cases of poor response to conservative hydroxyapatite composite plus gentamicin is the high
treatment, progressive neurologic impairment, spinal in- local concentration of gentamicin at the desired location
stability, or progressive bone alteration [4–6]. There is still [24], the complete resorption of the BGS, and its
an ongoing debate about the most suitable surgical ap- osteoconductivity.
proach. Some spine surgeons prefer an anterior approach
with debridement, fusion with autograft, and anterior or Conclusions
posterior instrumentation [13, 14]. However, a minimally An injectable calcium sulfate/hydroxyapatite composite
invasive posterior approach might be less exhausting for eluting a high level of gentamicin can support the surgi-
the patient. Moreover, debridement of the posterior inter- cal treatment of spondylodiscitis in combination with
vertebral space and the epidural abscess might be easier posterior debridement, transpedicular screw-rod instru-
via the posterior approach [15]. Independent of the mentation, and systemic antibiotic therapy. A CT scan
surgical approach, usually autogenous bone grafts are confirmed complete fusion after 11 months.

Fig. 6 a, b and c Follow-up computed tomography scan of the lumbar spine at 11 months on 7 Dec 2015: consistent position of the posterior
instrumentation. Complete bony fusion of L4 and L5
Bostelmann et al. Journal of Medical Case Reports (2016) 10:349 Page 5 of 5

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