Presentation
Chronic draining tract on flank that has not resolved with treatment including antibiotics and exploratory surgeries.
Patient Data
The vertebral bodies of L2 - L4 are heterogeneous in appearance with marked osteolysis of the L4 vertebral body and the caudal aspect of L3. The cranial and caudal end plates of L4 and the caudal end plate of L3 are irregular and ill defined. There is sclerosis of the L2 vertebral body and the cranial aspect of L3. There has been progressive remodeling and bony production of the intervertebral foramen surrounding the L1 to L4 vertebral bodies most pronounced at the L3-4 disc space. There is marked periosteal new bone extending from the ventral aspects of L1 to L5. The included portion of the retroperitoneal space is unremarkable.
Vertebral osteomyelitis.
There is a peripherally contrast enhancing soft tissue tubular tract coursing from the right lateral body wall at the level of L6, through the right abdominal oblique musculature, traversing dorsally and axially to communicate with the right hypaxial musculature. There is marked contrast enhancement and moderate enlargement of the right hypaxial and abdominal oblique musculature in this region. This tract continues cranially within the right hypaxial musculature, travels through a smoothly marginated 6 mm wide columnar osseous defect in the right ventrolateral L4 vertebral body, and closely abuts the ventral vertebral canal/epidural space. This peripherally contrast enhancing tract travels cranially through regions of smoothly margined scalloped geographic lysis within the dorsal aspect of the L4 vertebral body, through the endplates and within the dorsal L3 vertebral body. There is no spinal cord deformation in this region. The contrast enhancing tissue continues within the right hypaxial musculature cranially, and is associated with scalloping osteolysis of the right ventrolateral margin of the L3 vertebral body. Two distinct regions of irregularly margined geographic osteolysis are present within the craniodorsal and caudodorsal L2 vertebral body. There is only a thin rim of bone with punctate lucencies delineating the ventral vertebral canal spanning L2-L4. There is marked smoothly margined new bone spanning the ventral margin of the L1-L4 vertebral bodies, and associated with the transverse processes and pedicles of L2-L4.
Draining tract is indicative of a probable plant foreign body with osteomyelitis and cellulitis.
Several pieces of plant material were removed from the draining tract at surgical exploration.
Case Discussion
The draining tract suggests migration of a foreign body either from the skin towards the vertebral column. The aggressive, chronic process is affecting more than one vertebral body. This is differentiated from primary discospondylitis in that there is extensive involvement of the vertebral bodies, and the lesion is not confined to the intervertebral disc.
Exploratory surgery was performed on the draining tract, and plant material was removed. Histopathology of the resected tissue revealed mixed bacterial population and plant material.
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