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Original article
Septic arthritis of the facet joint Arthrite septique articulaire postérieure V. André a,∗ , M. Pot-Vaucel a , C. Cozic a , E. Visée b , M. Morrier c , S. Varin a , G. Cormier a a
b
Service de rhumatologie, centre hospitalier départemental, site de La-Roche-sur-Yon–Les Oudairies, 85925 La-Roche-sur-Yon, France Service d’imagerie médicale, centre hospitalier départemental, site de La-Roche-sur-Yon, Les Oudairies 85925, La-Roche-sur-Yon, France c Services d’infectiologie, centre hospitalier départemental, site de La-Roche-sur-Yon, Les Oudairies, 85925 La-Roche-sur-Yon, France Received 6 January 2015; received in revised form 26 February 2015; accepted 2 April 2015
Abstract Objective. – Septic arthritis of the facet joint is a rare clinical entity. We report 11 cases of facet joint infections diagnosed in our institution. Patients and method. – Patients were identified via the computerized patients record (PMSI). Their features were collected and compared with published data. Results. – The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. Conclusion. – Assessing the facet joint is essential in case of inflammatory back pain, and the radiologist must be asked to perform this examination. © 2015 Published by Elsevier Masson SAS. Keywords: Septic arthritis of the facet joint; MRI
Résumé Objectif. – Les atteintes septiques isolées des articulations zygapophysaires sont rares. Nous rapportons notre expérience de cette atteinte à travers une série rétrospective de 11 patients. Patients et méthode. – Les dossiers ont été identifiés grâce au codage PMSI. Les caractéristiques des différents cas ont été colligées et comparées aux données de la littérature. Résultats. – Les manifestations cliniques sont proches de celles des spondylodiscites infectieuses associant à des degrés divers douleurs rachidiennes plus ou moins latéralisées avec raideur (11/11), fièvre (9/11), radiculalgie (5/11), asthénie. Dix patients avaient une atteinte lombaire et 1 patient une atteinte dorsale. Le syndrome inflammatoire était constant. Un accès rapide à l’IRM rachidienne avec des coupes intéressant l’articulation a permis de poser rapidement le diagnostic dans tous les cas et d’analyser une éventuelle extension du processus infectieux (épidurite 5/11, pyomyosite 5/11). Les hémocultures (8/11) et les prélèvements locaux ont permis de préciser le germe et d’adapter le traitement antibiotique dans tous les cas. Notre série se distingue des données de la littérature par la diversité des germes incriminés. Une porte d’entrée a pu être identifiée dans 4 cas. Une autre localisation septique était retrouvée dans 4 cas. L’évolution a été favorable avec le traitement médical dans 10 cas. Le
∗
Corresponding author. E-mail address: [email protected] (V. André).
http://dx.doi.org/10.1016/j.medmal.2015.04.001 0399-077X/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
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drainage chirurgical d’un abcès a été nécessaire chez un patient. Aucune complication neurologique n’a été rencontrée, probablement en raison d’un diagnostic précoce. Conclusion. – En cas de rachialgies suspectes, l’étude des articulations articulaires postérieures est indispensable et doit être précisée au radiologue. © 2015 Publi´e par Elsevier Masson SAS. Mots clés : Arthrite septique articulaire postérieur ; IRM
1. Introduction Cases of isolated septic arthritis of the facet joints (SAFJ) are a small proportion of all spinal infections. Only few series with few patients (< 10) have been published [1–10]. We report our experience through a retrospective series of 11 patients, to our knowledge the largest series published to date. Two of our cases were included in a previous publication [11,12]. We compared our data with previously published data. 2. Patients and methods We identified patients managed in our unit for SAFJ from diagnoses recorded in the computerized record of patients database (French acronym PMSI) by searching for the main diagnostic code of infectious spondylitis (M463) since there was no specific coding for SAFJ from 2000 to 2013. We identified patients having presented with SAFJ proven by imaging (MRI) without any associated spondylodiscitis, and with documented bacteriological results. The demographic, clinical, biological, and iconographic data at diagnosis and response to treatment was collected for each patient. This data was then compared with previously published data. 3. Results Eleven cases of posterior SAFJ were identified, accounting for 13.5% of all spinal infections managed in our unit during the study period, compared to 70 cases of infectious spondylitis. The main characteristics of these patients are listed in Table 1. The mean age at diagnosis was 67 years (34–83 years) with 7 male and 4 female patients. All patients complained of back pain with stiffness: lumbar in 10 cases and dorsal in 1 case. The vertebra involved were L4/L5 in 7 cases, L5/S1 in 2 cases, L3/L4 in 1 case, and T10/T11 in 1 case. The pain was one-sided in 2 cases. Radiculalgia was noted in 5 cases. None of the patients presented with neurological deficit. Nine patients were febrile. Risk factors were noted in 3 cases: 1 case of type 2 diabetes, 1 of chronic alcoholism, and 1 of myelodysplasia. Five patients reported a history of chronic low back pain, and 6 patients presented with osteoarthritis of the facet joint on X rays. The average delay before diagnosis was 20 days and 12.8 days when ruling out tuberculosis. Standard X rays performed initially did suggest any sign of an infectious disease. Technetium 99 m (99mTc)-labeled bisphosphonate scintigraphy was performed in 3 patients, showing increased uptake of the joint involved in every case (Fig. 1).
Fig. 1. Technetium scintigraphy (patient 1), fixation of the left facet joint T10T11. Scintigraphie au technétium (patient 1), fixation de l’articulaire postérieur gauche T10-T11.
CT was performed in 3 patients. The CT for patient 1 was performed 7 weeks after the onset of symptoms; it revealed an osteolysis of T11 left lateral hemi-arch, with an infiltrative process of the T10-T11 joint and of the paraspinal muscles. The CT for patient 8 was performed 3 months after the onset of symptoms; it also revealed a large lytic lesion of the posterior left L4-L5 joint with posterior epiduritis, and soft tissue infiltration. The CT for patient 10 was performed 1 week after the onset of symptoms and was normal. All patients underwent spinal MRI to confirm the diagnosis presenting as isolated synovitis (hypointense on T1, with enhancement after gadolinium injection, and hyperintense on T2) or greater inflammatory changes of the joint with narrowing and erosion of the intervertebral space and possible extension to soft tissues, and epiduritis (Fig. 2). Five patients presented with epiduritis at diagnosis. Five patients presented with pyomyositis (paraspinal abscess or psoas abscess). Two patients presented
Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
1
59
F
2
77
F
Inflammatory lumbar dorsal pain Febrile inflammatory lumbar sciatica
3
61
H
4
34
H
5
76
H
6
72
H
7
77
H
8
83
9
Time to diagnosis
Bacterium
Portal of entry
Remote focus
Identification
Imaging
T10-T11 left None identified
6 weeks
Staphylococcus aureus
None identified
No
Biopsy
L4-L5 right
None identified
6 days
Staphylococcus aureus
No
Blood culture
Medical Surgical* 12 weeks Medical 8 weeks
One-sided febrile inflammatory lumbar and gluteal pain Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar pain Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar pain
L4-L5 left
Type 2 diabetes
8 days
Yersinia Pseudotuberculosis
Malleolar cutaneous wound None identified
X ray/Scinti/CT/MRI Epiduritis Soft tissues X ray/Scinti/MRI Epiduritis
No
Puncture
X ray/MRI
Soft tissues
Medical 6 weeks
L4-L5 left
None identified
8 days
Staphylococcus aureus
None identified
No
Blood culture
X ray/MRI
Soft tissues
Medical 8 weeks
L4-L5 left
8 days
Strepto Oralis
None identified
No
Blood culture
X ray/MRI
No
Medical 10 weeks
L4-L5 right
Sideroblastic anemia None identified
5 days
Staphylococcus aureus
None identified
No
X ray/MRI
Soft tissues
Medical 8 weeks
L4-L5 right
None identified
3 weeks
Strepto Bovis
Colon polyps
Polyarthritis
X ray/MRI
Epiduritis
Medical 8 weeks
F
Mixed lumbar pain
L4-L5 left
None identified
3 months
None identified
No
70
H
L5-S1 right
Blood culture
H
L3-L4 left
5 days
Micromonas Micro
Sigmoid diverticulitis None identified
Endocarditis
71
Chronic alcohol abuse None identified
15 days
10
Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar and crural pain
Mycobacterium Tuberculosis Strepto gallolyticus
Blood culture Puncture Blood culture Puncture of the knee Biopsy
Blood culture
11
58
F
L5-S1 left
None identified
10 days
Pasteurella Multocida
Polyarthritis without endocarditis Sternoclavicular arthritis and right heel
One-sided febrile inflammatory lumbar pain
Risk factor
Wound on the foot
Blood culture Sternoclavicular puncture
Extension
Treatment
X ray/Scinti/CT/MRI Epiduritis Soft tissues X ray/MRI Epiduritis Soft tissues X ray/CT/MRI No
Medical 12 weeks
X ray/MRI
Medical 6 weeks
No
Medical 1 an Medical 12 weeks
Surgical treatment*: complication at 8 days of antibiotic treatment with fistulization to the skin of a paravertebral abscess requiring surgery.
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Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
Table 1 Characteristics of our 11 patients. Caractéristiques de nos 11 patients.
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One patient presented with tuberculous facet joint damage associated with mediastinal and mesenteric lymph node involvement without parenchymal lung disease. A portal of entry was observed in 4 cases: 2 cases of skin lesions and 2 cases of gastrointestinal lesions (polyps or diverticula). A remote septic location was observed in 3 cases: 2 cases of polyarthritis and 1 of biarthritis. One patient presented with endocarditis. The blood cultures were positive in 8 cases (73%). The blood cultures performed in case of multiple joint involvement were always positive. The diagnosis was made on local samples in other cases. Two patients underwent joint puncture under fluoroscopic guidance, and 1 patient under CT guidance. Two of these samples allowed identifying bacteria. Two patients underwent osteoarticular biopsy allowing identification of the bacterium. All patients presenting with a bacterial infection were treated with a bi-bactericidal antibiotic therapy adapted to the epidemiology, after consulting an infectious diseases physician, IV for 15 to 21 days switched to a mono- or bi-antibiotic therapy for a total treatment duration of 6 to 12 weeks. Tuberculous involvement was treated with an anti-TB treatment for 1 year. No patient presented with any neurological complications. One patient underwent surgery for a contiguous subcutaneous abscess. This treatment was associated with a strict bed rest for the first 15 days followed by wearing a rigid back brace for 1 to 2 months. The outcome was favorable in all patients with full recovery. 4. Discussion
Fig. 2. T1 Fat Sat weighted MRI after gadolinium injection (patient 6) demonstrating extensive periarticular inflammatory changes in the posterior paraspinal muscles extended from the right facet joint L4-L5. IRM rachidienne coupe axiale (A) et sagittale (B) séquence T1 Fat sat gado (patient 6), mise en évidence d’un réhaussement après injection de gadolinium de la capsule de l’articulaire postérieure L4-L5 droite associé à une prise de contraste des muscles paravertébraux adjacents et constitution d’une collection abcédée visible sur la coupe sagittale.
with both epiduritis and pyomyositis. MRI was contributive to the diagnosisas early as 5 days after the onset of symptoms for 1 patient and in the first 10 days for 6 patients. Staphylococcus aureus accounted for 36.4% of causative bacteria. Streptococci were isolated in 27.2% of cases. Other bacteria were found less frequently in the other cases (Yersinia pseudotuberculosis, Pasteurella multocida, Micromonas micros).
SAFJ are considered as rare events even though they are now known by clinicians. The characteristics of patients presenting with SAFJ included in the main published series (> 5 patients) are listed in Table 2. The actual impact of this condition was not directly assessed but compared to that of infectious spondylitis as reported in some series. The annual incidence of infectious spondylitis was assessed at 2 per 100,000 inhabitants, in 2001, by Hopkinson et al. [13] and this incidence appears to have been increasing over the last decade [14]. David Chaussé et al. estimated in 1981 that 1 case of SAFJ occurred for arthritis for every 500 cases of infectious spondylitis [15]. Our results correlate better with more recent data. Muffoleto et al. [4] and Narváez et al. [2] reported respectively 4% and 20% of SAFJ among all spinal infections managed in their institution. The easier access to MRI allowed obtaining an earlier diagnosis, probably partly accounting for this increase. Indeed, the natural course of infection is the extension to the paraspinal soft tissues, the psoas, the epidural space, the vertebral bodies, and disks. Cases of spondylitis complicating the outcome of SAFJ have been reported [9]. This condition preferentially affects adults with a mean age of 56 to 73 years, depending on the series [1–6]. Pediatric cases have also been reported [16–18]. The sex-ratio is close to 1, when considering data from the largest series. The risk factors are those usually found for septic arthritis: diabetes, chronic alcoholism, long-term corticosteroid therapy, underlying neoplastic disease, splenectomy, hematological disease, intravenous drug use, chronic renal failure, dialysis,
Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
Sex
Comorbidity
Location
Ergan et al., 1997 [5] 6 patients
62,3 (49–74)
3M 3F
2 type 2 diabetes
3 L4/L5 1 L3/L4 1 L2/L3 1 L5/S1
Muffolettoa et al., 2001 [4] 6 patients
56 (48–75)
3M 3F
2 drug addict. + diabetes 1 cirrhosis
Narvaez et al., 2006 [2] 10 patients
60 (33–82)
5M 5F
1 type 2 diabetes 1 LM 1 lung metastasis 1 cirrhosis 1 COBP
Doitaa et al., 2007 [1] 5 patients
70 (73–78)
5F
1 lung cancer
Michel-Bâtot et al., 2008 [3] 6 patients
61,5 (50–76)
5M 1F
1 type 2 diabetes 1 chronic alcohol abuse
Back pain
Radiculalgia
Neurologic deficit
Fever
Mean time to diagnosis
Imaging (Se)
Bc +
Local sampling (Se)
Portal of entry
Remote focus
6/6
4/6
1 MD 1 CES
6/6
ND
6/6
1/6 (100 %)
1 UI 1 gluteal abscess 1 OMC
1 meningitis
Exclusively lumbar involvement (level not specified) 2 bilateral involvement
6/6
2/6
2 MD 1 CES
1/6
4 weeks (2 days to 5 months)
5 BS (100 %) 6 CT (100 %) 4 MRI (100 %) 3 BS (100 %) 6 MRI (100 %)
3/6
3/6 (100 %)
0/6
2 L4/L5 2 L5/S1 2 L1/L2 2 L3/L4 1 C2/C3 1 T8/T9 Exclusively lumbar involvement (level not specified) 2 bilateral involvement 3 L3/L4 1 L4/L5 1 C4/C5 C3-C4 and C4-C5 bilateral
10/10
1/10
1 PP
9/10
8 days (2 to 21 days)
10 BS (100 %) 10 MRI (100 %)
9/10
1/10 (100 %)
1 UI 1 TI 2 digestive tract infections 1 post-surgical RPH 1 lymphangitis 1 skin ulcer
5/5
2/5
0/5
1/5
7.2 days (0 to 19 days)
5 MRI (100 %)
1/4
2/5 (0 %)
ND
0/5
6/6
0/6
1 TP
3/6
42.7 days (21 to 100 days)
3/6
3/6 (100 %)
1 dental focus 1 digestive infection 1 mesotherapy
1 endocarditis 1 SPI 1 AC arthritis
Germ
Epiduritis
Abscess psoas
Abscess PVM
6 BS (100 %) 4 CT (100 %) 5 MRI (100 %) Duration of TTT
6 SA
5/6
5/6
5/5
4.3 months
4/6
0/6
2/6
7 SA 1 Sa 1 EF
7/10
1/10
7/10
8 weeks + drainage 5/6 6 weeks
1 Sa
4/5
0/5
3/5
6 weeks
3 SA1 SE1 SV1 EF
1/6
0/6
6/6
3 months
3 SA
2 SS
1 meningitis 1 endocarditis 1 SC arthritis 1 wrist arthritis
Surg.
Outcome
1/6 (CES) 2/6 (MD,CES) 1/10 (PP)
Favorable 6/6 Favorable 6/6 Favorable 9/10 PP 1/10 Favorable 5/5
1/5 (unfavorable outcome) 1/6 (TP)
Favorable 5/6 Death 1/6
Se: sensibility in %; Bc+: blood culture positive; PVM: paravertebral muscles; TTT: treatment; Surg.: surgical management; M: male patient; F: female patient; NIDD: non insulin dependent diabetes; MD: motor deficit; CES: cauda equina syndrome; LM: lymphoma; PP: incomplete paraplegia; TP: tetra pyramidal syndrome; ND: not documented; BS: bone scintigraphy; UI: urinary infection; COM: chronic osteomyelitis; TI: testicular infection; RPH: retroperitoneal hematoma; SC: sternoclavicular; AC: acromioclavicular; SA: staphylococcus aureus; SS: streptococcus species; Sa: streptococcus agalactiae; EF: enterococcus faecalis; SE: staphylococcus epidermis; SV: streptococcus viridans. a Inclusion in a surgical unit.
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Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
Table 2 Characteristics of patients in the main reported series (> 5 patients). Caractéristiques des patients appartenant aux principales séries de la littérature (> 5 patients).
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transplantation, and cirrhosis [1–6,19,20]. Narvaez estimated that 1 of these factors was observed in 38% of reported cases [2]. Six of our 11 patients presented with a degenerative disease of the facet joints, which for some authors would promote bacterial infection [5]. Superinfection of synovial cysts extending from facet joints has been described [21]. The clinical presentation is similar to that of infectious spondylitis with spinal pain, spinal syndrome with paravertebral stiffness and contracture. Some authors have mentioned an often more sudden and severe initial presentation than for infectious discitis [2,4]. The facet joint origin may also be suspected in some cases of one-sided pain [22]. Radiculalgia is observed in 30% of cases (10 to 66% depending on series). Fever is observed in 60% of cases (20 to 100% depending on series). The location of infection is preferentially lumbar. Ninety percent of locations are lumbar, 9% are cervical, and 1% thoracic according to the main reported series. But these results should be reconsidered because some studies included only lumbar locations. Narvaez, in a review including clinical cases, reported 86% of lumbar location (predominant in L4/L5) compared to 4.5% and 9.5% for thoracic and cervical locations respectively. Bilateral involvement has been reported [1,3,4]. The diagnosis is made on imaging data. Standard X rays (front, side, 3/4) are rarely contributive initially. Abnormalities such as irregular facet joint, joint space narrowing, pseudo enlargement with erosion of banks or subchondral geodes have been reported, but after 6 to 12 weeks of evolution [2,5]. CT can highlight a distension of the posterior articular cavity or abnormalities observed on standard X rays. CT also reveals paravertebral or intraductal soft tissue abnormalities [22]. CT may also help to guide a diagnostic procedure. However, the examination may be normal initially. Narváez et al. found abnormalities in their series only after 15 days of evolution [2]. 99mTc-labeled bisphosphonate scintigraphy is a sensitive examination highlighting a vertical paramedian localized uptake better observed on posterior cross-sections. The combined use of CT cross-sections may allow a more precise location of the infection. Scintigraphic abnormalities may be observed in the first week of evolution. A case of false negative was, however, reported [9]. Another advantage of CT is the identification of remote articular foci of infection, sometimes overlooked clinically [3]. The key diagnostic examination is MRI with axial and cross-sections allowing assessment of facets. Abnormalities may be observed 48 hours after onset of symptoms [2,3]. The abnormalities observed in the joint are effusion, hypointense T1-weighted capsule and ligament structures, which are enhanced after gadolinium injection, and hyperintense in T2. MRI also allows studying the adjacent soft tissues and the spread of infection to paraspinal muscles, psoas, or to the epidural space. The bacteria we identified in our series differed from usually reported ones. Indeed, staphylococci are the most frequently identified in more than 80% of cases, followed by Streptococcus species (9 to 16%), and gram negative bacilli (2 to 7%) [2,3]. Isolated tuberculous involvement of facet joints are rare (1 reported case to our knowledge) [17]. Involvement of facet joints have been reported in spinal brucellosis, but rarely isolated [23],
and in the course of Candida albicans or Aspergillus infection [24]. The joint is contaminated by blood, usually from a urinary, digestive, or dermatologic focus. Several cases of inoculation due to local procedures have been reported [25–28]. Bacteriological isolation is performed most frequently by blood culture (72% of the cases in our series). A local puncture with CT or radioscopic guidance may allow isolation of the bacterium. In some cases, surgical biopsy is required. Culture in specific media and identification should be performed according to clinical data. The extension of infection to the epidural space is frequent, observed in 60% of cases. Neurological complications such as radicular motor deficit, hemiparesis, paraparesis, tetraparesis, or cauda equina syndrome have been frequently reported [3–5,29,30] and observed in 20% of cases of the studied series. In these cases, surgical treatment was sometimes associated with antibiotics to obtain an ad integrum recovery. Meningeal involvement and endocarditis may lead to an adverse outcome and have also been reported in the course of staphylococcal or streptococcal infections [3,5,16,28,31]. Abscesses of paraspinal muscles or psoas have also often been observed. Remote articular locations may be more rarely observed and may help, when puncture is performed, identify bacteria [32]. Various differential diagnoses may be considered depending on the clinical presentation. Inflammatory signs revealed by MRI in the joint have been reported during flares of mechanically induced presentation [33]. Inflammatory facet joint involvement and fever can be observed in microcrystalline diseases, gout [34], or chondrocalcinosis [35]. Facet joint involvement is typical in case of spondyloarthropathy. A case of Klebsiella pneumoniae facet joint infectious arthritis, however, was reported in an HLA-B27 + patient [36]. RA have been reported rarely [37]. Abnormalities of the facet joints with extension to the epidural space or adjacent soft tissues may also occur, but more rarely, in case of primary amyloidosis [38] or of renal failure with dyalisis [39]. Malignant tumor sites related to a myeloma, lymphoma, or metastases may be observed. The management of this condition is multidisciplinary, involving radiologists, rheumatologists, infectious disease specialists, and surgeons. The medical treatment is the same as that of infectious spondylitis. Surgical treatment is indicated in case of severe neurological deficits or in case of unfavorable outcome, despite an adequate antibiotic treatment. Some authors recommend percutaneous drainage of the joint to minimize pain and promote healing [4]. In every case, searching for a portal of entry is mandatory. The outcome with treatment is usually favorable although back pain may persist. Narváez et al. reported a death rate of 2% in their literature review, and neurological sequels despite surgical treatment [2]. 5. Conclusion SAFJ should be suspected and specifically screened for in case of suggestive clinical symptoms. Possible neurological or systemic complications required making an early diagnosis for which MRI is the gold standard examination. Even if staphylococcal infection is the most commonly reported, our results
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suggest making a thorough investigation for bacterial identification, in order not to overlook a less frequently involved bacterium. Medical treatment with antibiotics and initial bed rest is usually sufficient. Surgical treatment may be necessary in case of neurological complications. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements M. Pot-Vaucel, C. Cozic, E. Visée, M. Morrier, S. Varin, and G. Cormier participated in the data collection, drafting, and correction of the article. References [1] Doita M, Nabeshima Y, Nishida K, Fujioka H, Kurosaka M. Septic arthritis of lumbar facet joints without predisposing infection. J Spinal Disord Tech 2007;20(4):290–5. [2] Narváez J, Nolla JM, Narváez JA, Martinez-Carnicero L, De Lama E, Gómez-Vaquero C, et al. Spontaneous pyogenic facet joint infection. Semin Arthritis Rheum 2006;35(5):272–83. [3] Michel-Batôt C, Dintinger H, Blum A, Olivier P, Laborde F, BettembourgBrault, et al. A particular form of septic arthritis: septic arthritis of facet joint. Joint Bone Spine 2008;75(1):78–83. [4] Muffoletto AJ, Ketonen LM, Mader JT, Crow WN, Hadjipavlou AG. Hematogenous pyogenic facet joint infection. Spine (Phila Pa 1976) 2001;26(14):1570–6. [5] Ergan M, Macro M, Benhamou CL, Vandermarcq P, Colin T, L’Hirondel JL, et al. Septic arthritis of lumbar facet joints. A review of six cases. Rev Rhum Engl Ed 1997;64(6):386–95. [6] Douvrin F, Callonnec F, Proust F, Janvresse A, Simonet J, Thiebot J. Lumbar interapophyseal septic arthritis. A propos of 3 cases. J Neuroradiol 1996;23(4):234–40. [7] Ehara S, Khurana JS, Kattapuram SV. Pyogenic vertebral osteomyelitis of the posterior elements. Skeletal Radiol 1989;18(3):175–8. [8] Peris P, Brancós MA, Gratacós J, Moreno A, Miró JM, Mu˜noz J. Septic arthritis of spinal apophyseal joint. Report of two cases and review of the literature. Spine (Phila Pa 1976) 1992;17(12):1514–6. [9] Pilleul F, Garcia J. Septic arthritis of the spine facet joint: early positive diagnosis on magnetic resonance imaging. Review of two cases. Joint Bone Spine 2000;67(3):234–7. [10] Krishnan V, Amritanand R, Sundararaj GD. Methicillin-resistant Staphylococcus aureus as a cause of lumbar facet joint septic arthritis: a report of two cases. J Bone Joint Surg Am 2010;92(2):465–8. [11] Cormier G, Lucas V, Varin S, Hamelin JP, Tanguy G. Yersinia pseudotuberculosis infection of a lumbar facet joint. Joint Bone Spine 2007;74(1):110–1. [12] Blanchais A, Cormier G, Varin S, Hamelin JP, Tanguy G. Pasteurella multocida septic oligoarthritis. Med Mal Infect 2010;40(2):123–5. [13] Hopkinson N, Stevenson J, Benjamin S. A case ascertainment study of septic discitis: clinical, microbiological and radiological features. QJM 2001;94(9):465–70. [14] Lora-Tamayo J, Euba G, Narváez JA, Murillo O, Verdaguer R, Sobrino B, et al. Changing trends in the epidemiology of pyogenic vertebral osteomyelitis: the impact of cases with no microbiologic diagnosis. Semin Arthritis Rheum 2011;41(2):247–55. [15] David Chaussé J, Dehais J, Boyer M, Darde ML, Imbert Y. Les infections articulaires chez l’adulte : atteintes périphériques et vertébrales à germes banaux et bacilles tuberculeux. Rev Rhum Mal Osteoartic 1981;48:69–76.
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[16] Nishimura Y, Ishida H, Shin N, Mori K, Yoshihara T, Kasubuchi Y, et al. Streptococcus pneumoniae-associated arthritis of a lumbar facet joint in a 4-year-old boy. Pediatr Int 2004;46(1):101–3. [17] Avadhani A, Shetty AP, Rajasekaran S. Isolated tuberculosis of the lumbar apophyseal joint. Spine J 2010;10(3):e1–4. [18] Smida M, Lejri M, Kandara H, Sayed M, Ben Chehida F, Ben Ghachem M. Septic arthritis of a lumbar facet joint case report and review of the literature. Acta Orthop Belg 2004;70(3):290–4. [19] Dayer MJ, Gransden W, Goldsmith DJ. Facet joint osteomyelitis in a patient on long-term hemodialysis. Am J Kidney Dis 2000;36(5):1041–4. [20] Belzunegui J, Rodríguez-Arrondo F, González C, Queiro R, Martínez de Bujo M, Intxausti JJ, et al. Musculoskeletal infections in intravenous drug addicts: report of 34 cases with analysis of microbiological aspects and pathogenic mechanisms. Clin Exp Rheumatol 2000;18(3):383–6. [21] Sean M, Quaidoo J, McCarthy K, Dimar J. Juxtafacet cyst infection. Eur Spine J 2013;22(Suppl. 3):S388–93. [22] Masson C, Lafitte A, Audran M. Arthritis septique de l’articulation interapophysaire postérieure du rachis. Rev Rhum 2006;73:369–72. [23] Ozaksoy D, Yücesoy K, Yücesoy M, Kovanlikaya I, Yüce A, Naderi S. Brucellar spondylitis: MRI findings. Eur Spine J 2001;10(6):529–33. [24] Williams RL, Fukui MB, Meltzer CC, Swarnkar A, Johnson DW, Welch W. Fungal spinal osteomyelitis in the immunocompromised patient: MR findings in three cases. AJNR Am J Neuroradiol 1999;20(3):381–5. [25] Okazaki K, Sasaki K, Matsuda S, Yuge I, Omiya K, Kido H. Pyogenic arthritis of a lumbar facet joint. Am J Orthop (Belle Mead NJ) 2000;29(3):222–4. [26] Weingarten TN, Hooten WM, Huntoon MA. Septic facet joint arthritis after a corticosteroid facet injection. Pain Med 2006;7(1):52–6. [27] Arun R, Al-Nammari SS, Mehdian SM. Multilevel vertebral osteomyelitis and facet joint infection following epidural catheterisation. Acta Orthop Belg 2007;73(5):665–9. [28] Hoelzer BC, Weingarten TN, Hooten WM, Wright RS, Wilson WR, Wilson PR. Paraspinal abscess complicated by endocarditis following a facet joint injection. Eur J Pain 2008;12(3):261–5. [29] Halla JT, Bliznak J, Hardin JG, Finn S. Septic arthritis of the C1-C2 lateral facet joint and torticollis: pseudo-Grisel’s syndrome. Arthritis Rheum 1991;34(1):84–8. [30] Okada F, Takayama H, Doita M, Harada T, Yoshiya S, Kurosaka M. Lumbar facet joint infection associated with epidural and paraspinal abscess: a case report with review of the literature. J Spinal Disord Tech 2005;18(5):458–61. [31] Dizdar O, Alyamac¸ E, Onal IK, Uzun O. Group B streptococcal facet joint arthritis: case report. Spine (Phila Pa 1976) 2005;30(14):E414–6. [32] Dauwe DM, Van Oyen JJ, Samson IR, Hoogmartens MJ. Septic arthritis of a lumbar facet joint and a sternoclavicular joint. Spine (Phila Pa 1976) 1995;20(11):1304–6. [33] Czervionke LF, Fenton DS. Fat-saturated MR imaging in the detection of inflammatory facet arthropath(facet synovitis) in the lumbar spine. Pain Med 2008;9(4):400–6. [34] Saketkoo LA, Robertson HJ, Dyer HR, Virk ZU, Ferreyro HR, Espinoza LR. Axial gouty arthropathy. Am J Med Sci 2009;338(2):140–6. [35] Feydy A, Lioté F, Carlier R, Chevrot A, Drapé JL. Cervical spine and crystal-associated diseases: imaging findings. Eur Radiol 2006;16(2):459–68 [Epub 2005 Apr 23]. [36] Chevalier X, Marty M, Larget-Piet B. Klebsiella pneumoniae septic arthritis of a lumbar facet joint. J Rheumatol 1992;19(11):1817–9. [37] Stoddard JE, Chiverton N. Thoracic facet joint synovitis causing thoracic spinal cord compression and myelopathy in a patient with rheumatoid arthritis. Rheumatology (Oxford) 2011;50(11):2141–2. [38] Haridas A, Basu S, King A, Pollock J. Primary isolated amyloidoma of the lumbar spine causing neurological compromise: case report and literature review. Neurosurgery 2005;57(1):E196 [discussion E196]. [39] Yamamoto T, Matsuyama Y, Tsuji T, Nakamura H, Yanase M, Ishiguro N. Destructive spondyloarthropathy in hemodialysis patients: comparison between patients with and those without destructive spondyloarthropathy. J Spinal Disord Tech 2005;18(3):283–5.
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Original article
Septic arthritis of the facet joint Arthrite septique articulaire postérieure V. André a,∗ , M. Pot-Vaucel a , C. Cozic a , E. Visée b , M. Morrier c , S. Varin a , G. Cormier a a
b
Service de rhumatologie, centre hospitalier départemental, site de La-Roche-sur-Yon–Les Oudairies, 85925 La-Roche-sur-Yon, France Service d’imagerie médicale, centre hospitalier départemental, site de La-Roche-sur-Yon, Les Oudairies 85925, La-Roche-sur-Yon, France c Services d’infectiologie, centre hospitalier départemental, site de La-Roche-sur-Yon, Les Oudairies, 85925 La-Roche-sur-Yon, France Received 6 January 2015; received in revised form 26 February 2015; accepted 2 April 2015
Abstract Objective. – Septic arthritis of the facet joint is a rare clinical entity. We report 11 cases of facet joint infections diagnosed in our institution. Patients and method. – Patients were identified via the computerized patients record (PMSI). Their features were collected and compared with published data. Results. – The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. Conclusion. – Assessing the facet joint is essential in case of inflammatory back pain, and the radiologist must be asked to perform this examination. © 2015 Published by Elsevier Masson SAS. Keywords: Septic arthritis of the facet joint; MRI
Résumé Objectif. – Les atteintes septiques isolées des articulations zygapophysaires sont rares. Nous rapportons notre expérience de cette atteinte à travers une série rétrospective de 11 patients. Patients et méthode. – Les dossiers ont été identifiés grâce au codage PMSI. Les caractéristiques des différents cas ont été colligées et comparées aux données de la littérature. Résultats. – Les manifestations cliniques sont proches de celles des spondylodiscites infectieuses associant à des degrés divers douleurs rachidiennes plus ou moins latéralisées avec raideur (11/11), fièvre (9/11), radiculalgie (5/11), asthénie. Dix patients avaient une atteinte lombaire et 1 patient une atteinte dorsale. Le syndrome inflammatoire était constant. Un accès rapide à l’IRM rachidienne avec des coupes intéressant l’articulation a permis de poser rapidement le diagnostic dans tous les cas et d’analyser une éventuelle extension du processus infectieux (épidurite 5/11, pyomyosite 5/11). Les hémocultures (8/11) et les prélèvements locaux ont permis de préciser le germe et d’adapter le traitement antibiotique dans tous les cas. Notre série se distingue des données de la littérature par la diversité des germes incriminés. Une porte d’entrée a pu être identifiée dans 4 cas. Une autre localisation septique était retrouvée dans 4 cas. L’évolution a été favorable avec le traitement médical dans 10 cas. Le
∗
Corresponding author. E-mail address: [email protected] (V. André).
http://dx.doi.org/10.1016/j.medmal.2015.04.001 0399-077X/© 2015 Published by Elsevier Masson SAS.
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drainage chirurgical d’un abcès a été nécessaire chez un patient. Aucune complication neurologique n’a été rencontrée, probablement en raison d’un diagnostic précoce. Conclusion. – En cas de rachialgies suspectes, l’étude des articulations articulaires postérieures est indispensable et doit être précisée au radiologue. © 2015 Publi´e par Elsevier Masson SAS. Mots clés : Arthrite septique articulaire postérieur ; IRM
1. Introduction Cases of isolated septic arthritis of the facet joints (SAFJ) are a small proportion of all spinal infections. Only few series with few patients (< 10) have been published [1–10]. We report our experience through a retrospective series of 11 patients, to our knowledge the largest series published to date. Two of our cases were included in a previous publication [11,12]. We compared our data with previously published data. 2. Patients and methods We identified patients managed in our unit for SAFJ from diagnoses recorded in the computerized record of patients database (French acronym PMSI) by searching for the main diagnostic code of infectious spondylitis (M463) since there was no specific coding for SAFJ from 2000 to 2013. We identified patients having presented with SAFJ proven by imaging (MRI) without any associated spondylodiscitis, and with documented bacteriological results. The demographic, clinical, biological, and iconographic data at diagnosis and response to treatment was collected for each patient. This data was then compared with previously published data. 3. Results Eleven cases of posterior SAFJ were identified, accounting for 13.5% of all spinal infections managed in our unit during the study period, compared to 70 cases of infectious spondylitis. The main characteristics of these patients are listed in Table 1. The mean age at diagnosis was 67 years (34–83 years) with 7 male and 4 female patients. All patients complained of back pain with stiffness: lumbar in 10 cases and dorsal in 1 case. The vertebra involved were L4/L5 in 7 cases, L5/S1 in 2 cases, L3/L4 in 1 case, and T10/T11 in 1 case. The pain was one-sided in 2 cases. Radiculalgia was noted in 5 cases. None of the patients presented with neurological deficit. Nine patients were febrile. Risk factors were noted in 3 cases: 1 case of type 2 diabetes, 1 of chronic alcoholism, and 1 of myelodysplasia. Five patients reported a history of chronic low back pain, and 6 patients presented with osteoarthritis of the facet joint on X rays. The average delay before diagnosis was 20 days and 12.8 days when ruling out tuberculosis. Standard X rays performed initially did suggest any sign of an infectious disease. Technetium 99 m (99mTc)-labeled bisphosphonate scintigraphy was performed in 3 patients, showing increased uptake of the joint involved in every case (Fig. 1).
Fig. 1. Technetium scintigraphy (patient 1), fixation of the left facet joint T10T11. Scintigraphie au technétium (patient 1), fixation de l’articulaire postérieur gauche T10-T11.
CT was performed in 3 patients. The CT for patient 1 was performed 7 weeks after the onset of symptoms; it revealed an osteolysis of T11 left lateral hemi-arch, with an infiltrative process of the T10-T11 joint and of the paraspinal muscles. The CT for patient 8 was performed 3 months after the onset of symptoms; it also revealed a large lytic lesion of the posterior left L4-L5 joint with posterior epiduritis, and soft tissue infiltration. The CT for patient 10 was performed 1 week after the onset of symptoms and was normal. All patients underwent spinal MRI to confirm the diagnosis presenting as isolated synovitis (hypointense on T1, with enhancement after gadolinium injection, and hyperintense on T2) or greater inflammatory changes of the joint with narrowing and erosion of the intervertebral space and possible extension to soft tissues, and epiduritis (Fig. 2). Five patients presented with epiduritis at diagnosis. Five patients presented with pyomyositis (paraspinal abscess or psoas abscess). Two patients presented
Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
1
59
F
2
77
F
Inflammatory lumbar dorsal pain Febrile inflammatory lumbar sciatica
3
61
H
4
34
H
5
76
H
6
72
H
7
77
H
8
83
9
Time to diagnosis
Bacterium
Portal of entry
Remote focus
Identification
Imaging
T10-T11 left None identified
6 weeks
Staphylococcus aureus
None identified
No
Biopsy
L4-L5 right
None identified
6 days
Staphylococcus aureus
No
Blood culture
Medical Surgical* 12 weeks Medical 8 weeks
One-sided febrile inflammatory lumbar and gluteal pain Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar pain Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar pain
L4-L5 left
Type 2 diabetes
8 days
Yersinia Pseudotuberculosis
Malleolar cutaneous wound None identified
X ray/Scinti/CT/MRI Epiduritis Soft tissues X ray/Scinti/MRI Epiduritis
No
Puncture
X ray/MRI
Soft tissues
Medical 6 weeks
L4-L5 left
None identified
8 days
Staphylococcus aureus
None identified
No
Blood culture
X ray/MRI
Soft tissues
Medical 8 weeks
L4-L5 left
8 days
Strepto Oralis
None identified
No
Blood culture
X ray/MRI
No
Medical 10 weeks
L4-L5 right
Sideroblastic anemia None identified
5 days
Staphylococcus aureus
None identified
No
X ray/MRI
Soft tissues
Medical 8 weeks
L4-L5 right
None identified
3 weeks
Strepto Bovis
Colon polyps
Polyarthritis
X ray/MRI
Epiduritis
Medical 8 weeks
F
Mixed lumbar pain
L4-L5 left
None identified
3 months
None identified
No
70
H
L5-S1 right
Blood culture
H
L3-L4 left
5 days
Micromonas Micro
Sigmoid diverticulitis None identified
Endocarditis
71
Chronic alcohol abuse None identified
15 days
10
Febrile inflammatory lumbar sciatica Febrile inflammatory lumbar and crural pain
Mycobacterium Tuberculosis Strepto gallolyticus
Blood culture Puncture Blood culture Puncture of the knee Biopsy
Blood culture
11
58
F
L5-S1 left
None identified
10 days
Pasteurella Multocida
Polyarthritis without endocarditis Sternoclavicular arthritis and right heel
One-sided febrile inflammatory lumbar pain
Risk factor
Wound on the foot
Blood culture Sternoclavicular puncture
Extension
Treatment
X ray/Scinti/CT/MRI Epiduritis Soft tissues X ray/MRI Epiduritis Soft tissues X ray/CT/MRI No
Medical 12 weeks
X ray/MRI
Medical 6 weeks
No
Medical 1 an Medical 12 weeks
Surgical treatment*: complication at 8 days of antibiotic treatment with fistulization to the skin of a paravertebral abscess requiring surgery.
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Table 1 Characteristics of our 11 patients. Caractéristiques de nos 11 patients.
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One patient presented with tuberculous facet joint damage associated with mediastinal and mesenteric lymph node involvement without parenchymal lung disease. A portal of entry was observed in 4 cases: 2 cases of skin lesions and 2 cases of gastrointestinal lesions (polyps or diverticula). A remote septic location was observed in 3 cases: 2 cases of polyarthritis and 1 of biarthritis. One patient presented with endocarditis. The blood cultures were positive in 8 cases (73%). The blood cultures performed in case of multiple joint involvement were always positive. The diagnosis was made on local samples in other cases. Two patients underwent joint puncture under fluoroscopic guidance, and 1 patient under CT guidance. Two of these samples allowed identifying bacteria. Two patients underwent osteoarticular biopsy allowing identification of the bacterium. All patients presenting with a bacterial infection were treated with a bi-bactericidal antibiotic therapy adapted to the epidemiology, after consulting an infectious diseases physician, IV for 15 to 21 days switched to a mono- or bi-antibiotic therapy for a total treatment duration of 6 to 12 weeks. Tuberculous involvement was treated with an anti-TB treatment for 1 year. No patient presented with any neurological complications. One patient underwent surgery for a contiguous subcutaneous abscess. This treatment was associated with a strict bed rest for the first 15 days followed by wearing a rigid back brace for 1 to 2 months. The outcome was favorable in all patients with full recovery. 4. Discussion
Fig. 2. T1 Fat Sat weighted MRI after gadolinium injection (patient 6) demonstrating extensive periarticular inflammatory changes in the posterior paraspinal muscles extended from the right facet joint L4-L5. IRM rachidienne coupe axiale (A) et sagittale (B) séquence T1 Fat sat gado (patient 6), mise en évidence d’un réhaussement après injection de gadolinium de la capsule de l’articulaire postérieure L4-L5 droite associé à une prise de contraste des muscles paravertébraux adjacents et constitution d’une collection abcédée visible sur la coupe sagittale.
with both epiduritis and pyomyositis. MRI was contributive to the diagnosisas early as 5 days after the onset of symptoms for 1 patient and in the first 10 days for 6 patients. Staphylococcus aureus accounted for 36.4% of causative bacteria. Streptococci were isolated in 27.2% of cases. Other bacteria were found less frequently in the other cases (Yersinia pseudotuberculosis, Pasteurella multocida, Micromonas micros).
SAFJ are considered as rare events even though they are now known by clinicians. The characteristics of patients presenting with SAFJ included in the main published series (> 5 patients) are listed in Table 2. The actual impact of this condition was not directly assessed but compared to that of infectious spondylitis as reported in some series. The annual incidence of infectious spondylitis was assessed at 2 per 100,000 inhabitants, in 2001, by Hopkinson et al. [13] and this incidence appears to have been increasing over the last decade [14]. David Chaussé et al. estimated in 1981 that 1 case of SAFJ occurred for arthritis for every 500 cases of infectious spondylitis [15]. Our results correlate better with more recent data. Muffoleto et al. [4] and Narváez et al. [2] reported respectively 4% and 20% of SAFJ among all spinal infections managed in their institution. The easier access to MRI allowed obtaining an earlier diagnosis, probably partly accounting for this increase. Indeed, the natural course of infection is the extension to the paraspinal soft tissues, the psoas, the epidural space, the vertebral bodies, and disks. Cases of spondylitis complicating the outcome of SAFJ have been reported [9]. This condition preferentially affects adults with a mean age of 56 to 73 years, depending on the series [1–6]. Pediatric cases have also been reported [16–18]. The sex-ratio is close to 1, when considering data from the largest series. The risk factors are those usually found for septic arthritis: diabetes, chronic alcoholism, long-term corticosteroid therapy, underlying neoplastic disease, splenectomy, hematological disease, intravenous drug use, chronic renal failure, dialysis,
Please cite this article in press as: André V, et al. Septic arthritis of the facet joint. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.04.001
Sex
Comorbidity
Location
Ergan et al., 1997 [5] 6 patients
62,3 (49–74)
3M 3F
2 type 2 diabetes
3 L4/L5 1 L3/L4 1 L2/L3 1 L5/S1
Muffolettoa et al., 2001 [4] 6 patients
56 (48–75)
3M 3F
2 drug addict. + diabetes 1 cirrhosis
Narvaez et al., 2006 [2] 10 patients
60 (33–82)
5M 5F
1 type 2 diabetes 1 LM 1 lung metastasis 1 cirrhosis 1 COBP
Doitaa et al., 2007 [1] 5 patients
70 (73–78)
5F
1 lung cancer
Michel-Bâtot et al., 2008 [3] 6 patients
61,5 (50–76)
5M 1F
1 type 2 diabetes 1 chronic alcohol abuse
Back pain
Radiculalgia
Neurologic deficit
Fever
Mean time to diagnosis
Imaging (Se)
Bc +
Local sampling (Se)
Portal of entry
Remote focus
6/6
4/6
1 MD 1 CES
6/6
ND
6/6
1/6 (100 %)
1 UI 1 gluteal abscess 1 OMC
1 meningitis
Exclusively lumbar involvement (level not specified) 2 bilateral involvement
6/6
2/6
2 MD 1 CES
1/6
4 weeks (2 days to 5 months)
5 BS (100 %) 6 CT (100 %) 4 MRI (100 %) 3 BS (100 %) 6 MRI (100 %)
3/6
3/6 (100 %)
0/6
2 L4/L5 2 L5/S1 2 L1/L2 2 L3/L4 1 C2/C3 1 T8/T9 Exclusively lumbar involvement (level not specified) 2 bilateral involvement 3 L3/L4 1 L4/L5 1 C4/C5 C3-C4 and C4-C5 bilateral
10/10
1/10
1 PP
9/10
8 days (2 to 21 days)
10 BS (100 %) 10 MRI (100 %)
9/10
1/10 (100 %)
1 UI 1 TI 2 digestive tract infections 1 post-surgical RPH 1 lymphangitis 1 skin ulcer
5/5
2/5
0/5
1/5
7.2 days (0 to 19 days)
5 MRI (100 %)
1/4
2/5 (0 %)
ND
0/5
6/6
0/6
1 TP
3/6
42.7 days (21 to 100 days)
3/6
3/6 (100 %)
1 dental focus 1 digestive infection 1 mesotherapy
1 endocarditis 1 SPI 1 AC arthritis
Germ
Epiduritis
Abscess psoas
Abscess PVM
6 BS (100 %) 4 CT (100 %) 5 MRI (100 %) Duration of TTT
6 SA
5/6
5/6
5/5
4.3 months
4/6
0/6
2/6
7 SA 1 Sa 1 EF
7/10
1/10
7/10
8 weeks + drainage 5/6 6 weeks
1 Sa
4/5
0/5
3/5
6 weeks
3 SA1 SE1 SV1 EF
1/6
0/6
6/6
3 months
3 SA
2 SS
1 meningitis 1 endocarditis 1 SC arthritis 1 wrist arthritis
Surg.
Outcome
1/6 (CES) 2/6 (MD,CES) 1/10 (PP)
Favorable 6/6 Favorable 6/6 Favorable 9/10 PP 1/10 Favorable 5/5
1/5 (unfavorable outcome) 1/6 (TP)
Favorable 5/6 Death 1/6
Se: sensibility in %; Bc+: blood culture positive; PVM: paravertebral muscles; TTT: treatment; Surg.: surgical management; M: male patient; F: female patient; NIDD: non insulin dependent diabetes; MD: motor deficit; CES: cauda equina syndrome; LM: lymphoma; PP: incomplete paraplegia; TP: tetra pyramidal syndrome; ND: not documented; BS: bone scintigraphy; UI: urinary infection; COM: chronic osteomyelitis; TI: testicular infection; RPH: retroperitoneal hematoma; SC: sternoclavicular; AC: acromioclavicular; SA: staphylococcus aureus; SS: streptococcus species; Sa: streptococcus agalactiae; EF: enterococcus faecalis; SE: staphylococcus epidermis; SV: streptococcus viridans. a Inclusion in a surgical unit.
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Table 2 Characteristics of patients in the main reported series (> 5 patients). Caractéristiques des patients appartenant aux principales séries de la littérature (> 5 patients).
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transplantation, and cirrhosis [1–6,19,20]. Narvaez estimated that 1 of these factors was observed in 38% of reported cases [2]. Six of our 11 patients presented with a degenerative disease of the facet joints, which for some authors would promote bacterial infection [5]. Superinfection of synovial cysts extending from facet joints has been described [21]. The clinical presentation is similar to that of infectious spondylitis with spinal pain, spinal syndrome with paravertebral stiffness and contracture. Some authors have mentioned an often more sudden and severe initial presentation than for infectious discitis [2,4]. The facet joint origin may also be suspected in some cases of one-sided pain [22]. Radiculalgia is observed in 30% of cases (10 to 66% depending on series). Fever is observed in 60% of cases (20 to 100% depending on series). The location of infection is preferentially lumbar. Ninety percent of locations are lumbar, 9% are cervical, and 1% thoracic according to the main reported series. But these results should be reconsidered because some studies included only lumbar locations. Narvaez, in a review including clinical cases, reported 86% of lumbar location (predominant in L4/L5) compared to 4.5% and 9.5% for thoracic and cervical locations respectively. Bilateral involvement has been reported [1,3,4]. The diagnosis is made on imaging data. Standard X rays (front, side, 3/4) are rarely contributive initially. Abnormalities such as irregular facet joint, joint space narrowing, pseudo enlargement with erosion of banks or subchondral geodes have been reported, but after 6 to 12 weeks of evolution [2,5]. CT can highlight a distension of the posterior articular cavity or abnormalities observed on standard X rays. CT also reveals paravertebral or intraductal soft tissue abnormalities [22]. CT may also help to guide a diagnostic procedure. However, the examination may be normal initially. Narváez et al. found abnormalities in their series only after 15 days of evolution [2]. 99mTc-labeled bisphosphonate scintigraphy is a sensitive examination highlighting a vertical paramedian localized uptake better observed on posterior cross-sections. The combined use of CT cross-sections may allow a more precise location of the infection. Scintigraphic abnormalities may be observed in the first week of evolution. A case of false negative was, however, reported [9]. Another advantage of CT is the identification of remote articular foci of infection, sometimes overlooked clinically [3]. The key diagnostic examination is MRI with axial and cross-sections allowing assessment of facets. Abnormalities may be observed 48 hours after onset of symptoms [2,3]. The abnormalities observed in the joint are effusion, hypointense T1-weighted capsule and ligament structures, which are enhanced after gadolinium injection, and hyperintense in T2. MRI also allows studying the adjacent soft tissues and the spread of infection to paraspinal muscles, psoas, or to the epidural space. The bacteria we identified in our series differed from usually reported ones. Indeed, staphylococci are the most frequently identified in more than 80% of cases, followed by Streptococcus species (9 to 16%), and gram negative bacilli (2 to 7%) [2,3]. Isolated tuberculous involvement of facet joints are rare (1 reported case to our knowledge) [17]. Involvement of facet joints have been reported in spinal brucellosis, but rarely isolated [23],
and in the course of Candida albicans or Aspergillus infection [24]. The joint is contaminated by blood, usually from a urinary, digestive, or dermatologic focus. Several cases of inoculation due to local procedures have been reported [25–28]. Bacteriological isolation is performed most frequently by blood culture (72% of the cases in our series). A local puncture with CT or radioscopic guidance may allow isolation of the bacterium. In some cases, surgical biopsy is required. Culture in specific media and identification should be performed according to clinical data. The extension of infection to the epidural space is frequent, observed in 60% of cases. Neurological complications such as radicular motor deficit, hemiparesis, paraparesis, tetraparesis, or cauda equina syndrome have been frequently reported [3–5,29,30] and observed in 20% of cases of the studied series. In these cases, surgical treatment was sometimes associated with antibiotics to obtain an ad integrum recovery. Meningeal involvement and endocarditis may lead to an adverse outcome and have also been reported in the course of staphylococcal or streptococcal infections [3,5,16,28,31]. Abscesses of paraspinal muscles or psoas have also often been observed. Remote articular locations may be more rarely observed and may help, when puncture is performed, identify bacteria [32]. Various differential diagnoses may be considered depending on the clinical presentation. Inflammatory signs revealed by MRI in the joint have been reported during flares of mechanically induced presentation [33]. Inflammatory facet joint involvement and fever can be observed in microcrystalline diseases, gout [34], or chondrocalcinosis [35]. Facet joint involvement is typical in case of spondyloarthropathy. A case of Klebsiella pneumoniae facet joint infectious arthritis, however, was reported in an HLA-B27 + patient [36]. RA have been reported rarely [37]. Abnormalities of the facet joints with extension to the epidural space or adjacent soft tissues may also occur, but more rarely, in case of primary amyloidosis [38] or of renal failure with dyalisis [39]. Malignant tumor sites related to a myeloma, lymphoma, or metastases may be observed. The management of this condition is multidisciplinary, involving radiologists, rheumatologists, infectious disease specialists, and surgeons. The medical treatment is the same as that of infectious spondylitis. Surgical treatment is indicated in case of severe neurological deficits or in case of unfavorable outcome, despite an adequate antibiotic treatment. Some authors recommend percutaneous drainage of the joint to minimize pain and promote healing [4]. In every case, searching for a portal of entry is mandatory. The outcome with treatment is usually favorable although back pain may persist. Narváez et al. reported a death rate of 2% in their literature review, and neurological sequels despite surgical treatment [2]. 5. Conclusion SAFJ should be suspected and specifically screened for in case of suggestive clinical symptoms. Possible neurological or systemic complications required making an early diagnosis for which MRI is the gold standard examination. Even if staphylococcal infection is the most commonly reported, our results
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