Osteomyelitis of the Spine Following Needle Biopsy of the Prostate

Vol. 94, Sept. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1965 by The Williams & Wilkins Coo

OSTEOMYELITIS OF THE SPINE FOLLOWING NEEDLE BIOPSY OF THE PROSTATE ORLAND ELIASON

AND

DAVID DUNLAP

From the Tfeterans Administration Hospital, Minneapolis, Minnesota

In 1940 Batson performed a series of experirnents which led him to conclude that the vertebral veins, under certain conditions, may act as a conduit for the transmission of sepsis and cancer from the lower urinary tract. 1 - 3 The vertebral veins are a plexiform, valveless, longitudinal system of veins that envelop the entire vertebral column both· internally and externally. This system communicates with the cranial sinuses superiorly and with the pelvic veins caudally. It also communicates with the intercostal and lumber veins and with the veins of the pelvic bones, shoulder girdle and upper femur. The azygous system. forms a direct venous pathway between the vertebral system and the lung and parietal pleura (fig. 1). Batson injected a thin, radiopaque substance into the dorsal penile vein of animals and cadavers. He found that when he applied pressure to the a,bdomen, the contrast medium passed into the vertebral veins and their tributaries rather than into the inferior vena cava. vVe were able to confirm these findings in living men by injecting 30 cc 50 per cent diatrizoate sodium (hypaque) directly into the prostate during routine biopsies perfornied with a Franklin-Silverman needle. This was performed only when venous bleeding was noted. The injections were made rapidly but not forcefully, with no discomfort to the patient. The vertebral veins filled only when abdominal compression was applied with the strap apparatus used during excretory urography (fig. 2). Since the original publications of Batson's work, many authors have noted the relationship between urinary tract sepsis and subsequent infections of the spine. 4- 8 In 19.58 Henriques thoroughly Accepted for publication December 23, 1964. Read at annual meeting of North Central Section, American Urological Association, Inc., Columbus, Ohio, September 30~0ctober 3, 1964. 1 Batson, 0. V.: Function of vertebral veins and their role in spread of metastases. Ann. Surg., 112: 138-149, 1940. 2 Batson, 0. V.: Role of vertebral veins in metastatic processes. Ann. Intern. JVIed., 16: 3845, 1942. 3 Batson, 0. V.: The vertebral vein system. Amer. J. Roentgenol., 78: 195-212, 1957. 4 Adlerman, E. J. and Duff, J.: Osteomyelitis

reviewed the .55 cases that had been reported since 1940 and added six of his own. 9 All but 11 of these 55 cases of infection followed surgery. Cultures of urine and bone from many of these patients revealed the same organism.. The time sequence of clinical and radiographic findings suggested a direct relationship. The distribution of osseous lesions particularly suggests that the vertebral veins are the main mechanism of transport. 8- 10 The lumbar vertebrae were involved in about 50 per cent of cases, the dorsal in about 20 per cent and the cervical in about 10 per cent. The upper femur demonstrated lesions in about 5 per cent and, occasionally, bones of the pelvis, sacrum and shoulder girdle were affected. This is what one would expect if septic emboli are forced up the vertebral veins by variations in intra-abdominal pressure. Henriques believes that thrombosis due to the sluggish flow of blood in this area may be a contributing factor. It is very likely then, that under conditions of increased intra-abdominal pressure such as those produced by coughing or straining, pelvic sepsis or tumor may reach the vertebrae without having to pass through the lung, heart and arterial system. The distribution of metastatic carcinoma of the prostate also suggests this mechanism of spread. However, vViley and Trueta believe that infection is carried to the vertebrae by the arterial system. 11 They point out that the infection usually of the cervical vertebras as a complication of urinary tract disease. J.A.M.A., 148: 283-285, 1952. 5 De Feo, E.: Osteomyelitis of the spine following prostatic surgery. Radiology, 62: 396-401, 1954. 6 Deming, C. L. and Zaff, F.: Metastatic vertebral osteomyelitis complicating prostatic surgery. Trans. Amer. Assn. Genito-Urin. Surg., 35: 287289, 1943. 7 Kendrick, J. I. and Hartman, J. T.: Infections metastatic to the vertebral column. J.A.M.A., 186: 1093-1095, 1963. 8 Henson, S. W., Jr. and Coventry, JVI. B.: Osteomyelitis of the vertebrae as a result of infection in the urinary tract. Surg., Gynec. & Obstet., 102: 207-214, 1956. 9 Henriques, C. Q.: Osteomyelitis as a complication in urology. Brit. J. Surg., 46: 19-28, 1958. 10 Wilensky, A. 0.: Osteomyelitis of vertebrae. Ann. Surg., 89: 561 & 731, 1929. 11 Wiley, A. M. and Trueta, J.: The vascular anatomy of the spine and its relationship to pyo-

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Fm. 1. Diagrammatic illustration of vertebral vein system. From Batson. 1 starts in the metaphysis of the vertebrae, an area where the arteries seem larger, more numerous and easier to fill than the veins. They also postulated that the frequency of vertebral involvement, as opposed to other bones, can be explained by the persistence of red marrow in the vertebrae and that the distribution of infection in the spine is governed by the degree of mobility. However, as pointed out, the relatively immobile dorsal segment is more frequently involved than the cervical segment. To our knowledge, there are no published cases of osteomyelitis following needle biopsy of the prostate. We would like to present 2 case histories. In the first, the osseous lesion followed a needle biopsy only. In the second, transurethral resection of the prostate followed the needle biopsy, but we believe that the biopsy was the initiating factor. CASE REPORTS

Case 1. V. B., a 68-year-old man, had a 52 gm. transurethral resection in 1958 for benign prostatic hyperplasia. In October 1963 he was examined because of perineal aching and was found to have a firm area over the right seminal vesicle. A transperineal Franklin-Silverman needle biopsy of the prostate was performed. The patient received demethylchlortetracycline (declomycin, Lederle

genie vertebral osteomyelitis. J. Bone Joint Surg.,

41-B: 796-809, 1959.

Laboratories) following the procedure. The pathology report showed benign hyperplasia. In late October a second biopsy was performed; the patient received no antibiotics following this procedure. The pathology report indicated benign tissue. Two days following, the second procedure the patient had chills, temperature to 102F (39C), nausea, and persistent pain in the sacral region. He was admitted to the hospital 5 days later, at which time examination of the abdomen, back, genitalia, rectum and nervous system was within normal limits. His temperature was 98.4F (37C) on admission but rose to lOlF (38.3C) within a few hours. Initial blood studies showed hemoglobin of 8.8 gm. per cent, a white blood count (WBC) of 1,700 with a normal differential and a platelet count of 56,000. The urine was significantly infected with Escherichia coli on admission but yielded Proteus in mid-November. Low-grade fever persisted for 10 days and the patient was treated with demethylchlortetracycline. However, back pain persisted and in mid-November x-ray films of the spine demonstrated a lesion of the third and fourth lumbar vertebrae (fig. 3, A). This was subsequently treated by the orthopedic service with a body cast and antibiotics (penicillin and streptomycin) (fig. 3, B). Pespite an intensive hematolug,-ical investigation, no cause for the pancytopenia was found and the blood count returned toward normal with corticoid therapy. Case 2. E. 0., a 68-year-old man, was seen in October 1963 with a 2-year history of prostatism. His prostate gland was small and firm. Cystoscopy and transperineal Franklin-Silverman needle biopsy showed benign prostatic hyperplasia. Repetition of the needle biopsy on November 5 again showed benign tissue. No antibiotic coverage was used for either procedure because the urine culture obtained at admission revealed no growth in 24 hours. The patient had persistent fever after the second biopsy and urine cultures were then positive for gamma streptococci. He was treated initially with chloramphenicol (chloromycetin, Parke Davis) and later with penicillin, but the low-grade fever persisted. No definite cause for the fever could be found and on December 6 a transurethral resection of the prostate was performed. Postoperatively the patient received a course of demethylchlortetracycline (declomycin, Lederle Laboratories) and by December 9 he was afebrile for the first time since the second needle biopsy. On January 15 he returned complaining of pain in the

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FIG. 2. A, hypaque injection into prostate without abdominal compression. Only hypogastric, common ileac and inferior vena cava fill. B, injection of hypaque into prostate. Vertebral veins show filling. Abdominal compression was used in study.

thoracic spine and lower chest. There was no costovertebral angle or spinous process tenderness. Several days later he had chills, fever, severe back pain and a marked dorsal kyphosis and was admitted to the orthopedic service: His temperature was normal but pain was elicited by percussion of the ninth and tenth thoracic spinous processes. The urine was significantly infected with E. coli. Hematologic studies showed hemoglobin of 13.1 gm. pe~ cent and a WBC of 9,450 ~th a normal differential count. A destructive process of the ninth and tenth thoracic vertebral bodies and the intervening disk space'was seen on roentgenograms (fig. 4). The patient'· was treated initially with a plaster flexion jack~t and antibiotics. His hospital course was protracted but ultimate healing was satisfactory. DISCUSSION

There are 4 phases in the development of osteomyelitis of the spine. First, there must be a focus

of infection. In our report only the urinary tract is considered, although certainly infection anywhere may be a primary source. In the second phase, there must be bacteremia. This may be fulminating with high-spiking fever, but more often there is only low-grade fever with anorexia and malaise. Occasionally the patient is asymptomatic. Appropriate blood cultures may reveal organisms similar to those found in the urine. The WBC is variable and often the patient will be anemic. Many times the patient is treated with antibiotics, the diagnosis being a cold or fever of non-specific origm and the course of the disease halted. However, some cases proceed into the third phase of localization. The average interval between the original infection or operative procedure and the appearance of localizing symptoms is 27 days. 5 Cases have been reported in which the interval was 3 years. 6 The back pain may be vague and diffuse with spontaneous recovery and no radio-

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FIG. 3. A, patient V. B., shows typical changes of osteomyelitis. Note narrowing of disk space and loss of trabeculation and fuzzy appearance of upper and lower films of adjacent vertebrae. B, healing stage, note reactive bone formation with osseous bridging anteriorly and laterally.

FIG. 4. Patient E. 0. Note partial destruction and collapse of ninth and tenth thoracic vertebrae

graphic changes. Henson and Coventry are of the opinion that most cases fall into this group and that consequently the incidence is actually greater than generally appreciated. 8 The pain may be very

severe with localized tenderness to percussion and splinting of the para-spinous muscles. The discomfort may be increased by moving or standing and is often worse at night. Generally this type of

OSTEOMYELITIS OF SPINE FOLLOWING PROSTATIC BIOPSY

pain is more severe than that of metastatic carcinoma. Malaise and anore1ria are common. The WBC is usually not above 10,000 cells per cc mm. but frequently the hemoglobin is low. Invariably there is an increased erythrocyte sedimentation rate. The temperature is seldom elevated. The cmnplaints and physical findings may simulate back strain, sciatica or a slipped intervertebral disk. The diagnosis is verified by typical radiographic changes that occur, on the average, 4 to 5 weeks after the onset of symptoms. Initially there is narrowing of the disk space. The adjacent vertebrae then demonstrate loss of trabeculation and rarefaction with a fuzzy appearance of the upper and lower plates (fig. 3, A). Partial or complete collapse of the vertebral bodies may follow, as exemplified by our second case (fig. 4). Up to this point, radiographic differentiation from tuberculosis or metastatic cancer of the spine is difficult. A needle biopsy of the lesion, according to the method of Craig,12 may provide a diagnosis as well as material yielding a positive culture, which will aid in the choice of an appropriate antibiotic. Later, during the healing period, reactive bone formation and eventual osseous bridging occur anteriorly and laterally. This is the so-called "parrot beak" appearance and radiographically distinguishes the lesion from tuberculosis or tumor (fig. 3, B). Extension or complication constitutes the fourth general phase of the disease. The septic process may extend into the spinal canal, resulting in suppurative meningitis and even paraplegia secondary to extradural compression. Local soft tissue abscesses may form or the infection may extend along fascial planes and points at a considerable distance from the spine. Tertiary lesions of osteomyelitis rn.ay occur in the vertebral as well as in more distal bones. 9 Once the diagnosis has been established, treat12 Craig, F. S.: Vertebral-body biopsy. J. Bone Joint Surg., 38A: 93-102, 1956.

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ment consists of cast or frame immobilization until radiographic evidence of healing occurs. In addition, appropriate antibiotics are given until the patient is asymptomatic, usually a period of 4 to 8 weeks. Also of gTeat importance is the correction of anemia and good supportive care. Complications may require direct surgical intervention. Admittedly, the occurrence of osteomyelitis of the spine is relatively rare following prostatic needle biopsies or surgery of the lower urinary tract. We perform an average of 250 needle biopsies of the prostate a year and in reviewing our hospital records found no other cases of radiographically proven osteomyelitis. However, there were several cases in which subclinical or abortive osteomyelitis was suspected. Perhaps suitable radiographic studies would have revealed more. The severity in terms of morbidity, rather than the frequency of such cases, calls for preventive measures and early, adequate therapy. It is obvious that prevention is served best by avoiding operations on infected urinary tracts when possible and by good preoperative management in all instances. It is our opinion that antibiotics should be used prophylactically in most cases of urinary tract manipulation or surgery when infection is known to exist. We believe that a broad spectrum antibiotic should be given in all cases of transperineal needle biopsy of the prostate. When one considers the likelihood of creating a hematoma in an area of relatively poor drainage and the incidence of prostatitis in the elderly, it is surprising that complications are not more common. SUMMARY

A description of the vertebral vein system and its probable role in the relationship between osteomylitis of the spine and urinary tract infections has been given. Two such cases are reported. When a febrile course associated with back pain follows urologic surgery or manipulation, the possibility of osteomyelitis should be kept in mind and serial x-rays obtained. Suggestions for prevention and treatment are given.