Virginia Research Day 2021

Medical Resident Research Case Reports

15 Bad to the Tailbone: Osteomyelitis as a Result of Sacral Colpopexy

Lumbosacral osteomyelitis as a result of sacral colpopexy is a very rare and unusual but known complication of the procedure. There are as few as 33 case reports in the literature regarding this specific complication. Osteomyelitis is a familiar condition treated by internists most commonly associated with hematogenous spread or direct contamination of the bone via surgery, trauma or a wound. However, internists and surgeons rarely see this condition as a result of sacral colpopexy and the early warning signs of this condition might easily be overlooked. This case report will discuss lumbosacral osteomyelitis traceable to the repair of pelvic floor prolapse with a sacral colpopexy. A fifty four year old woman with history of uterine prolapse underwent a robotic- assisted hysterectomy and sacral colpopexy with placement of synthetic mesh. One month after the procedure patient complained of “tailbone” pain. A CT scan of her abdomen and pelvis demonstrated stranding in the prevertebral lumbosacral area. She was next seen two months later, continuing to complain of severe lower Madeline Kirby, MD Corresponding author: makirby@carilionclinic.org Carilion Clinic Virginia Tech School of Medicine Virginia Tech

back pain. She was treated with physical therapy and various pain medications without relief. Four months after her original surgery, she returned to the clinic complaining of pain and paresthesias radiating down her left leg. X-Ray of lumbar spine demonstrated the anterior L5-S1 disc with erosive changes and endplate irregularities concerning for discitis. MRI of the lumbar spine showed edema of the L5-S1 vertebrae with abnormal disc signal concerning for osteomyelitis which corresponded to the spinal level at which her sacral colpopexy occurred. Once admitted to the hospital, she underwent a CT guided bone biopsy. Bone cultures grew Escherichia Coli and surgical pathology of the bone biopsy demonstrated chronic osteomyelitis. She was taken back to the OR where she underwent removal of vaginal mesh along with disc space debridement and washout. Intraoperative cultures of the mesh also grew out Escherichia coli, which further solidified the causative relationship between the sacral colpopexy and the osteomyelitis. The patient is currently completing eight weeks of oral levofloxacin.

Osteomyelitis is an uncommon but serious complication of a routine and fairly common procedure for pelvic floor prolapse. This serious infection requires long-term antibiotic therapy and possible return to the operating room. Research on this complication is limited to case reports and a single retrospective cohort study that demonstrated an elevated risk of osteomyelitis after robotic assisted colpopexy as compared to the abdominal approach. The delay in our patient’s diagnosis led to the development of chronic osteomyelitis. This case report demonstrates that clinicians should maintain a heightened awareness of suspicion for patients complaining of back pain after such a procedure to ensure no delay in diagnosis and treatment.

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