Lumbosacral osteomyelitis is a rare but morbid complication following sacrocobalpexy, with only a few cases reported in the urogynecologic literature. The proposed mechanisms of infection include hematogenous seeding, direct inoculation of the intervertebral disc by the sacral suture, or seeding of the vaginal portion of mesh with subsequent ascension to the sacrum. The presenting signs and symptoms of osteomyelitis can be nonspecific or variable, thereby making diagnosis a challenge. Common findings of vertebral osteomyelitis include back pain, elevated C-reactive protein, and elevated erythrocyte segmentation rate. Other findings such as fever, neurologic impairment, spinal tenderness, leukocytosis, and high neutrophil percentage are not always present. Imaging plays an important role in the diagnosis of vertebral osteomyelitis. MRI is more sensitive than CT for detection of early osteomyelitis, making it the imaging modality of choice. However, there is a reported 2-4 week delay between the onset of symptoms and detectable changes on MRI. This can cause difficulty when diagnosing osteomyelitis and decreases the utility of MRI for monitoring clinical response. The objectives of this video presentation is to present a case of lumbosacral osteomyelitis following sacral colopexy procedure, review the radiographic features of osteomyelitis and disguidance on MRI, and highlight the challenges encountered in diagnosis and treatment. A 79-year-old vaginal multipurse patient presented to the office with symptoms of pelvic organ prolapse. Her past medical and surgical history was significant for a total abdominal hysterectomy and bilateral salpingo-ufrectomy. On exam, she was found to have stage 3 vaginal bulge prolapse. She had previously undergone conservative measures to treat her prolapse symptoms and now desired surgical management. After extensive counseling, she underwent an uncomplicated robotic-assisted laparoscopic sacral colopexy. A permanent monofilament suture was used to secure a lightweight polypropylene mesh to the anterior and posterior walls of the vagina. Two additional permanent monofilament sutures were used to secure the ends of the mesh to the anterior longitudinal ligament of the sacrum below the sacral promontory. The mesh was then reperinealized. Her postoperative recovery was uncomplicated and she was discharged home on postoperative day zero. Two weeks following her surgery, she was admitted with fevers, abdominal pain, back pain, and left hip pain. She had a leukocytosis of 12,000 and an elevated C-reactive protein of 196. A CT abdomen pelvis did not show any intra-abdominal abscess, however, there were inflammatory changes around the sigmoid colon consistent with acute diverticulitis. Given her presenting symptoms, an MRI of the lumbar spine was also performed. On these sagittal T2-weighted images, there is normal vertebral body and disc architecture. In the pelvis, we see postoperative changes associated with mesh placement. There is no evidence of discitis or epidural abscess. Gram-positive streptococcus anginosus. She was treated and discharged with a two-week course of Ceftraxone and Flagyl for suspected diverticulitis. Her symptoms improved with IV antibiotics and she had an interval improvement in her leukocytosis and C-reactive protein values. Eleven weeks following her initial surgery, she was readmitted to an outside hospital for worsening back pain. Her white blood cell count was normal. Her C-reactive protein was downtrending but was still elevated. An erythrocyte sedimentation rate was also obtained, which was also elevated. An MRI of the lumbar spine was repeated. Her previous MRI images are shown on the left side of the screen and the new MRI is on the right. On T2 imaging, we see destruction of the L5S1 vertebral disc with replacement of the disc face with fluid. On corresponding T1 images, there is new bone marrow edema of the entire L5 and upper S1 vertebral bodies. These findings are compatible with pyogenic discitis and vertebral osteomyelitis at the L5S1 level. A CT-guided biopsy was performed by interventional radiology of the L5S1 disc face. The resulting culture was positive for pseudomonas. The patient was treated with an 8-week course of IV cefepime. The patient was again readmitted 17 weeks following her initial surgery for worsening back pain. She was afebrile, but there was still an increase in her CRP and ESR values. A repeat MRI of the sacrum demonstrated similar appearance of the L5S1 discitis and osteomyelitis with no associated epidural or iliopsoas abscess. Given worsening of symptoms despite medical management, the patient was taken to the operating room for a laparoscopic excision of the sacral mesh and sutures. The OR cultures resulted positive for pseudomonas. The patient was treated with an additional 12 weeks of IV cefepime. The patient experienced interval improvement in her symptoms and lab values. However, one week following discontinuation of antibiotics, she again developed worsening back pain and was readmitted. She was afebrile, but she had worsening of her CRP and ESR values. On MRI, there was overall worsening appearance of the infectious process with development of a possible abscess in the ventral epidural space. Ultimately, the patient was taken to the operating room by the orthopedic spine surgery team where she underwent an anterior retroperitoneal L5S1 discectomy and an L5S1 anterior lumbar interbody fusion with placement of a titanium interbody device. She recovered without complication and was discharged to an inpatient rehab facility after one week. She received an additional 6 weeks of IV meropenem. On her most recent set of labs, her CRP has normalized and her ESR continues to downtrend. She has since been discharged from rehab and has completed her antibiotics. She remains symptom-free. Given the variability in presenting signs and symptoms, your gynecologist should maintain a high index of suspicion for lumbosacral osteomyelitis in patients presenting with back pain or fevers following sacral colopexy. Although MRI can be helpful in detecting early osteomyelitis, MRI findings may lag up to four weeks behind first clinical symptoms. Surgical intervention may be required in addition to aggressive long-term antibiotic therapy. And finally, clinical response should be monitored based on patient symptoms and CRP and ESR values.

Lumbosacral osteomyelitis

sacral colpopexy

diagnosis challenges

pelvic organ prolapse

pseudomonas