Sacral Colpopexy Followed by Refractory Candida albicans Osteomyelitis and Discitis Requiring Extensive Spinal Surgery

University of California, San Diego, Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, San Diego, California, USA.
Obstetrics and Gynecology (Impact Factor: 5.18). 08/2012; 120(2 Pt 2):464-8. DOI: 10.1097/AOG.0b013e318256989e
Source: PubMed


Sacral colpopexy is an effective approach to treat vaginal vault prolapse. We report a case of serious Candida albicans infection at the site of sacral mesh attachment.
A 63-year-old woman developed back pain 4 months after sacral colpopexy. Imaging revealed L5 and S1 osteomyelitis and discitis. This was refractory to medical management and surgical debridement with mesh removal and tissue excision in the surgical plane. Cultures demonstrated C albicans. This ultimately required extensive spinal surgery, including two discectomies, L5 corpectomy, partial corpectomies, canal decompression, strut fusion, and posterior screw and rod stabilization and fusion.
C albicans lumbosacral osteomyelitis and discitis is a rare but serious complication after sacral colpopexy that can result in significant morbidity.

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Available from: Charles W Nager, Feb 10, 2015
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    • "Spondylodiscitis is rare, but its consequences might be devastating with a wide spectrum of disability and severe pain. Spondylodiscitis cases following SC procedures were identified with microbial pathogen related mechanisms in several papers [7] [8] [10] [11]. However, in a recent review, Propst et al. [10] reported that only 29% (8/28) of the cases could be treated with antibiotics despite positive culture results. "
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    ABSTRACT: Spondylodiscitis is a rare but severe complication of sacral colpopexy (SC) procedure. Although the term ‘spondylodiscitis’ refers to infection of vertebral body and intervertebral disc space, neither the infecting microorganism could be isolated nor any purulent material could be observed during the second surgery and there was failure of different regimens of antibiotherapy. This type of spondylodiscitis cases might be explained by the graft rejection hypothesis. We hypothesize that the initiator of the rejection process is the host response solely and infection is just a co-incidence. In this situation, infection is neither a cause of this reaction, nor a promoter. There might be no infection at all. We presented two spondylodiscitis cases most probably secondary to graft rejection reaction and reviewed the literature in order to increase the awareness of this destructive complication of SC, which can only be ameliorated by surgical mesh removal.
    Full-text · Article · Aug 2015
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    ABSTRACT: Sacrocolpopexy presacral sutures are placed at or slightly above the sacral promontory without knowledge of the location of intervertebral discs. We used magnetic resonance imaging to assess the anatomic relationship of the sacral promontory to intervertebral discs. We reviewed spinal magnetic resonance images of women imaged at Loyola University Medical Center between January 2010 and February 2012. Sagittal T1 fluid-attenuated inversion recovery sequence images of the lumbosacral spine were used to identify the promontory as the most prominent point where S1 intersected with the superior anatomic structures. All measurements were obtained at the midline of the spinal cord. The mean age of 73 study subjects was 59 years (range, 22-89 years). The promontory was an intervertebral disc in many women (53 [73%]); the remaining images confirmed a nondisc promontory at the superior aspect of S1 in 20 patients (27%). The distance between the promontory and the next bony structure (L5) was 13 mm (25th-75th interquartile range, 11-16). In women without disc at the promontory, the median distance between the promontory and the base of L5 disc was 1.29 mm (interquartile range, 1.1-2.2). The mean height of the disc was 13.3 mm (4.4-20.6 mm). Age was not associated with the most prominent structure (P = 0.2), nor was it correlated to disc height (P = 0.27, r = 0.13) or distance to L5 (P = 0.75, r = 0.04). Given the high proportion of women with an intervertebral disc at the promontory, suture placement strategies that avoid this location may avoid-reduce disc-related sequelae after sacrocolpopexy.
    No preview · Article · Jan 2013 · Journal of Pelvic Medicine and Surgery
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    ABSTRACT: : To further characterize the anatomy of the fifth lumbar to first sacral (L5-S1) disc space and to provide anatomic landmarks that can be used to predict the locations of the disc, sacral promontory, and surrounding structures during sacrocolpopexy. : The lumbosacral anatomy was examined in 25 female cadavers and 100 computed tomography (CT) studies. Measurements were obtained using the midpoint of the sacral promontory as a reference. Data were analyzed using Pearson χ, unpaired Student's t test, and analysis of covariance. : The average height of the L5-S1 disc was 1.8±0.3 cm (range 1.3-2.8 cm) in cadavers and 1.4±0.4 cm (0.3-2.3) on CT (P<.001). The average angle of descent between the anterior surfaces of L5 and S1 was 60.5±9 degrees (39.5-80.5 degrees) in cadavers and 65.3±8 degrees (42.6-88.6 degrees) on CT (P=.016). The average shortest distance between the S1 foramina was 3.4±0.4 cm in cadavers and 3.0±0.4 cm on CT (P<.001). The average height of the first sacral vertebra (S1) was 3.0±0.2 cm in cadavers and 3.0±0.3 on CT (P=.269). : In the supine position, the most prominent structure in the presacral space is the L5-S1 disc, which extends approximately 1.5 cm cephalad to the "true" sacral promontory. During sacrocolpopexy, awareness of a 60-degree average drop between the anterior surfaces of L5 and S1 vertebra should assist with intraoperative localization of the sacral promontory and avoidance of the L5-S1 disc. The first sacral nerve can be expected approximately 3 cm from the upper surface of the sacrum and 1.5 cm from the midline. : II.
    No preview · Article · Feb 2013 · Obstetrics and Gynecology
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