Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh

Abstract Introduction: Lumbar spondylodiscitis is a rare and severe complication of laparoscopic sacrohysteropexy with a polypropylene mesh. However, a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy has not been reported so far. We present a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy with a mesh. We also discuss 33 cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh. Patient concerns: A 46-year-old woman with 3 previous vaginal deliveries underwent laparoscopic mesh sacrohysteropexy for stage III uterine prolapse. One month after surgery, the patient developed persistent symptoms, such as stiffness of the lumbosacral portion, low back pain (LBP), persistent swelling, pain between the right iliac crest and the buttock, inability to bend down, and pain in the right lower limb. Symptoms were alleviated by a nonsteroidal anti-inflammatory drug. However, in the last 7 days, symptoms worsened and she was unable to stand or walk. The patient had very limited leg mobility. Diagnosis: Blood routine examination, erythrocyte sedimentation rate, C-reactive protein, and magnetic resonance imaging (MRI) of the lumbar spine indicated lumbar pyogenic spondylodiscitis. Interventions: Removal of mesh and hysterectomy via laparoscopy were performed immediately, and antibiotics were given simultaneously. However, on the basis of MRI findings and persistent symptoms, debridement, laminectomy, spinal canal decompression, bone grafting, and internal fixation via pedicle screw placement were performed 5 months after laparoscopic sacrohysteropexy. Outcomes: All symptoms were alleviated 5 days after the operation. The patient could stand in the erect position and raise her lower limbs within 2 weeks. She could resume her normal activities within 2 months after the operation, and her X-ray appeared normal. Conclusion: Persistent LBP and radiating pain may be the signals of lumbar spondylodiscitis. MRI is the gold standard diagnostic examination for lumbar spondylodiscitis. Awareness of symptoms, such as LBP and radiating pain symptoms, timely diagnosis, mesh removal, and referral to orthopedists are important to prevent more severe complications. Surgical practice needs to be improved further and any other infections should be treated immediately as the most likely causes of lumbar spondylodiscitis are related to the mesh and other infections.


Introduction
Laparoscopic sacrohysteropexy with a mesh is a variation of the sacral colpopexy to correct apical prolapse in women who desire uterine preservation. [1] Spondylodiscitis, also referred to as pyogenic discitis and vertebral osteomyelitis, is defined as an infection limited to the intervertebral disc (discitis) and the adjacent vertebrae (vertebral osteomyelitis). [2] Spondylodiscitis is a condition that includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. [3] Awareness of symptoms, timely diagnosis, and multidisciplinary approach to the management of this condition are important to prevent other severe complications. [4] We present a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy with a mesh that was referred to orthopedists for surgery. We also evaluate the current literature to understand how to manage lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh.

Case report
A 46-year-old woman with 3 previous vaginal deliveries suffered from stage III uterine prolapse for 1 year and it had worsened during the last 6 months. Five months ago, laparoscopic sacrohysteropexy was performed using a Yshaped polypropylene mesh. A prophylactic antibiotic was used within 24 hours in the absence of infection. Her past medical history was unremarkable. After the procedure, the pelvic organ prolapse disappeared. One month after surgery, the patient developed discomfort in the lumbosacral portion that continuously persisted for 4 months. The symptoms included stiffness of the lumbosacral portion, low back pain (LBP), persistent swelling, pain between the right iliac crest and the buttock, inability to bend down, and pain in the right lower limb. Symptoms were alleviated after a nonsteroidal antiinflammatory drug was prescribed in the outpatient clinic. But in the last 7 days, symptoms were not alleviated and they worsened, and the patient was unable to stand or walk. The legs could only be moved away from the bed up to 20 cm because of pain. Primitive reflexes were negative and there was no loss of sensory function. Then the patient was referred for admission. Blood routine examination, erythrocyte sedimentation rate, C-reactive protein, and magnetic resonance imaging (MRI) of the lumbar spine indicated lumbar pyogenic spondylodiscitis (Fig. 1). Y-shaped polypropylene mesh was removed and hysterectomy was conducted via laparoscopy immediately, and antibiotics were given simultaneously. During the operation, a festering wound was seen at the location of the stitches over the lumbosacral portion and the mesh suture was placed higher than its usual level. Escherichia coli bacteria were found at the location of the stitches. Tienam was given for 2 weeks as E coli bacteria are sensitive to this drug. The patient was referred to orthopedists because of persistent symptoms. MRI indicated bony destruction of the lower part of the L5 vertebra and the dome of the sacrum and absence of favorable evolution (Fig. 2). Through the retroperitoneal lumbar approach, destruction of the vertebral body between the fifth lumbar vertebra and the first sacral vertebra was seen, and degeneration of the intervertebral disc and necrosis of the lumina of the L5 vertebra were also seen. Debridement, laminectomy, spinal canal decompression, bone grafting, and internal fixation via pedicle screw placement were conducted 5 months after laparoscopic sacrohysteropexy. Symptoms were alleviated 5 days after the operation, and the pain decreased. The patient was discharged on the seventh day after the operation. The patient was able to stand in the erect position and raise her lower limbs within 2 weeks. The patient returned to normal activity within 2 months after the operation, and the X-ray also appeared normal (Fig. 3).

Discussion
Laparoscopic sacrohysteropexy with a mesh is considered to be the gold standard for apical prolapse in young women who desire uterine preservation. [1] Mesh graft can lead to infections and graft rejection, and different conditions require different management therapies. [5] Lumbar spondylodiscitis is a rare and severe complication, which can cause LBP, fever, and radiating pain symptoms, such as pain in the buttock and leg, and even mobility limitation. [6] A case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy has not been reported so far. Only cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh have been reported. We performed a literature search via PubMed, and we found 33 cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh ( Table 1). Summary of the characteristics is presented in Table 2. Thirty-four women with a median age of 60 years (range, 42-80 years) were diagnosed with spondylodiscitis following sacrohysteropexy, sacral colpopexy, and (or) rectopexy with a mesh. They visited their doctors with symptoms. The median time to symptom presentation was 14 months, and it ranged from 6 days to 8 years. LBP occurred in every case. Further, 38% of the patients suffered from fever and 35% of the patients suffered from radiating pain symptoms, which mostly predicted the need for referral to orthopedists for surgical interventions ( Table 3). Regardless of the recovery time after surgery, the possibility of spondylodiscitis must be considered when the patients present with LBP, fever, and especially radiating pain symptoms, which may predict the presence of severe spondylodiscitis requiring multidisciplinary surgical interventions.
MRI can indicate the early stage of spondylodiscitis reflecting the obvious imaging changes. In our study, 97% of cases of spondylodiscitis were diagnosed by MRI; excluding 1 case that was diagnosed by computed tomography (CT) and MRI was not  Table 1 Cases of spondylodiscitis following sacrohysteropexy, sacral colpopexy, and rectopexy with a mesh. Suture placement 2 cm above the sacral promontory, higher than the usual level of placement Ugurl-ucan, [6] 2018 52 Total laparoscopic hysterectomy and sacrocolpopexy removal of the epidural phlegmon and decompression of the S1 nerve root After 3 wk Laparotomy mesh removal and anterior L5-S1 discectomy and debridement.

Ab for 6 wk
The location of the mesh was above the S1 vertebra and not within the disc conducted. CT-guided aspiration can sometimes be useful for diagnosing local infection. Seventy-one percent of the patients developed local pathogen infection, which included bacterial and fungal infections. It was only infection, and not graft rejection. [5] CT-guided aspiration can sometimes be useful for diagnosing local infection and for prescribing the correct drugs.
Antibiotics alone were effective in only 4 cases, that is, 12% of the total cases; thus, showing a low percentage. Most of the patients needed surgical interventions. Mesh removal and debridement were effective in majority of the cases, while 44% of the cases needed multidisciplinary surgical interventions, mainly orthopedic surgery. Further, 88% of the patients were able to return to normal daily activity, and only 6% of the patients suffered from intermittent LBP.
The possible causes of lumbar spondylodiscitis were mainly related to the mesh (32%) and other infections (29%), while the other causes of lumbar spondylodiscitis were not noted. Meshrelated causes included vaginal mesh erosion (24%), including mesh penetration into the rectum in 1 case, and suture placement at a level higher than the usual placement level (9%). Other infections included urinary tract infection in 5 cases (15%), vaginitis in 2 cases (6%), postoperative pelvic abscess in 1 case (3%), wound infection at 1 of the port sites in 1 case (3%), and dental extraction of infected teeth in 1 case (3%). Surgical practice needs to be improved further and any other infections should be treated immediately.
In conclusion, persistent LBP and radiating pain may be the signals of lumbar spondylodiscitis. MRI is the gold standard diagnostic examination for lumbar spondylodiscitis. Awareness of symptoms, especially LBP, fever, and radiating pain symptoms, and timely MRI of the lumbar spine can help the early diagnosis of spondylodiscitis. Local bacterial culture can be useful for prescribing more effective antibiotics. Mesh removal and debridement are the main gynecological surgical interventions. Timely referral to orthopedists can prevent additional surgeries. (excluding 1 case of mesh removal because of mesh erosion) Referral to orthopedists for surgical intervention, 15 (44) CT = computed tomography, MRI = magnetic resonance imaging, UTI = urinary tract infection. Table 3 The relationship between occurrence of radiating pain symptoms and referral to orthopedists.