Case 1
A 58-year-old Persian female was admitted with acute paraparesis and urinary retention within hours. She had a history of occasional hemoptysis and severe back pain 6 and 5 weeks before admission, respectively. Her past medical history was getting Covid-19 8 weeks ago. Her body mass index (BMI) was 25.9. She was visited in the outpatient clinic and did not take any antiviral drugs and dexamethasone. Physical examination showed lower extremity weakness and her muscular strength was graded as 2 (on a scale of 0-5). She has no loss of sensory function and plantar reflex was down. Pre-operative CT scan and Magnetic resonance imaging (MRI) are shown in Fig. 1a & 1b & 1c. Image findings were compatible with spondylodiscitis. Laboratory tests showed the following results: white blood cell (WBC) count; 11,700/μL (neutrophil 68.4% and lymph 26.6%); C-reactive protein (CRP) 72 mg/L; erythrocyte sedimentation rate (ESR) 38 mm/h; and wright and coombs wright tests were negative. The patient underwent T6-T12 pedicle screw insertion. A laminectomy and facetectomy were performed at T8–T10 level, and evacuation of pus was done. A partial T8 and T9 corpectomy with expandable cage reconstruction was performed (Fig. 1d).
Histopathological examination did not confirm the diagnosis of an acid-fast bacillus (AFB). Cultures on sample discs were negative for any bacteria as tuberculosis (TB). Also, TB and Covid-19 PCR tests on the sample disc were negative.
Case 2
A 39-year-old Persian male, presented with back pain that radiates through the buttocks and down into the back of the legs, with a history of occasional fever and chills in the past 2 months. He did not have urinary or fecal incontinence. There were no underlying disorders such as diabetes, and his BMI was 25. He was also treated for Covid-19 in the last 10 weeks. he was not treated with antiviral drugs and dexamethasone for Covid-19. Motor examination revealed (Medical Research Council (MRC) grading) 4/5 power in the proximal and distal muscle groups of both legs. He has no loss of sensory function. Laboratory tests revealed the following values: WBC count 11,800/μL (neutrophil 65% and lymph 23.7%); CRP 140 mg/L; ESR 55 mm/h; and wright and coombs wright tests were negative. The patient underwent radiological examinations (Fig. 1a & 1b), and spondylodiscitis was diagnosed. The deteriorating condition of our patient led to the decision to perform surgery. After pedicle screw insertion in L4 and L5 pedicles, laminectomy, facetectomy, and discectomy were performed. A partial corpectomy with mesh cage reconstruction and fusion with allograft and autograft was performed (Fig. 1c).
Specimens were processed for microscopy and culture. Also, a PCR test for tuberculosis DNA was done on tissue samples. The results were negative.
Case 3
A Persian male at age 47, was presented with low back pain in the past month. He was also treated for Covid-19 in the last 2 months as an outpatient.The patient did not have a specific disease. He did not take any special medicine, except painkillers for low back pain. Also, his BMI was 24.2. Motor examination presented MRC grading 5/5 power in upper and lower limbs. His sensory function was normal, with no sign of sphincter dysfunction. Spine CT and MRI imaging are shown in Fig. 1a & 1b & 1c. The patient laboratory tests showed the following findings: WBC count 12,800/μL (neutrophil 70.5% and lymph 13.3%); CRP 95 mg/L; ESR 82 mm/h; and wright, coombs wright, and 2 Mercaptoethanol (2ME) tests were negative. Spondylodiscitis was diagnosed clinically and radiologically. During the posterior-only approach, the pedicle screw was inserted in L3 and L4 pedicles, and then laminectomy, facetectomy, discectomy, and fusion with allograft and autograft bone were done (Fig. 1d).
Histopathological examination confirmed the diagnosis of spondylodiscitis with no acid-fast bacillus (AFB). Cultures on sample discs were negative for any bacteria and tuberculosis (TB). Also, TB and Covid-19 PCR tests on the sample disc were negative.
Case 4
A 39-year-old man, 68 kg, 170 cm, was referred to our hospital with a 2-week history of persistent back pain, with no past medical history; and he did not take any special medicine. A physician had examined him previously and had prescribed pain killers for pain management. His Covid-19 was treated as per the local protocol, forty days ago. Five days before admission he developed progressive complaints of reduced bilateral lower limb strength, severe problems with urination and urinary retention, and paresthesia of the lower extremities. Motor examination revealed (MRC) grading 3/5 power in the proximal and distal muscle groups of both legs. Thoracolumbar MRI and CT imaging are presented in Fig. 4a & 4b& 4c. The patient laboratory tests revealed the following findings: WBC count 9,300/μL (neutrophil 68.4% and lymph 22.2%); CRP 34 mg/L; ESR 89 mm/h; and wright, coombs wright, and 2ME tests were negative. The diagnosis of T7/T8 spondylodiscitis and the epidural abscess was established clinically and radiologically. Intraoperatively, the decision was made to do T7/T8 laminectomy, facetectomy, and evacuation of pus. After that, pedicle screw insertion, discectomy, interbody and posterolateral fusion were done (Fig. 4d).
Cultures on sample discs were negative for any bacteria. Histopathological and PCR analyses were negative for TB and Covid-19.
The patient had immediate relief from his back pain. He was able to resume his daily activities 1 month after the surgery.