versão impressa ISSN 1413-7852
Acta ortop. bras. v.9 n.4 São Paulo out./dez. 2001
RELATO DE CASO
Report of a rare case of foreign body in a lumbar vertebra
Helton Luiz Antonio DefinoI; Antônio Carlos ShimanoII
Professor of Departamento de Cirurgia, Ortopedia e Traumatologia da Faculdade
de Medicina de Ribeirão Preto- USP
IIMechanical Engineer of the Bioengineering Lab of Faculdade de Medicina de Ribeirão Preto- USP
A rare case of
foreign body (a piece of cloth tissue) found in the body of L5, presenting symptoms
related to compression of the fifth left lumbar root is presented.
Clinical and radiological picture, with emphasis on rarity of the lesion, the treatment performed and its result after 3-year follow-up are discussed.
Key Words: Lumbar spine; vertebral infection
In daily practice a doctor sometimes can face situations resulting form a range of incidents leading to injuries one would never wonder that could come from daily life accidents and a that are very unlikely to happen. The clinical case we report here is an example of this, and it is very much likely we will not be able to report another similar case to the end of our professional life. The rarity of this case and the findings linked to it motivated us to report it.
The patient was a 62 years old male who worked in building construction, who presented with a complaint of lumbar pain irradiated to the L5 dermatome. The pain worsened with movements and improved at rest in Fowley's position. Symptoms started approximately one month after a fall from a scaffolding of construction. He reported that during the fall had an perforating wound at his buttocks and that the wound was still open and draining secretion even though several surgical cleanings were performed.
At physical examination it was found a punctiform wound at left buttocks draining sero-purulent secretion. Lumbar spine had straightened lordosis, and all lumbar spine movements were painfully limited.
Neurological examination was compatible to left L5 root commitment as expressed by decrease in strength of hallex extension, sensation decrease in the lateral aspect of left leg, and positive elevation of the left lower limb test.
Imagery tests demonstrated an injury in fifth lumbar vertebra, with an irregular and circumscribed material, well limited in relation to the body of the vertebra and partially invading the vertebral canal (Figure 1). S1 and L4 bodies also presented an injury area in all scans (Figure 2).
Analyzing the clinical picture and complementary examinations, we could state that there was a compression of the L5 left root, associated to a pathological process of the fifth lumbar vertebra. There was doubt about the etiology of the process in L5, and also about the time it started (did it exist before the fall or was a result of it?)
The patient underwent surgery for decompression of L5 root and biopsy of L5 body. During the exposure of the root, it was observed that it was hyperemic and biopsy of the L5 body was performed through the same exposure, being removed a fragment of the posterior wall of L5 body, curettage of part of the cancellous bone of the vertebral body. During the removal of cancellous bone we found and removed a very badly smelling fragment of cloth tissue (jeans) inside the vertebral body. At the moment it was not possible to understand the origin of that piece of cloth tissue measuring about 1x3 cm. After a better analysis, it was concluded to be a piece of the tissue of the pants the patient wearied at the moment of the accident (Figure 3).
Starting from this observation and reviewing the imagery examinations, it was possible to understand the mechanism of the injury. During the fall an iron rod that penetrated the buttocks leaded a piece of cloth to the body of L5. This fragment of cloth tissue produced the infection of the vertebral body leading to its partial destruction and partial compression of L5 root. The presence of secretion in the wound could now be understood as well as the difficulty in obtaining healing.
The clinical follow-up demonstrated a good result and at this moment, with a 3 years follow-up, the patient has no symptoms.
This kind of injury here described has some picturesque aspects. An iron rod penetrated his buttocks, reached his sacrum and the fourth lumbar vertebra, leaving a piece of cloth tissue of his pants inside the body of L5. The path of the iron rod was restricted to bone tissue, and, considering how other very close structures were not involved makes this a very rare case.
For mere chance it was possible to remove the tissue fragment, what not only allowed the diagnosis but also to solve the problem. Regarding the biopsy, it could have been performed through vertebral pedicle, and very probably we would not have removed the tissue fragment. We can only wonder what would the evolution be if the tissue fragment was not removed during the surgery.
At the time this patient was treated we did not have the availability of MRI, which would certainly help the diagnosis.
Regarding treatment, a fixation from L4 to S1 was performed with a Hartchild rectangle during the decompression of the root and biopsy of the vertebral body (Figure 4), since we believed it would be necessary an anterior surgical approach for cleaning and debridement of the vertebral body, that was not performed due to lack of local conditions. We were then afraid of reaching this infected area. Maybe now, more experienced in surgical treatment of bone infections our choice would certainly be an anterior approach, with a surgical debridement of the vertebral body and cortico-spongeous bone grafting. The method of fixation used nowadays would be with the use of pedicular screws associating the anterior debridement to iliac bone grafting. However the results achieved with the treatment were satisfactory from a clinical and radiological point of view, with an ankylosis of L4-L5 segment even though loosing lordosis of this lumbar spine segment. Symptoms remitted completely, and the buttocks wound heal. (Figure 4)
Fixation material was removed 2 years after the surgery due to secretion through the surgical scar. Secretion and fistula was observed in the posterior scar, even though ankylosis occurred in the anterior part of the spine. Once the fixation material was removed, a complete healing of the surgical wound was observed.
Trabalho recebido em 25/05/2000. Aprovado em 15/12/2000
This work had partial support of CNPq
Acknowledgements: - The authors acknowledge BAUMER for making the implants used in mechanical assays.