Proximal Junctional Spondylodiscitis Following Adult Spinal Deformity Surgery: Case Series and Review of the Literature

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Figure 1
Preoperative (A) and initial standing postoperative radiographs (B). Follow-up radiographs demonstrating proximal junctional failure (C). T2 magnetic resonance image with metal artifact suppression demonstrating instrumentation failure with pedicle screw in the spinal canal (D). Note increased signal in the proximal junctional disc space (asterisk) (D). Standing radiographs at final follow-up (E).
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Figure 2
Preoperative (A) and initial standing postoperative radiographs (B). Follow-up radiographs demonstrating proximal junctional failure (C). T2 magnetic resonance image demonstrating T9 and T10 compression fractures and discitis at T7-T8 and T8-T9 with adjacent epidural abscess (D). Standing radiographs at final follow-up (E).
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Figure 3
Sagittal (A) and axial (B) T2 magnetic resonance images on presentation demonstrating discitis with osteomyelitis and epidural abscess of T10 and T11. Initial postoperative supine radiographs (C).

Table

Demographic and clinical summary of presented cases of proximal junctional spondylodiscitis.

	Case 1	Case 2	Case 3
Age, y	58	68	76
Gender	Female	Male	Female
Comorbidities	Anemia, scoliosis	Anterior cervical discectomy and fusion, asthma, hypertension	Chronic obstructive pulmonary disease, rheumatoid arthritis, PE, chronic deep vein thrombosis
Index operation	ALIF L3-L4, L4-L5, L5-S1 T4-pelvis PSIF, PCOs T6-S1, posterior ligamentous repair T3-T5	ALIF L4-L5, L5-S1 T10-pelvis, PCOs T12-S1, vertebroplasty of T9 and T10, posterior ligamentous repair T9-T11	T11-L5 PSIF and ALIF L5-S1 (performed at outside hospital)
Presenting symptoms	Significant back pain, difficulty with ambulation, bowel/bladder incontinence	Back pain	T10 sensory level, bilateral lower extremity weakness, severe back pain
Preoperative infectious laboratory findings	None	WBC 7.6, platelets 538, erythrocyte sedimentation rate 46, CRP 14.7	WBC 13.5, CRP 71.4
Proximal junctional pathology	Instrumentation pullout proximal junction; increased T2 signal in proximal junctional disc (T3-T4)	Pathologic fracture at UIV +1, epidural abscess	Pathologic fractures at upper instrumented vertebra, UIV +1, incomplete spinal cord injury
Time to infection/proximal junctional failure	3 mo	2 y	6 mo
Microbiology	Staphyloccocus aureus	No growth	Methicillin-resistant S aureus

Abbreviations: ALIF, anterior lumbar interbody fusion; CRP, C-reactive protein; PCO, posterior column osteotomy; PE, pulmonary embolism; PJS, proximal junctional spondylodiscitis; PSIF, posterior spinal instrumentation and fusion; UIV +1, unfused adjacent segment; UIV, upper instrumented vertebra; WBC, white blood cell count.