title: Vertebral osteomyelitis and epidural abscess after laparoscopic uterus-preserving cervicosacropexy.
abstract: Abdominal sacrocolpopexy is a standard surgical technique to repair apical vaginal prolapse. When approached laparoscopically, a uterus-preserving technique was suggested as potentially favorable for avoiding mesh-related complications. A 52-year-old Caucasian woman came to the emergency department with right-sided low back pain and vaginal discharge more than 1 year after undergoing a laparoscopic, uterus-preserving, cervicosacropexy with Mersilene (Ethicon Inc., Somerville, NJ) mesh and permanent Gore-Tex (W.L. Gore and Associates, Inc., Flagstaff, AZ) suture. Lumbar spine magnetic resonance imaging revealed diskitis and an epidural abscess at the L5 to S1 vertebral levels, and a fistulous tract was identified extending from the rectovaginal space to the affected vertebrae. The patient underwent a fine-needle aspiration of the epidural abscess and intravenous antibiotic therapy was started. However, because of a lack of symptom resolution she was taken to the operating department on hospital day 11 and underwent a total abdominal hysterectomy, left salpingectomy, right salpingo-oophorectomy, bilateral ureterolysis, and excision of an infected Mersilene mesh. Surgical findings were notable for 2 pinpoint areas in the upper vagina consistent with fistulae tracts communicating with the retroperitoneal space. The patient recovered well from her surgery, and was discharged to a rehabilitation facility. Vertebral osteomyelitis, with or without an epidural abscess, is a rare complication of sacrocolpopexy. The findings of this case suggest this complication likely occurred as a result of a permanent suture being placed entirely (or nearly entirely) through the vaginal mucosa resulting in fistulae formation, bacterial seeding of the Mersilene mesh, and subsequent osteomyelitis. This highlights the importance of mesh and suture selection, and determining the most appropriate sites for mesh attachment.
authors.affiliation: Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. ktdowning@partners.org
authors.forename: Keith T
authors.initials: KT
authors.lastname: Downing
mesh_terms: D020802:Epidural Abscess / Q000209:etiology*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008159:Lumbar Vertebrae / Q000382:microbiology; D008875:Middle Aged; D010019:Osteomyelitis / Q000209:etiology* / Q000601:surgery; D012447:Sacrum / Q000382:microbiology; D013526:Surgical Mesh / Q000009:adverse effects* / Q000382:microbiology; D014596:Uterine Prolapse / Q000601:surgery; D014624:Vaginal Fistula / Q000150:complications / Q000209:etiology