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A 35-year-old male patient was diagnosed to have Crohn's disease of the large bowel in March 1994. This was managed by azathioprine and prednisolone. In October 1995, he developed pelvic and back pain, which was thought to be arising from a pelvic abscess. At laparotomy, an abscess was confirmed to arise in the appendiceal region with a chronic ileal fistula. The abscess was drained and a right hemicolectomy was performed.In February 1996, in the light of continued low back and leg pain, further investigations including plain radiographs, bone scintigraphy and CT of the lumbar spine were performed. These suggested vertebral osteomyelitis at L4/5, but a CT guided aspiration biopsy failed to identify the infective organism. The patient was treated empirically with ampicillin and metronidazole.The patient remained systemically unwell and failed to maintain his weight. He was therefore referred to our unit in June 1996. On examination he had severe tenderness over L4 and L5 posteriorly with paraspinal spasm. There was no neurological deficit. The ESR was elevated at 126 mm/hr (normal < 6 mm/h) and the C-reactive protein was 83 mg/l (normal < 10 mg/l). Further investigations were carried out: plain radiographs of the lumbosacral spine showed collapse of the L5 vertebral body (Fig. 1). MRI showed virtually complete destruction of the L5 vertebral body with involvement of the contiguous disc spaces. There was a sizable pre-sacral collection with an apparent fistulous communication with adherent bowel loops (Fig. 2). A water-soluble enema failed to demonstrate any communication between the large bowel and the pre-sacral abscess. Two weeks after admission a Hartmann's procedure was performed, which includes excision of the sigmoid colon, closure of the rectal stump and left-sided end colostomy. The rectosigmoid was found to be densely adherent to a pre-sacral abscess, which was drained, and a defunctioning colostomy performed. Histological examination of the resected large bowel showed transmural inflammation with a fistulous tract. Intraoperative cultures were negative.In the absence of neurological deficit and in view of the extensive scarring likely to be encountered in the pre-sacral region, conservative treatment of the spinal disease was considered most appropriate. The patient was referred for nutritional support and treated with intravenous cefotaxime, metronidazole and gentamicin for 1 month, followed by a 1-month course of oral ciprofloxacin, amoxycillin and metronidazole.At follow-up, 13 months after the onset of low back pain and 9 months after the cessation of antibiotic treatment, the patient had no back or leg pain. There was significant improvement in his general condition. Plain radiographs of the lumbosacral spine showed some healing of the vertebral lesions at L4 and L5 (Fig. 3). There was a residual kyphosis at the lumbosacral junction because of loss of height of the L5 vertebral body. The C-reactive protein levels on three consecutive monthly occasions were less than 6 mg/l and the Abstract Vertebra...

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Study design: Case report and literature review. Objective: To illustrate that ossification of the proximal thoracic ligamenta flava can be a rare cause of acute myelopathy in a Caucasian patient and that timely surgery can lead to a good outcome. Setting: Nottingham, UK. Methods: Proximal multiple contiguous ossified thoracic ligamenta flava from T3/T4 to T5/T6 causing acute myelopathy was diagnosed in a Caucasian man based on history and examination followed by magnetic resonance imaging and computed tomography scanning. The literature is reviewed for all reported cases of ossified ligamenta flava causing myelopathy in Caucasians. Results: Following prompt diagnosis and T3 to T5 laminectomies, our patient made nearcomplete neurological recovery over a 10-month period. This condition usually affects the lower thoracic spine. Although chronic and subacute myelopathy secondary to this circumstance has been reported in Caucasians, acute myelopathy has not been reported and proximal thoracic involvement has been reported twice. Conclusion: Ossification of the proximal thoracic ligamenta flava can be a rare cause of acute myelopathy in Caucasians. Prognosis following decompressive surgery is usually good.

We have reviewed 41 patients with malignant extradural