Tetraplegia after complicated sigmoid polypectomy

Abstract

A 79-year-old man was admitted with a 6-week history of low-grade fever, neck pain and progressive weakness. Eight weeks before admission, he underwent a colonoscopy for anal bleeding, and a voluminous 2-cm sessile polyp in the sigmoid colon with signs of recent haemorrhage was removed using snare cautery. This was complicated immediately by arterial bleeding. Haemostasis was achieved with the injection of 1:10 000 epinephrine solution, argon plasma coagulation and haemoclipping. Pathology revealed a low-grade tubulovillous adenoma.Physical examination disclosed neck tenderness, flaccid tetraplegia, C3 sensory level, hyperreflexia and loss of anal tone. Blood cultures revealed methicillin-sensitive Staphylococcus aureus (MSSA). Magnetic resonance imaging showed multilevel cervical spinal canal stenosis, septic arthritis of the right C3 ⁄ 4 facet joint and an anterior epidural abscess extending between C3 and C5, causing spinal cord compression (Fig. 1). Echocardiography showed no vegetations. He was submitted to urgent decompression laminectomy. Over the next few weeks, neurological recovery was poor.Bacteremia occurs in about 4% of colonoscopic procedures, but it is asymptomatic. Transient systemic or distant infection is not considered a complication of colonoscopy, but the risk of bacteria entering the blood stream to multiply at distant sites in susceptible hosts exists. The absence of data on the frequency of colonoscopy-related systemic infection may be related to the infrequency of cases and the difficulty in establishing a temporal relationship, because patients may fail to report a previous procedure. There are, however, rare clinical reports of distant infections associated with colonoscopy and polypectomy [1][2][3][4][5]. Although their connection to such procedures may be based only on circumstantial evidence, it should not be ignored because of the high morbidity. It is also worth noting that underlying colonic lesions per se are a risk factor for distant infection.To our knowledge, there have been no previous cases of spinal infection complicating polypectomy. Moreover, spontaneous septic arthritis of facet joints of the cervical spine is very rare in adult nondrug users and St. aureus is the most implicated microorganism. In this case, inoculation of bacteria in the spine occurred during the polypectomy-related transitory bacteremia. After the complete formation of septic arthritis and epidural empyema, the patient presented a full-blown clinical picture of secondary septicaemia. The significant bleeding requiring passage of several instruments and the invasive haemostasis might be implicated in the spinal infection and may have been related to contamination of instruments, since MSSA is usually not found in the normal intestinal flora. The physician should be alert of the possibility of infection after polypectomy to avoid delay in diagnosis that could lead to disastrous sequences as in this case.