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Margaryan D, Renz N, Bervar M, Zahn R, Onken J, Putzier M, Vajkoczy P, Trampuz A. Spinal implant-associated infections: a prospective multicentre cohort study. Int J Antimicrob Agents 2020; 56:106116. [PMID: 32726675 DOI: 10.1016/j.ijantimicag.2020.106116] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
This study evaluated the clinical, laboratory, microbiological, radiological and treatment characteristics of patients with early-onset and late-onset spinal implant-associated infections. Patients diagnosed with spinal implant-associated infection between 2015-2019 were prospectively included and treated according to a standardised algorithm. Infections were classified as early-onset (≤6 weeks) and late-onset (>6 weeks). Among 250 patients, 152 (61%) had early-onset and 98 (39%) had late-onset infection. Local inflammatory signs was the most common manifestation in early-onset infections (84%), whereas late-onset infections presented mainly with persisting or increasing local pain (71%). Sonication fluid was more often positive than peri-implant tissue samples (90% vs. 79%; P = 0.016), particularly in late-onset infections (92% vs. 75%; P = 0.005). Predominant pathogens were coagulase-negative staphylococci, Staphylococcus aureus and Cutibacterium spp. Debridement and implant retention was the most common surgical approach in early-onset infections (85%), whereas partial or complete implant exchange was mainly performed in late-onset infections (62%). Of the 250 patients, 220 (88%) received biofilm-active antibiotics, and median treatment duration was 11.7 weeks. Moreover, 49 patients (20%) needed more than one revision for infection and six patients (2.4%) died during hospital stay. Concluding, most spinal implant-associated infections were acquired during surgery and presented within 6 weeks of surgery. Infections presented mainly with local inflammatory signs in early-onset and with persisting or increasing pain in late-onset infections. Sonication was the most sensitive microbiological method, particularly in late-onset infections. Debridement and implant retention was used in well-integrated implants without loosening, independent of the time of infection onset.
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Affiliation(s)
- Donara Margaryan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Maja Bervar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Robert Zahn
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Julia Onken
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Michael Putzier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
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Impact of the localization on disease course and clinical management in spondylodiscitis. Int J Infect Dis 2020; 99:122-130. [PMID: 32721536 DOI: 10.1016/j.ijid.2020.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 07/19/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Spondylodiscitis is a severe infection of the spine that can take a diverse number of disease courses depending on its localization, resulting in specific therapeutic strategies. This study aims to identify localization specific characteristics and clinical parameters for spondylodiscitis. METHODS A retrospective review was performed of 211 patients from 2013-2018 with proven spondylodiscitis. In total, 33 were cervical, 48 thoracic and 112 lumbar. In 18 patients disseminated infestations of several localizations were found. The patient records were evaluated for clinical and outcome parameters and demographic characteristics. RESULTS Patient age, Body Mass Index, inpatient and intensive care stay, and inpatient complications did not differ significantly between different infection localizations. C-reactive protein (CrP) levels showed a significantly reduced value in the thoracic area compared to other localizations. For comorbidities, there was a significantly higher prevalence of endocarditis in disseminated and lumbar infestations compared to thoracic and cervical cases. Epidural abscesses showed a highly increased incidence in cervical cases. With a 30-day mortality rate of 12.1% for cervical, 12.5% thoracic, 13.4% lumbar, and 22.2% in disseminated disease, no significant difference was observed. CONCLUSIONS The present study determined that, although the 30-day mortality rate does not differ according to the localization of the infection, specific clinical parameters, such as CrP values or comorbidities, showed localization-dependent differences.
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103
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Screven R, Noureldine MHA, Krafft PR, Alikhani P. Expandable Titanium Cages in the Emergent Treatment of Severe Spinal Deformity Secondary to Osteomyelitis: A Series of Three Complex Cases. Asian J Neurosurg 2020; 15:397-404. [PMID: 32656140 PMCID: PMC7335120 DOI: 10.4103/ajns.ajns_28_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/26/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022] Open
Abstract
The literature lacks robust evidence on the benefits versus risks of instrumenting and fusing the spinal column in the setting of active osteomyelitis. We report three patients with vertebral osteomyelitis and subsequent severe and complex kyphotic deformities. Patients 1 and 2 had previous instrumentation that required revision because of hardware failure in the thoracic and thoracolumbar regions, respectively. Patient 3 developed a severe cervical kyphotic deformity at 2 months after being diagnosed and treated with antibiotics for osteomyelitis, necessitating emergent instrumentation and fusion. All the three patients are doing very well so far. Spinal instrumentation and fusion for correction of kyphotic deformity is sometimes necessary in the context of active osteomyelitis and should be done emergently and without hesitation when spinal cord injury from spinal instability is of concern.
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Affiliation(s)
- Ryan Screven
- Department of Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Mohammad Hassan A Noureldine
- Department of Neurosurgery, Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, Johns Hopkins University School of Medicine, Saint Petersburg, Florida, USA
| | - Paul R Krafft
- Department of Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Puya Alikhani
- Department of Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine, Tampa, USA
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104
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Palumbo P, Bruno F, Arrigoni F, Zappia M, Ierardi AM, Guglielmi G, Zugaro L, Carotti M, Di Cesare E, Splendiani A, Brunese L, Masciocchi C, Barile A. Diagnostic and interventional management of infective spine diseases. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:125-135. [PMID: 32945287 PMCID: PMC7944670 DOI: 10.23750/abm.v91i8-s.9994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/11/2020] [Indexed: 01/10/2023]
Abstract
Spondylodiscitis (SD) is one of the main causes of back pain. Although the low mortality, high morbidity is related to spondilodiscitys, leading spine instability, chronic pain or neurological deficit. Diagnostic imaging plays a primary role in diagnosing spondylodiscitis. However different accuracy is highlighted by different diagnostic tool, depending also on timing of disease which represents a cardinal element for the phenotypic manifestation of the disease, beyond spatial resolution and tissue characterization proper of specific modality imaging. Conventional Radiology (CR), Computed Tomography (CT) and MRI (Magnetic Resonance Imaging) all have proven to be of primary importance in the approach to spondylodiscitis, although magnetic resonance imaging has demonstrated the greatest advantage in identifying the disease from its earliest stages, demonstrating high sensitivity and specificity (92% and 96%, respectively). This review focus on the role of different imaging modality in the approach to the spondylodiscitis, also addressing the role of interventional radiology that is pivotal not only for a diagnosis of certainty through biopsy, but also for a minimally-invasive treatment of paravertebral abscesses spondylodiscitis-related. (www.actabiomedica.it)
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Affiliation(s)
| | - Federico Bruno
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Francesco Arrigoni
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Marcello Zappia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.
| | - Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
| | - Luigi Zugaro
- Department of Emergency Radiology, San Salvatore Hospital, L'Aquila, Italy.
| | - Marina Carotti
- University Department of Radiology - Division of Special and Pediatric Radiology Hospital "Umberto I - Lancisi - Salesi", Ancona, Italy.
| | - Ernesto Di Cesare
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Alessandra Splendiani
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.
| | - Carlo Masciocchi
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Antonio Barile
- Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy.
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105
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Ryang YM, Akbar M. [Pyogenic spondylodiscitis: symptoms, diagnostics and therapeutic strategies]. DER ORTHOPADE 2020; 49:691-701. [PMID: 32642943 DOI: 10.1007/s00132-020-03945-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pyogenic spondylodiscitis is a rare disease that is being diagnosed with increasing frequency in recent years. It is associated with a high morbidity and mortality. DIAGNOSIS Often, because of its nonspecific symptoms, pyogenic spondylodiscitis is diagnose with some delay. In addition to pathogen detection, MRI is the gold standard to diagnose pyogenic spondylodiscitis. Also, x-ray imaging and CT can be carried out for surgical planning and for subsequent follow-up imaging. If blood or tissue cultures are negative, open surgical biopsies should be preferred over CT-guided biopsies. THERAPY The therapy can be conservative, such as immobilization, as well as antibiotics and analgesics, or surgical. If, for example, neurological deficits, spinale instabilities or deformities, septic disease progression or extensive abscess formations are present, surgical therapy is indicated. The surgical treatment strategies depend on the severity of the disease. OUTLOOK The prognosis is dependent on a rapid diagnosis and a swift start to therapy. There is no clear evidence with regard to treatment options (conservative vs. surgical therapy).
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Affiliation(s)
- Y-M Ryang
- Klinik für Neurochirurgie und Zentrum für Wirbelsäulentherapie, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125, Berlin, Deutschland.
| | - M Akbar
- Clinic für Wirbelsäulenerkrankungen und -Therapien, MEOCLINIC, Berlin, Deutschland
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106
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Ahn KS, Kang CH, Hong SJ, Kim BH, Shim E. The correlation between follow-up MRI findings and laboratory results in pyogenic spondylodiscitis. BMC Musculoskelet Disord 2020; 21:428. [PMID: 32616029 PMCID: PMC7333318 DOI: 10.1186/s12891-020-03446-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although MRI is the gold-standard imaging method in the diagnosis of spondylodiscitis, role of follow-up imaging is debated and there can be discrepancies with regard to the significance of bony or soft tissue responses to treatment. Purpose of our study is to test whether the MRI changes on follow-up imaging correlate with laboratory findings of treatment response. METHODS A total of 48 patients with pyogenic spondylodiscitis who underwent baseline and follow-up MRI were retrospectively reviewed. The extent of bone marrow edema, paravertebral soft tissue inflammation, and disc height were compared on baseline and follow-up MRIs with the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels obtained from the medical records at baseline and on follow-up. Relationships between the MRI and laboratory changes were analyzed using the Spearmann correlation test. RESULTS The mean MRI follow-up period was 42.25 days. Based on the CRP (resolved: n = 19, resolving: n = 19, and aggravated: n = 10), there was significant correlation between the laboratory results and the changes in the bone and soft tissues (p < 0.01, both). The correlation was best with soft tissue changes (rho: 0.48) followed by bony changes (rho: 0.41). Based on the ESR (resolved: n = 8, resolving: n = 22, and worsened: n = 18), the correlation was stronger with bone changes (rho: 0.45, p < 0.01) than it was with soft tissue changes (rho: 0.39, p = 0.01). CONCLUSION Follow-up MRI findings of pyogenic spondylodiscitis show variable tissue responses. CRP was best correlated with soft tissue changes, while ESR showed the best association with bony changes.
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Affiliation(s)
- Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Chang Ho Kang
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea.
| | - Suk-Joo Hong
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Baek Hyun Kim
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Korea
| | - Euddeum Shim
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Korea
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Abstract
The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.
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108
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McFarland JR, Branch D, Gonzalez A, Campbell G, Lall RR. L5 Fracture Dislocation Secondary to Cold Abscess Treated by Posterior Corpectomy With Expandable Cage Placement. Cureus 2020; 12:e8756. [PMID: 32714694 PMCID: PMC7377670 DOI: 10.7759/cureus.8756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Infections of the lumbar spine can have serious sequelae, including neurological deficits, paralysis, and death. Prolonged infection can result in fracture of the vertebrae, local abscesses, and infiltration and compression of local vascular structures. In cases with significant instability or neurological compromise, a common treatment approach is vertebral corpectomy with interbody cage followed by long-term antibiotics. The following case describes a patient with a three-month history of progressively worsening lower back pain, lower extremity radiculopathy, and bilateral lower extremity edema, in the setting of a nontraumatic three-column fracture dislocation of L5 with grade 4 retrolisthesis of L4 on L5. A posterior-only corpectomy with placement of an expandable cage, to be followed by pedicle screw placement from L3-S1/ilium, was performed. The procedure was successful, and the patient was discharged on postoperative day 5 without complication and with resolution of his edema. Histopathological analysis demonstrated acute and chronic inflammation, but extensive tests and cultures failed to identify a causative organism. This case highlights several interesting features, including a technically challenging and seldom-performed procedure, as well as the ability of lumbar spinal infections to present with leg edema due to involvement the inferior vena cava and iliac vessels. For patients with three-column fractures of L5 due to an inflammatory process or trauma, a single-stage posterior corpectomy with placement of an expandable cage may be considered as an appropriate treatment option.
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Affiliation(s)
- Joseph R McFarland
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Daniel Branch
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Adam Gonzalez
- Pathology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Gerald Campbell
- Pathology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Rishi R Lall
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, USA
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Kihira S, Koo C, Mahmoudi K, Leong T, Mei X, Rigney B, Aggarwal A, Doshi AH. Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy. AJNR Am J Neuroradiol 2020; 41:1316-1322. [PMID: 32554421 DOI: 10.3174/ajnr.a6623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/23/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Pathology and microbiology results for suspected spondylodiscitis on MR imaging are often negative in up to 70% of cases. We aimed to predict whether MR imaging features will add diagnostic value when combined with clinical biomarkers to predict positive findings of spondylodiscitis on pathology and/or microbiology from percutaneous biopsy. MATERIALS AND METHODS In this retrospective single-center institutional review board-approved study, patients with radiologically suspected spondylodiscitis and having undergone percutaneous biopsies were assessed. Demographic characteristics, laboratory values, and tissue and blood cultures were collected. Pathology and microbiology results were used as end points. Three independent observers provided MR imaging-based scoring for typical MR imaging features for spondylodiscitis. Multivariate logistic regression and receiver operating characteristic analysis were performed to determine an optimal combination of imaging and clinical biomarkers in predicting positive findings on pathology and/or microbiology from percutaneous biopsy suggestive of spondylodiscitis. RESULTS Our patient cohort consisted of 72 patients, of whom 33.3% (24/72) had spondylodiscitis. The mean age was 63 ± 16 years with a male/female ratio of 41:31. Logistic regression revealed a combination with an area under the curve of 0.72 for pathology and 0.68 for pathology and/or microbiology. Epidural enhancement on MR imaging improved predictive performance to 0.87 for pathology and 0.78 for pathology and/or microbiology. CONCLUSIONS Our findings demonstrate that epidural enhancement on MR imaging added diagnostic value when combined with clinical biomarkers to help predict which patients undergoing percutaneous biopsy will have positive findings for spondylodiscitis on pathology and/or microbiology.
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Affiliation(s)
- S Kihira
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - C Koo
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - K Mahmoudi
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - T Leong
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - X Mei
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - B Rigney
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - A Aggarwal
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - A H Doshi
- From the Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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110
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Yu CH. Full-endoscopic debridement and drainage treating spine infection and psoas muscle abscess. JOURNAL OF SPINE SURGERY 2020; 6:415-423. [PMID: 32656379 DOI: 10.21037/jss.2020.01.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background In recent years, full-endoscopic debridement and drainage (FEDD) is gaining popularity treating spondylodiscitis. Comparing to tradition open surgery, FEDD possess many advantages including lower anesthesia risk and minimally invasiveness. In this study, we report our surgical technique of FEDD and preliminary clinical outcome in 34 consecutive patients with minimum 12 months follow-up. Methods In our institute, "early intervention and minimally invasive surgery" is our primary strategy to treat spine infection. Surgical approaches of FEDD include transforaminal and interlaminar technique. Selection of surgical approach depends on the location of spine infection. "Trocar-rotating technique" is a novel method to treat psoas muscle abscess. Additional instrumentation is suggested in complicated patients with unstable spinal segment. Results Since June 2016 to June 2018, 34 patients including 22 males and 12 females with average aged 62.3 years (21 to 82 years old) sustained spine infection were treated by FEDD. Twenty-eight patients belong to primary spondylodiscitis and 15 patients among them sustained concomitant psoas abscess. Five patients was post-operative infection and one patient was mixed infection including lumbar spondylodiscitis, psoas abscess and multi-level posterior epidural abscess. Positive culture was obtained in 27 patients (27/34=79%) while gram-positive cocci (Staphyloccocci and Streptoccoi) are the most frequent pathogen (67%). Infection was controlled in 28 patients (28/34=82%). Six patients were defined as treatment failure with infection recurrence, they underwent repeat FEDD surgery or open revision surgeries. There was no major intra-operative complications expect two patients sustained transient paresthesia and one instrument broken. Superficial wound infection was encountered in 2 patients and healed after local debridement. Conclusions FEDD is a safe and effective procedure. We hope that, FEDD surgery will be the first-line surgery method to treat lumbar spine infection globally in the near future.
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Affiliation(s)
- Ching-Hsiao Yu
- Department of Orthopaedic Surgery, Taoyuan General Hospital, Taoyuan
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111
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Comparison of the Diagnostic Value of MRI and Whole Body 18F-FDG PET/CT in Diagnosis of Spondylodiscitis. J Clin Med 2020; 9:jcm9051581. [PMID: 32455982 PMCID: PMC7290470 DOI: 10.3390/jcm9051581] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022] Open
Abstract
Spondylodiscitis is a spine infection for which a diagnosis by a magnetic resonance imaging (MRI) is considered the most appropriate imaging technique. The aim of this study was to compare the role of an 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and an MRI in this field. For 56 patients with suspected spondylodiscitis for whom MRI and 18F-FDG PET/CT were performed, we retrospectively analyzed the results. Cohen’s κ was applied to evaluate the agreement between the two techniques in all patients and in subgroups with a different number of spinal districts analyzed by the MRI. Sensitivity, specificity, and accuracy were also evaluated. The agreements of the 18F-FDG PET/CT and MRI in the evaluation of the entire population, whole-spine MRI, and two-districts MRI were moderate (κ = 0.456, κ = 0.432, and κ = 0.429, respectively). In patients for whom one-district MRI was performed, 18F-FDG PET/CT and MRI were both positive and completely concordant (κ = 1). We also separately evaluated patients with suspected spondylodiscitis caused by Mycobacterium tuberculosis for whom the MRI and 18F-FDG PET/CT were always concordant excepting in 2 of the 18 (11%) patients. Sensitivity, specificity, and accuracy of the MRI and 18F-FDG PET/CT were 100%, 60%, 97%, and 92%, 100%, and 94%, respectively. Our results confirmed the 18F-FDG PET/CT diagnostic value in the diagnosis of spondylodiscitis is comparable to that of MRI for the entire spine evaluation. This could be considered a complementary technique or a valid alternative to MRI.
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112
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Lazary A, Klemencsics I, Szoverfi Z, Kiss L, Biczo A, Szita J, Varga PP. Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations. Surg Infect (Larchmt) 2020; 22:193-199. [PMID: 32326845 DOI: 10.1089/sur.2019.344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). Methods: A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Results: Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Conclusions: Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.
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Affiliation(s)
- Aron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
| | - Istvan Klemencsics
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
| | - Zsolt Szoverfi
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
| | - Laszlo Kiss
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Adam Biczo
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Julia Szita
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.,School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Peter Pal Varga
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
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113
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Dolan RT, Butler JS, Vaccaro AR, White AP, Giele HP. Current Strategies for Reconstruction of Soft Tissue Defects of the Spine. Clin Spine Surg 2020; 33:9-19. [PMID: 31913180 DOI: 10.1097/bsd.0000000000000936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Spinal surgery has been revolutionized by advances in instrumentation, bone graft substitutes, and perioperative care. Extensive dissection, creation of large areas of dead space, and the use of instrumentation in compromised patients, however, predisposes to high rates of wound complications. Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. Recognition of high-risk patients and prediction of wound closure difficulties, combined with preemptive reconstructive surgical strategies may prevent complications. The purpose of this review is to discuss the principles of spine wound management and provide a synopsis of the soft tissue reconstructive strategies utilized in spinal surgery. We review the senior author's preferred reconstructive algorithm for the management of these complex wounds, in addition to outcomes data relating to the timing of reconstructive surgery.
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Affiliation(s)
- Roisin T Dolan
- Department of Plastic & Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Joseph S Butler
- National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Andrew P White
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Henk P Giele
- Department of Plastic & Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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114
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Douraiswami B, Subramani S, Varman M. Unprecedented clinical presentation of fungal spondylodiscitis as an extradural mass in an immunocompetent individual. J Clin Orthop Trauma 2020; 11:942-946. [PMID: 32904184 PMCID: PMC7452353 DOI: 10.1016/j.jcot.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Balaji Douraiswami
- Department of Orthopaedics, Hairmyres Hospital, NHS Lanarkshire, Glasgow, G75 8RG, United Kingdom
- Corresponding author.
| | - Suresh Subramani
- Department of Orthopaedics, SRM Medical College & Research Centre, Chennai, 603 203, India
| | - Mahendhira Varman
- Department of Orthopaedics, Tagore Medical College, Chennai, 600127, India
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115
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Atesok K, Vaccaro A, Stippler M, Striano BM, Carr M, Heffernan M, Theiss S, Papavassiliou E. Fate of Hardware in Spinal Infections. Surg Infect (Larchmt) 2019; 21:404-410. [PMID: 31855116 DOI: 10.1089/sur.2019.206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Removal of hardware with irrigation and debridement in patients with surgical site infections (SSIs) is performed commonly. However, the removal of hardware from patients with SSIs after spinal procedures is controversial. Moreover, primary spinal infections such as spondylodiscitis may require instrumentation along with surgical debridement. The purpose of this article was to evaluate critically and summarize the available evidence related to retention of hardware in patients with deep SSIs, and the use of instrumentation in surgical treatment of primary spinal infections. Methods: A literature search utilizing PubMed database was performed. Studies reporting the management of deep SSIs after instrumented spinal procedures, and of primary spinal infections using instrumentation published in peer-reviewed journals were included. Identified publications were evaluated for relevance, and data were extracted from the studies deemed relevant. Results: Because SSIs occur typically during the early post-operative period before stable bony fusion has been achieved, the removal of instrumentation may be associated with instability of the spinal column, pseudarthrosis, progressive deformity, pain, loss of function, and deterioration in the activities of daily living (ADL). Hence, early SSIs after spinal instrumentation are usually treated without removal of hardware. Moreover, primary spinal infections such as spondylodiscitis may require surgical debridement and instrumentation in cases with associated instability. Conclusions: Retaining or using instrumentation in patients with SSIs after spinal procedures or in patients with primary spinal infections, respectively, are commonly practiced in the field of spine surgery. Further evidence is required for the development of definitive algorithms to guide spine surgeons in decision making regarding the fate of instrumentation in the treatment of spinal infections.
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Affiliation(s)
- Kivanc Atesok
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alexander Vaccaro
- Department of Orthopedic Surgery, Thomas Jefferson University, The Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Martina Stippler
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Brendan M Striano
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael Carr
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael Heffernan
- Department of Orthopaedic Surgery, Childrens Hospital of New Orleans, LSU Health Science Center, New Orleans, Louisiana, USA
| | - Steven Theiss
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Efstathios Papavassiliou
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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116
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Tong YJ, Liu JH, Fan SW, Zhao FD. One-stage Debridement via Oblique Lateral Interbody Fusion Corridor Combined with Posterior Pedicle Screw Fixation in Treating Spontaneous Lumbar Infectious Spondylodiscitis: A Case Series. Orthop Surg 2019; 11:1109-1119. [PMID: 31701667 PMCID: PMC6904647 DOI: 10.1111/os.12562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/17/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022] Open
Abstract
Objective Surgery is indicated when antibiotic treatment fails in pyogenic spondylodiscitis, which is caused by pathogens such as the Staphylococcus species. The aim of the present study was to investigate the efficacy and safety of the oblique lateral interbody fusion (OLIF) corridor approach combined with posterior pedicle screw fixation for treating pyogenic spondylodiscitis. Methods This was a retrospective case series study. A total of 11 patients with an average age of 60.7 years (range, 40–70 years; 10 males and 1 females) with lumbar pyogenic spondylodiscitis who underwent single‐stage debridement and reconstruction using the OLIF corridor combined with posterior pedicle screw fixation were recruited in our study from June 2016 to July 2017. All patients had single‐level pyogenic spondylodiscitis between T12 and L5. The baseline data, perioperative outcomes (operative time, intra‐operative blood loss, and intra‐operative complication), postoperative laboratory tests (erythrocyte sedimentation rate [ESR], C‐reactive protein [CRP], white blood count [WBC], and tissue culture results), long‐term complications (recurrence, fixation failure, and bony non‐fusion rates), and duration of antibiotic administration were reviewed. Outcomes evaluated using a variety of scales including visual analog scale (VAS) score and Oswestry disability index (ODI), were compared pre‐operatively and post‐operatively. Results The mean follow‐up period of time was 18.3 months. The average operative time and intra‐operative blood loss were 217.0 ± 91.91 min and 220.9 ± 166.10 mL, respectively. There were no intra‐operative complications, except in 1 patient who encountered somatosensory evoked potentials changes and 1 patient who had motor evoked potentials changes, both without post‐surgery neurological deficits. Causative organisms were identified in 4 patients: Staphylococcus aureus in 1 patient and Streptococcus in 3 patients. At approximately 8.8 weeks after surgery, WBC, CRP, and ESR had returned to normal levels. All patients were pain free with no recurring infection. There was no fixation failure during follow up. Solid bony fusions were observed in all cases within 6 months. At the final follow up, the mean VAS (0.6 ± 0.69) and ODI (14.4 ± 4.27) were significantly lower than those before surgery (P < 0.05). Conclusion One‐stage debridement with autogenous iliac bone graft through the OLIF corridor combined with posterior pedicle screw fixation is effective and safe for single‐level spontaneous lumbar pyogenic spondylodiscitis after antibiotic treatment fails.
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Affiliation(s)
- Yong-Jun Tong
- Key laboratory of Musculoskeletal System Degeneration and Degeneration Translational Research of Zhejiang Province, Hangzhou, China.,Department of Orthopaedics, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Jun-Hui Liu
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key laboratory of Musculoskeletal System Degeneration and Degeneration Translational Research of Zhejiang Province, Hangzhou, China
| | - Shun-Wu Fan
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key laboratory of Musculoskeletal System Degeneration and Degeneration Translational Research of Zhejiang Province, Hangzhou, China
| | - Feng-Dong Zhao
- Department of Orthopaedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key laboratory of Musculoskeletal System Degeneration and Degeneration Translational Research of Zhejiang Province, Hangzhou, China
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Supreeth S, Al Ghafri KA, Jayachandra RK, Al Balushi ZY. First Report of Candida auris Spondylodiscitis in Oman: A Rare Presentation. World Neurosurg 2019; 135:335-338. [PMID: 31525477 DOI: 10.1016/j.wneu.2019.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Candida auris is an emerging superbug which was recently discovered and has spread widely across the world. With a steady rise in incidence involving multisystems, this presents a unique challenge to caregivers. CASE DESCRIPTION A 50-year-old man with sickle cell disease, diabetes mellitus, and multiple surgeries presented with progressive low back pain radiating to bilateral limbs and intact neurology. Radiologic and laboratory investigations suggested spondylodiscitis with epidural collection, which was operated with posterior decompression and stabilization. The tissue analysis was reported as C. auris, which was accordingly treated with caspofungin. Magnetic resonance imaging at 4 months showed resolution of infection with return of inflammatory markers to normal. CONCLUSIONS C. auris appears to be an emerging superbug, which is hospital-acquired. All practitioners must be aware of its existence and presentation. Given the low incidence, high mortality, and no clear guidelines of management so far, formulation of any such strategies is complicated. Further studies and research are needed for this superbug.
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Landi A, Grasso G, Iaiani G, Gregori F, Mancarella C, di Bartolomeo A, Domenicucci M, Delfini R. Spontaneous Spinal Discitis and Spondylodiscitis: Clinicotherapeutic Remarks. J Neurosci Rural Pract 2019; 8:642-646. [PMID: 29204028 PMCID: PMC5709891 DOI: 10.4103/jnrp.jnrp_67_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alessandro Landi
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Giovanni Grasso
- Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), Section of Neurosurgery, University of Palermo, Palermo, Italy
| | - Giancarlo Iaiani
- Department of Infectious and Tropical Disease, "Sapienza" University of Rome, Rome, Italy
| | - Fabrizio Gregori
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Cristina Mancarella
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Alessandro di Bartolomeo
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Maurizio Domenicucci
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Roberto Delfini
- Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
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119
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Fu TS, Wang YC, Lin TY, Chang CW, Wong CB, Su JY. Comparison of Percutaneous Endoscopic Surgery and Traditional Anterior Open Surgery for Treating Lumbar Infectious Spondylitis. J Clin Med 2019; 8:jcm8091356. [PMID: 31480610 PMCID: PMC6780224 DOI: 10.3390/jcm8091356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Minimally invasive surgery is becoming popular for treating spinal disorders. The advantages of percutaneous endoscopic debridement and drainage (PEDD) for infectious spondylitis include direct observation of the lesion, direct pus drainage, and earlier pain relief. We retrospectively reviewed 37 patients who underwent PEDD and 31 who underwent traditional anterior open debridement and interbody fusion with bone grafting from 2004 to 2012. The causative organisms were isolated from 30 patients (81.1%) following PEDD, and from 25 patients (80.6%) following open surgery (p = 0.48). Staphylococcus aureus was the most common pathogen (38.2%). In the PEDD group, blood loss (<50 mL versus 585 ± 428 mL, p < 0.001) was significantly lesser and the duration of hospitalization (24.4 ± 12.5 days versus 31.5 ± 14.6 days, p = 0.03) was shorter than that in the open surgery group. Serologically, there were significantly faster C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) normalization rates in the PEDD group (p < 0.001, p = 0.009, respectively). In the two-year follow-up radiographs, 26 out of 30 (86.7%) open surgery patients showed bony fusions of the infected segments. On the contrary, sclerotic change of the destructive endplates was observed and the motion of infected spinal segments was still preserved in the PEDD group. There was no significant difference in the change of sagittal profile, including primary correction gain, correction loss, and actual correction gain/loss. PEDD is an effective alternative option and should be considered prior to traditional extensive spinal surgery—particularly for patients with early-stage spinal infection or serious complicated medical conditions.
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Affiliation(s)
- Tsai-Sheng Fu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan.
| | - Ying-Chih Wang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Tung-Yi Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Chia-Wei Chang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Chak-Bor Wong
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Juin-Yih Su
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
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120
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Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J Nucl Med Mol Imaging 2019; 46:2464-2487. [PMID: 31399800 DOI: 10.1007/s00259-019-04393-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/04/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome. METHODS An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology. RESULTS A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria. CONCLUSIONS This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.
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Ahmad FU, Bisson EF, Burks SS, Chang JJ, Chugh AJ, Côté I, Frerich JM, Gersey ZC, Hendricks BK, Karsy M, Kasliwal M, Krause KL, Manzano GR, Morgan CD, Snyder LA, Swinney CC, Than KD, Theodotou CB, Veeravagu A, Ventura J. Spine. Oper Neurosurg (Hagerstown) 2019; 17:S153-S181. [PMID: 31099842 DOI: 10.1093/ons/opz073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Faiz U Ahmad
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Stephen Shelby Burks
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jason J Chang
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon
| | - A Jessey Chugh
- Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio
| | - Ian Côté
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jason M Frerich
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Zachary C Gersey
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael Karsy
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Manish Kasliwal
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Katie L Krause
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon
| | - Glen R Manzano
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Clinton D Morgan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Laura A Snyder
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christian C Swinney
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Khoi D Than
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon
| | - Christian B Theodotou
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Anand Veeravagu
- Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Jacqueline Ventura
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Balcescu C, Odeh K, Rosinski A, Wang J, Prasad P, Leasure J, Ungurean V, Kondrashov D. High Prevalence of Multifocal Spine Infections Involving the Cervical and Thoracic Regions: A Case for Imaging the Entire Spine. Neurospine 2019; 16:756-763. [PMID: 31284339 PMCID: PMC6945002 DOI: 10.14245/ns.1836296.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/27/2019] [Indexed: 12/18/2022] Open
Abstract
Objective Pyogenic spinal infections account for 2%–4% of orthopaedic infections. They are often difficult to diagnose, resulting in a delay in diagnosis. Risk factors for orthopaedic and spinal infection are well-documented in the literature, yet there is a paucity of studies examining risk factors specifically for multifocal spinal infections. The objective of this study was to identify predictors of multifocal spinal infections in comparison to unifocal spinal infections.
Methods The medical records, imaging studies, and bacteriology data of 20 patients treated surgically for pyogenic spinal infection over 6 years at a tertiary referral center were reviewed and analyzed after receiving Institutional Review Board approval. Univariate and multivariate analyses were performed to identify factors associated with a multifocal spinal infection.
Results Seven patients (35%) had multifocal infections. Three were bifocal, and 4 were trifocal. Patients with surgically treated cervical or thoracic spinal infections had a high rate of concomitant multifocal spinal infections (71% and 83%, respectively). Other potential predictors (e.g., patient age, body mass index, magnetic resonance image findings, etc.) did not reach statistical significance. Each of the multifocal infections involved the lumbar spine.
Conclusion In this study, the spinal region was the only statistically significant risk factor for multifocal infection. Patients who are diagnosed with a spinal infection that requires operative treatment should have their entire spine evaluated with magnetic resonance imaging to detect multifocal involvement promptly.
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Affiliation(s)
- Christian Balcescu
- St. Mary's Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Khalid Odeh
- St. Mary's Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | | | - Jonathan Wang
- St. Mary's Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Priya Prasad
- The Taylor Collaboration, San Francisco, CA, USA
| | | | - Victor Ungurean
- St. Mary's Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | - Dimitriy Kondrashov
- St. Mary's Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
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Sangondimath G, Mallepally AR, Yelamarthy PKK, Chhabra HS. Severe Pott's Kyphosis in a 19-Month-Old Child: Case Report and Review of Literature. World Neurosurg 2019; 130:30-36. [PMID: 31252083 DOI: 10.1016/j.wneu.2019.06.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation. CASE DESCRIPTION This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4-D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4-D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4-D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months. CONCLUSIONS Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries.
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124
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Could Hyperbaric Oxygen Be a Solution in the Treatment of Spinal Infections? ACTA ACUST UNITED AC 2019; 55:medicina55050164. [PMID: 31137457 PMCID: PMC6571771 DOI: 10.3390/medicina55050164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/02/2019] [Accepted: 05/16/2019] [Indexed: 12/20/2022]
Abstract
Background and Objective: Pyogenic spinal infections are rare and potentially devastating, requiring prompt recognition and management. Parallel to the ever-increasing number of invasive spinal procedures, its incidence is on a steady rise, particularly in an expanding elderly population. The aim of this study was to evaluate the efficacy of hyperbaric oxygen (HBO2) therapy in the treatment of this heterogeneous group of disorders. Materials and Methods: Nineteen patients who were referred to our center for HBO2 with a clinical diagnosis of spinal infections (vertebral osteomyelitis, pyogenic spondylitis, spondylodiscitis, surgical site infection following spine surgery, epidural abscess) were retrospectively reviewed. Results: Infection resolution was adequately achieved in 12 of 13 patients (92.3%) on magnetic resonance imaging at the end of HBO2 treatment or during the first month of follow-up. The mean follow-up period was 11 months (range 1 month to 3 years). Conclusions: This study suggests that HBO2 therapy is efficacious in patients with pyogenic spinal infections complicated by primary therapy failure or by medical comorbidities that may impede the eradication of microbial infection and delay wound healing. HBO2 therapy may be useful for reducing long hospital stays, repeated surgeries, and morbidities.
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Abstract
AIMS HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients' CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them. PATIENTS AND METHODS Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; sd 15.0). RESULTS In total, 53 patients had tuberculous, nine bacterial, and one cryptococcal spondylodiscitis. There were 29 HIV-positive patients, 29 HIV-negative patients, and five patients with unknown HIV status. The local incidence of TB spondylodiscitis was 1.54/100 000 and that of non-TB spondylodiscitis was 0.29/100 000 per annum. TB patients were younger with similar clinical presentation and infective markers, but were more likely to have a paraspinal abscess. They were also less likely to have a hyperintense disc on MRI. There was no difference between the two HIV groups. CONCLUSION In areas of endemic TB and HIV, TB remains the most common cause of spondylodiscitis at five times the rate of non-tuberculous causes. HIV managed with HAART increases the rate of infection but does not influence the bacteriology unless there is a low CD4. There was little to differentiate the groups. TB /HIV co-infected patients were younger than non-TB and HIV-negative patients. Non-TB patients were more likely to have disc hyperintensity on MRI and TB patients were more likely to have abscess formation, but as both groups exhibited these features, neither was diagnostic. Culture confirmation remains necessary. Cite this article: Bone Joint J 2019;101-B:617-620.
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Affiliation(s)
- R N Dunn
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur and Red Cross Children's Hospital, Cape Town, South Africa
| | - S Castelein
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - M Held
- University of Cape Town, Groote Schuur and Red Cross Children's Hospital, Cape Town, South Africa
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Pandita N, Paul S, Yadav G, Kalia RB, Kandwal P. Evaluation of Challenges in Diagnosis of Spontaneous Subacute Pyogenic Spondylodiscitis in Immunocompetent Patients: Experiences from a Tertiary Care Center. Asian Spine J 2019; 13:621-629. [PMID: 30966724 PMCID: PMC6680042 DOI: 10.31616/asj.2018.0220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/29/2018] [Indexed: 12/18/2022] Open
Abstract
Study Design Prospective clinical study. Purpose We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis. Overview of Literature Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis. Methods Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis. Results Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated. Conclusions Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum Creactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.
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Affiliation(s)
- Naveen Pandita
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Gagandeep Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Roop Bhushan Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Pankaj Kandwal
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Li G, Li P, Chen Q, Thu HE, Hussain Z. Current Updates on Bone Grafting Biomaterials and Recombinant Human Growth Factors Implanted Biotherapy for Spinal Fusion: A Review of Human Clinical Studies. Curr Drug Deliv 2019; 16:94-110. [PMID: 30360738 DOI: 10.2174/1567201815666181024142354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Owing to their great promise in the spinal surgeries, bone graft substitutes have been widely investigated for their safety and clinical potential. By the current advances in the spinal surgery, an understanding of the precise biological mechanism of each bone graft substitute is mandatory for upholding the induction of solid spinal fusion. OBJECTIVE The aim of the present review is to critically discuss various surgical implications and level of evidence of most commonly employed bone graft substitutes for spinal fusion. METHOD Data was collected via electronic search using "PubMed", "SciFinder", "ScienceDirect", "Google Scholar", "Web of Science" and a library search for articles published in peer-reviewed journals, conferences, and e-books. RESULTS Despite having exceptional inherent osteogenic, osteoinductive, and osteoconductive features, clinical acceptability of autografts (patient's own bone) is limited due to several perioperative and postoperative complications i.e., donor-site morbidities and limited graft supply. Alternatively, allografts (bone harvested from cadaver) have shown great promise in achieving acceptable bone fusion rate while alleviating the donor-site morbidities associated with implantation of autografts. As an adjuvant to allograft, demineralized bone matrix (DBM) has shown remarkable efficacy of bone fusion, when employed as graft extender or graft enhancer. Recent advances in recombinant technologies have made it possible to implant growth and differentiation factors (bone morphogenetic proteins) for spinal fusion. CONCLUSION Selection of a particular bone grafting biotherapy can be rationalized based on the level of spine fusion, clinical experience and preference of orthopaedic surgeon, and prevalence of donor-site morbidities.
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Affiliation(s)
- Guanbao Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Pinquan Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Qiuan Chen
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Hnin Ei Thu
- Department of Pharmacology and Dental Therapeutics, Faculty of Dentistry, Lincoln University College, Jalan Stadium, SS 7/15, Kelana Jaya, 47301 Petaling Jaya, Selangor, Malaysia
| | - Zahid Hussain
- Department of Pharmaceutics, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Bandar Puncak Alam 42300, Selangor, Malaysia
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128
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Bazarov AY, Sergeev KS, Osintsev VM, Lebedev IA, Barinov AL, Faryon AO, Katrechko GA. [Secondary spondylogenic epidural abscess]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:75-82. [PMID: 30900690 DOI: 10.17116/neiro20198301175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents the results of a retrospective analysis of 200 patients with hematogenous osteomyelitis of the spine who were treated in the Tyumen Regional Clinical Hospital #2. Neurological disorders were present in 37 patients (group I); 163 patients (group II) had no neurological disorders; according to CT and MRI, secondary spondylogenic epidural abscess was diagnosed in 24 patients. At admission, the severity of neurological deficit assessed using the Frankel scale was as follows: Grade A - 6 cases, Grade B - 7 cases, Grade C - 17 cases, Grade D - 5 cases, and Grade E - 2 cases (epidural abscess without neurological deficit). At discharge, the severity of neurological deficit was as follows: Grade A - 3 cases, Grade B - 2 cases, Grade C - 13 cases, Grade D - 11 cases, and Grade E - 8 cases. In group I, 35 out of 37 patients underwent surgery; of these, 21 patients had improvements. There were no statistically significant differences in neurological deficit changes between patients with and without epidural abscess. In 12 patients, the neurological status remained unchanged. Two patients died. We present an analysis of the severity of neurological symptoms, depending on the spinal lesion level, and the results of microbiological tests. Changes in neurological symptoms in lesions of various spinal parts are described. Cervical spine lesions and the process caused by S. aureus are shown to significantly increase the risk of neurological disorders. An active surgical approach for complicated forms of spinal osteomyelitis provided partial or complete regression of neurological disorders in 62.2% of cases.
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Affiliation(s)
- A Yu Bazarov
- Regional Clinical Hospital #2, Tyumen, Russia; Tyumen State Medical University, Tyumen, Russia
| | - K S Sergeev
- Regional Clinical Hospital #2, Tyumen, Russia
| | | | - I A Lebedev
- Tyumen State Medical University, Tyumen, Russia
| | - A L Barinov
- Regional Clinical Hospital #2, Tyumen, Russia
| | - A O Faryon
- Regional Clinical Hospital #2, Tyumen, Russia
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129
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Nagata K, Ando T, Nakamoto H, Kato S, Sasaki K, Oshima Y. Adaptation and limitation of anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine. J Orthop Sci 2019; 24:219-223. [PMID: 30318425 DOI: 10.1016/j.jos.2018.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/12/2018] [Accepted: 09/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Surgical strategy for pyogenic spondylitis is controversial when vertebral body erosion is severe. Radical debridement and anterior column reconstruction is indicated for the purpose of early ambulatory to prevent secondary complication for long bed rest. However, such aggressive debridement and risk of perioperative complications are trade-off. The purpose of this study was to evaluate the risk factor of poor prognosis after anterior column debridement and reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine. METHODS We performed a retrospective review of 40 patients diagnosed with pyogenic spondylitis in lower thoracic and lumbar spine who were introduced to our institution due to losing ambulatory ability and underwent anterior column debridement and reconstruction between January 2008 and May 2016. After the patient population was split into a regaining ambulatory group (Group A; n = 23) and a poor prognosis group (Group P; n = 17), we used Fisher exact tests and t-tests as appropriate for univariate analyses to compare patient characteristics and outcomes between the 2 groups. RESULTS Univariate analysis showed that the significant variables were massive bleeding (>2000 ml) (P < 0.01), Charlson Comorbidity Index ≥3 (P = 0.01), and two-stage surgery needed (P = 0.04). Logistic regression analysis showed that the factors associated with poor prognosis were massive bleeding (Odds Ratio 11.9; 95% confidence interval 1.8 to 119.7; P = 0.04). CONCLUSIONS Massive bleeding was associated with poor prognosis after debridement followed by anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine.
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Affiliation(s)
- Kosei Nagata
- The University of Tokyo Hospital, Japan; Hitachi General Hospital, Japan.
| | | | | | - So Kato
- The University of Tokyo Hospital, Japan
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130
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van Duijvenbode DC, Kuiper JWP, Holewijn RM, Stadhouder A. Parvimonas micra Spondylodiscitis: A Case Report and Systematic Review of the Literature. J Orthop Case Rep 2019; 8:67-71. [PMID: 30740380 PMCID: PMC6367290 DOI: 10.13107/jocr.2250-0685.1216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Treatment and risk factors for Parvimonas micra spinal infections are scarcely researched. This study reports a case and presents a systematic review of the literature to provide evidence-based ground for diagnosis and treatment of P. micra spinal infections. Case Report This is a case of a 78-year-old male with severe back and leg pain. Advanced imaging demonstrated the destruction of L2-L3 with an extensive fluid collection in the remaining intervertebral space, paravertebral myositis, and multiple abscesses. A decompression of L2 and L3 and a posterior spondylodesis from T12 to L5 was performed. Intraoperative cultures showed P. micra. The postoperative treatment consisted of intravenous penicillin for 2 weeks and subsequent oral clindamycin for 4 weeks. At 1-year follow-up, the patient was in good health and reported only occasional back pain. Conclusions A total of 15 additional cases of P. micraspinal infections were identified. The antibiotic treatment showed a great variety in the treated patients. Nevertheless, the outcome of these patients was good concerning relapse of the infection and pain. Spinal infections caused by P. micra are rare, but can be successfully treated according to the guidelines for spinal infection.
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Affiliation(s)
- D C van Duijvenbode
- Department of Orthopaedic Surgery, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - J W P Kuiper
- Department of Orthopaedic Surgery, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - R M Holewijn
- Department of Orthopaedic Surgery, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - A Stadhouder
- Department of Orthopaedic Surgery, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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131
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Zoller SD, Park HY, Olafsen T, Zamilpa C, Burke ZD, Blumstein G, Sheppard WL, Hamad CD, Hori KR, Tseng JC, Czupryna J, McMannus C, Lee JT, Bispo M, Romero Pastrana F, Raineri EJ, Miller JF, Miller LS, van Dijl JM, Francis KP, Bernthal NM. Multimodal imaging guides surgical management in a preclinical spinal implant infection model. JCI Insight 2019; 4:124813. [PMID: 30728332 DOI: 10.1172/jci.insight.124813] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/09/2019] [Indexed: 01/16/2023] Open
Abstract
Spine implant infections portend disastrous outcomes, as diagnosis is challenging and surgical eradication is at odds with mechanical spinal stability. Current imaging modalities can detect anatomical alterations and anomalies but cannot differentiate between infection and aseptic loosening, diagnose specific pathogens, or delineate the extent of an infection. Herein, a fully human monoclonal antibody 1D9, recognizing the immunodominant staphylococcal antigen A on the surface of Staphylococcus aureus, was assessed as a nuclear and fluorescent imaging probe in a preclinical model of S. aureus spinal implant infection, utilizing bioluminescently labeled bacteria to confirm the specificity and sensitivity of this targeting. Postoperative mice were administered 1D9 probe dual labeled with 89-zirconium (89Zr) and a bars represent SEM dye (NIR680) (89Zr-NIR680-1D9), and PET-CT and in vivo fluorescence and bioluminescence imaging were performed. The 89Zr-NIR680-1D9 probe accurately diagnosed both acute and subacute implant infection and permitted fluorescent image-guided surgery for selective debridement of infected tissue. Therefore, a single probe could noninvasively diagnose an infection and facilitate image-guided surgery to improve the clinical management of implant infections.
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Affiliation(s)
- Stephen D Zoller
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Howard Y Park
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Tove Olafsen
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, California, USA
| | - Charles Zamilpa
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, California, USA
| | - Zachary Dc Burke
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Gideon Blumstein
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - William L Sheppard
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | | | - Kellyn R Hori
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | | | | | - Jason T Lee
- Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, California, USA
| | - Mafalda Bispo
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Francisco Romero Pastrana
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elisa Jm Raineri
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Jeffery F Miller
- California NanoSystems Institute, UCLA, Los Angeles, California, USA.,Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Lloyd S Miller
- Department of Orthopaedic Surgery.,Department of Dermatology, and.,Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kevin P Francis
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA.,PerkinElmer, Hopkinton, Massachusetts, USA
| | - Nicholas M Bernthal
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
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132
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Sertic M, Parkes L, Mattiassi S, Pritzker K, Gardam M, Murphy K. The Efficacy of Computed Tomography-Guided Percutaneous Spine Biopsies in Determining a Causative Organism in Cases of Suspected Infection: A Systematic Review. Can Assoc Radiol J 2019; 70:96-103. [DOI: 10.1016/j.carj.2018.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 12/20/2022] Open
Abstract
Purpose In suspected spondylodiscitis and vertebral osteomyelitis, computed tomography (CT)-guided biopsies are often performed to determine a causative organism and guide antimicrobial therapy. The aim of this study is to determine the diagnostic culture yield of CT-guided biopsies performed in cases of suspected spinal infections. Methods A literature search of PubMed and MEDLINE up to April 2017 was performed for keywords “CT guided vertebral biopsy infection,” “CT-guided spine biopsy infection,” “CT guided spine biopsy yield,” and “CT guided vertebral biopsy yield.” Inclusion criteria primarily consisted of studies exclusively using CT-guided biopsies in cases of suspected infectious lesions only. After study selection, published articles were analysed to determine diagnostic culture yield. Descriptive statistics were applied. Results 220 search results were screened; 11 met our inclusion criteria and were reviewed. In total, 647 biopsies of suspected infectious spinal lesions were performed. Positive cultures were obtained in 241 cases. Upon excluding one paper's skewed results, the net pooled results culture yield was 33%. Several cultures grew multiple organisms, leading to a total of 244 species identified. Most common isolated organisms include S taphylococcus aureus (n = 83), coagulase-negative S taphylococcus (n = 45), and Mycobacteria (n = 38). Conclusions The diagnostic culture yield of CT-guided biopsies in cases of suspected spinal infection is 33%. In the majority of cases, a causative organism is not identified. This suggests that improvements can be made in biopsy technique and specimen transfer to optimize culture yield and increase the clinical value of the procedure.
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Affiliation(s)
- Madeleine Sertic
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Leighanne Parkes
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sabrina Mattiassi
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth Pritzker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Gardam
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kieran Murphy
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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133
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Gregori F, Grasso G, Iaiani G, Marotta N, Torregrossa F, Landi A. Treatment algorithm for spontaneous spinal infections: A review of the literature. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 10:3-9. [PMID: 31000972 PMCID: PMC6469318 DOI: 10.4103/jcvjs.jcvjs_115_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment. Conclusion: A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.
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Affiliation(s)
- Fabrizio Gregori
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Giovanni Grasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Giancarlo Iaiani
- Department of Tropical and Infectious Diseases, Aou Policlinico Umberto I, Rome, Italy
| | - Nicola Marotta
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Fabio Torregrossa
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Alessandro Landi
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
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134
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Bryant AP, Noujaim DL, Moritani T. Discitis-Osteomyelitis. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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135
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Waheed G, Soliman MAR, Ali AM, Aly MH. Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients. Neurosurg Focus 2019; 46:E10. [PMID: 30611166 DOI: 10.3171/2018.10.focus18463] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/29/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVESpontaneous spondylodiscitis remains uncommon but is a serious complication of the vertebral column. Risk factors include diabetes, hemodialysis, intravenous drug abuse, and chronic steroid use, and pain is the most common presenting symptom. This study aims to review the literature and report on the incidence, management, and clinical outcome of spontaneous spondylodiscitis in 44 patients.METHODSThis is a prospective study including 44 patients with spontaneous spondylodiscitis managed in the neurosurgery department of Cairo University Hospitals during the period between January 2012 and October 2017. All patients had a full clinical assessment, laboratory tests, radiological studies in the form of MRI with and without contrast, and a postoperative follow-up of up to 12 months.RESULTSTwelve cases underwent conservative treatment in the form of complete bed rest, intravenous antibiotics, and a spinal brace. Ten cases underwent surgical intervention in the form of laminectomy, debridement, and open biopsy. Twenty-two cases underwent laminectomy and surgical stabilization with fusion. There were 15 cases of tuberculous spondylodiscitis, 6 cases of brucellosis, 6 cases of pyogenic infection, and 17 cases in which no organism could be detected.CONCLUSIONSOnce the primary diagnosis is confirmed, early and adequately prolonged antibiotic therapy is recommended for spontaneous spondylodiscitis. Some cases can be successfully treated with conservative treatment alone, whereas surgery may be needed in other cases such as severe destruction of endplates, spinal abscess formation, mechanical instability, neurological deficits, and severe pain that have failed to respond to conservative treatment.
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Affiliation(s)
- Ghada Waheed
- 1Shark Al Madina Hospital, Ministry of Health, Alexandria; and
| | | | - Ahmed M Ali
- 2Neurosurgery Department, Cairo University, Cairo, Egypt
| | - Mohamed H Aly
- 2Neurosurgery Department, Cairo University, Cairo, Egypt
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136
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Boody BS, Tarazona DA, Vaccaro AR. Evaluation and Management of Pyogenic and Tubercular Spine Infections. Curr Rev Musculoskelet Med 2018; 11:643-652. [PMID: 30280287 PMCID: PMC6220010 DOI: 10.1007/s12178-018-9523-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To review the most current diagnostic tools and treatment options for pyogenic and tubercular spine infection. RECENT FINDINGS Recent studies have focused on risk factors for failed nonoperative management in order to improve patient selection. Also, spine instrumentation and different grafting options have been safely utilized in the setting of an active infection without increasing the incidence of reoccurrence. However, the optimal surgical technique has yet to be established and instead should be patient specific. Spine infections include a broad spectrum of disorders including discitis, vertebral osteomyelitis, and spinal epidural abscess. It is paramount to recognized spine infections early due to the potential catastrophic consequences of paralysis and sepsis. The management of spine infections continues to evolve as newer diagnostic tools and surgical techniques become available. Magnetic resonance imaging with contrast is the imaging study of choice and computed tomography-guided biopsies are crucial for guiding antibiotic selection. Antibiotics are the mainstay of treatment and surgery is indicated in patients with neurological deficits, sepsis, spinal instability, and those who have failed nonoperative treatment.
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Affiliation(s)
- Barrett S Boody
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Daniel A Tarazona
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
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137
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de Leeuw CN, Fann PR, Tanenbaum JE, Buchholz AL, Freedman BA, Steinmetz MP, Mroz TE. Lumbar Epidural Abscesses: A Systematic Review. Global Spine J 2018; 8:85S-95S. [PMID: 30574443 PMCID: PMC6295821 DOI: 10.1177/2192568218763323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Spinal epidural abscesses (SEAs) are rare, but when missed or when diagnosis is delayed, SEA can lead to permanent neurological impairment or death. Limited information exists on the optimal treatment modalities for SEA, especially in the lumbar spine. We synthesize the current literature to identify the clinical features, diagnosis, management, and outcomes of lumbar SEA. METHODS Queries in 4 databases-EMBASE, MEDLINE, Scopus, and Web of Science-were performed using comprehensive search terms to locate published literature on lumbar SEA. RESULTS Ten articles reporting results for 600 cases of lumbar SEA were included, published between 2000 and 2017. Negative prognostic factors included diabetes, older age, methicillin-resistant Staphylococcus aureus, immune compromise, and more severe disease at presentation. Early first-line surgically treated patients responded better, specifically in terms of motor recovery, than those undergoing medical management or failing medical treatment, despite generally worse initial presentation. Elevated C-reactive protein, leukocytosis, and positive blood cultures predicted medical management failure. CONCLUSIONS This systematic review provides guidance to neurological and orthopedic spine surgeons seeking the best treatment for lumbar-localized SEA. This study is limited by a dearth of high-quality publications to support evidenced-based management recommendations. Surgical treatment appears to provide better outcomes than medical treatment alone, especially in those who present with a motor deficit. Further investigation is needed to confirm this finding. What is clear is that early recognition and treatment remains crucial to minimizing morbidity and mortality of SEA.
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Affiliation(s)
- Charles N. de Leeuw
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA,Charles N. de Leeuw, Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA.
| | - Patrick R. Fann
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA
| | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA
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138
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Morales H. Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings. Semin Ultrasound CT MR 2018; 39:587-604. [PMID: 30527523 DOI: 10.1053/j.sult.2018.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infectious processes of the spine are on the rise; in this scenario recognition of entities imitating infection is very important. The discovertebral unit is regarded as one of the most important and active sites in the spine. Importantly, the vertebral bony rim and the anterior corners of the vertebral bodies have significant vascularization, they are the last regions to ossify in the developmental process and suffer mechanical forces. Early septic or aseptic discitis-osteomyelitis, properly called spondylitis, involves these anterior regions. Early degeneration is characterized by disc desiccation; however, there is preferential involvement for the corners of the vertebral bodies as well. Many entities to include degenerative changes, inflammatory spondyloarthropathies, neuropathic spine, or pseudo arthrosis, among others, affect the discovertebral unit and can imitate infection. With some exceptions, important imaging findings for the identification of an infectious mimic include the absence of soft tissue enhancement or fluid collections in the paraspinal or epidural regions, and the involvement of multiple levels or the posterior elements. We review developmental, anatomical, and pathologic concepts correlating with imaging clues. Overall, our goal is to increase awareness and to improve recognition of mimicking entities.
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Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, University of Cincinnati Medical Center, Cincinnati, OH.
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139
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Guo S, Lu D. Clinical presentation, diagnosis, treatment and outcome of spinal epidural empyema in four cats (2010 to 2016). J Small Anim Pract 2018; 61:381-388. [PMID: 30387154 PMCID: PMC7228219 DOI: 10.1111/jsap.12943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 01/02/2018] [Accepted: 06/29/2018] [Indexed: 11/27/2022]
Abstract
This case series reviews previous publications and reports four feline spinal epidural empyema cases that presented with non-ambulatory thoracolumbar myelopathy. Two cats underwent myelography and two MRI. Bacteria were obtained in three cases, in two from epidural abscesses and from a tail base wound in one; histopathological examination of epidural tissue showed pyogranulomatous changes in the remaining cat. Three cats were treated by surgical decompression plus antimicrobial therapy and one cat was treated medically. All cats showed satisfactory improvement following treatment over a follow-up period of 3 months. Spinal epidural empyema is a rare condition but all cats in this series had favourable outcomes.
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Affiliation(s)
- S Guo
- CityU Peace Avenue Veterinary Clinic, Hong Kong, China
| | - D Lu
- CityU Peace Avenue Veterinary Clinic, Hong Kong, China
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140
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Predicting the need for surgical intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:751-761. [DOI: 10.1007/s00586-018-5775-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/03/2018] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
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141
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Mutch CA, Ordonez AA, Qin H, Parker M, Bambarger LE, Villanueva-Meyer JE, Blecha J, Carroll V, Taglang C, Flavell R, Sriram R, VanBrocklin H, Rosenberg O, Ohliger MA, Jain SK, Neumann KD, Wilson DM. [ 11C]Para-Aminobenzoic Acid: A Positron Emission Tomography Tracer Targeting Bacteria-Specific Metabolism. ACS Infect Dis 2018; 4:1067-1072. [PMID: 29712422 PMCID: PMC6045447 DOI: 10.1021/acsinfecdis.8b00061] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Imaging studies are frequently used to support the clinical diagnosis of infection. These techniques include computed tomography (CT) and magnetic resonance imaging (MRI) for structural information and single photon emission computed tomography (SPECT) or positron emission tomography (PET) for metabolic data. However, frequently, there is significant overlap in the imaging appearance of infectious and noninfectious entities using these tools. To address this concern, recent approaches have targeted bacteria-specific metabolic pathways. For example, radiolabeled sugars derived from sorbitol and maltose have been investigated as PET radiotracers, since these are efficiently incorporated into bacteria but are poor substrates for mammalian cells. We have previously shown that para-aminobenzoic acid (PABA) is an excellent candidate for development as a bacteria-specific imaging tracer as it is rapidly accumulated by a wide range of pathogenic bacteria, including metabolically quiescent bacteria and clinical strains, but not by mammalian cells. Therefore, in this study, we developed an efficient radiosynthesis for [11C]PABA, investigated its accumulation into Escherichia coli and Staphylococcus aureus laboratory strains in vitro, and showed that it can distinguish between infection and sterile inflammation in a murine model of acute bacterial infection.
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Affiliation(s)
- Christopher A. Mutch
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Alvaro A. Ordonez
- Center for Infection and Inflammation Imaging Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Hecong Qin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Matthew Parker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Lauren E. Bambarger
- Center for Infection and Inflammation Imaging Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Javier E. Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Joseph Blecha
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Valerie Carroll
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Celine Taglang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Robert Flavell
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Renuka Sriram
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Henry VanBrocklin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Oren Rosenberg
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Michael A. Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco CA 94110, USA
| | - Sanjay K. Jain
- Center for Infection and Inflammation Imaging Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kiel D. Neumann
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA 22903, USA
| | - David M. Wilson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94158, USA
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142
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Shah AA, Ogink PT, Harris MB, Schwab JH. Development of Predictive Algorithms for Pre-Treatment Motor Deficit and 90-Day Mortality in Spinal Epidural Abscess. J Bone Joint Surg Am 2018; 100:1030-1038. [PMID: 29916930 DOI: 10.2106/jbjs.17.00630] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spinal epidural abscess is a high-risk condition that can lead to paralysis or death. It would be of clinical and prognostic utility to identify which subset of patients with spinal epidural abscess is likely to develop a motor deficit or die within 90 days of discharge. METHODS We identified all patients ≥18 years of age who were admitted to our hospital system with a diagnosis of spinal epidural abscess during the period of 1993 to 2016. Explanatory variables were collected retrospectively. Bivariate and multivariable logistic regression was performed using these variables to identify independent predictors of motor deficit and 90-day mortality. Nomograms were then constructed to quantify the risk of these outcomes. RESULTS Of the 1,053 patients we identified with spinal epidural abscess, 362 presented with motor weakness. One hundred and thirty-four patients died within 90 days of discharge, inclusive of those who died during hospitalization. Multivariable logistic regression yielded 8 independent predictors of pre-treatment motor deficit and 8 independent predictors of 90-day mortality. We constructed nomograms that generated a probability of pre-treatment motor deficit or 90-day mortality on the basis of the presence of these factors. CONCLUSIONS By quantifying the risk of pre-treatment motor deficit and 90-day mortality, our nomograms may provide useful prognostic information for the treatment team. Timely treatment of neurologically intact patients with a high risk of developing a motor deficit is necessary to avoid residual motor weakness and improve survival. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul T Ogink
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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143
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Simultaneous occurrence of spinal epidural abscess and disk herniation causing irreversible neurologic deficits: A case report and review of the literature. Radiol Case Rep 2018; 13:719-723. [PMID: 29721126 PMCID: PMC5930181 DOI: 10.1016/j.radcr.2018.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/24/2018] [Indexed: 11/21/2022] Open
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144
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Lestin-Bernstein F, Tietke M, Briedigkeit L, Heese O. Diagnostics and antibiotic therapy for spondylodiscitis. J Med Microbiol 2018; 67:757-768. [PMID: 29687768 DOI: 10.1099/jmm.0.000703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose. Spondylodiscitis as a rare disease has increased in recent years; there are only a few recommendations regarding the diagnostics and treatment. The objective of this retrospective study was to characterise these patients and identify factors for a favourable healing process - with an emphasis on antibiotic therapy.Methodology. Findings/treatment regimens for all patients with spondylodiscitis treated at a tertiary care hospital in 2012/2013 were recorded. The patients were classified into two groups, depending on the healing process.Results. Fifty-seven patients met the clinical/radiological criteria for spondylodiscitis. The main symptom was massive back pain, combined with a moderate CRP elevation (median 96 mg l-1), and occasionally fever (39 %). CT-guided aspiration - in addition to blood cultures - improved the detection rate for the causative pathogen from 49 to 82 %. Thirty patients had a favourable clinical course; 25 had an unfavourable clinical course (prolonged clinical course, recurrence, death). Pathogen-specific antibiotic therapy had a decisive effect on the clinical course: initial high-dose intravenous therapy for at least 14 days was associated significantly more often with a favourable clinical course (90 vs 30 % after 24 months, P<0.001). Fourteen days after the start of treatment, marked pain reduction and a CRP reduction of at least 50 % were good prognostic parameters and markers of effective antibiotic therapy.Conclusion. Pathogen detection and establishment of an optimal antibiotic regimen are cornerstones of successful conservative therapy for spondylodiscitis. Targeted initial intravenous therapy for at least 14 days with a bactericidal antibiotic leads to a better clinical course.
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Affiliation(s)
- Franka Lestin-Bernstein
- Department for Clinical Hygiene and Infectiology, HELIOS Clinics of Schwerin, Wismarsche Str. 393-397 19049, Schwerin, Germany
| | - Marc Tietke
- Institute for Radiology and Neuroradiology, HELIOS Clinics of Schwerin, Schwerin, Germany
| | - Lutz Briedigkeit
- Institute for Laboratory and Transfusion Medicine, HELIOS Clinics of Schwerin, Schwerin, Germany
| | - Oliver Heese
- Neurosurgery and Spinal Surgery, HELIOS Clinics of Schwerin, Schwerin, Germany
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145
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Multidisciplinary management of pyogenic spondylodiscitis: epidemiological and clinical features, prognostic factors and long-term outcomes in 207 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:229-236. [PMID: 29667140 DOI: 10.1007/s00586-018-5598-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/09/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE Pyogenic spondylodiscitis (PS) is a potentially life-threatening infection burdened by high morbidity rates. Despite the rising incidence, the proper management of PS is still controversial. Aim of this study was to describe the clinical features of PS and to evaluate the prognostic factors and the long-term outcomes of a large population of patients. METHODS 207 cases of PS treated from 2008 to 2016 with a 2-year follow-up were enrolled. Clinical data from each patient were recorded. The primary outcome was the rate of healing without residual disability. Secondary outcomes included length of stay, healing from infection, death, relapse, and residual disability. Binomial logistic regression and multivariate analysis were used to evaluate prognostic factors. RESULTS Median diagnostic delay was 30 days and the rate of onset neurological impairment was 23.6%. Microbiological diagnosis was established in 155 patients (74.3%) and the median duration of total antibiotic therapy was 148 days. Orthopedic treatment was conservative for 124 patients and surgical in 47 cases. Complete healing without disability was achieved in 142 patients (77.6%). Statistically confirmed negative prognostic factors were: negative microbiological culture, neurologic impairment at diagnosis and underlying endocarditis (p ≤ 0.05). Healing from infection rate was 90.9%, while residual disabilities occurred in 23.5%. Observed mortality rate was 7.8%. CONCLUSION The microbiological diagnosis is the main predictive factor for successful treatment. Early diagnosis and multidisciplinary management are also needed to identify underlying aggressive conditions and to avoid neurological complications associated with poorer long-term outcomes. Despite high healing rates, PS may lead to major disabilities still representing a difficult challenge. These slides can be retrieved under Electronic Supplementary material.
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146
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Shweikeh F, Zyck S, Sweiss F, Sangtani A, Shweikeh M, Issa H, Steinmetz MP, Markarian GZ. Aspergillus spinal epidural abscess: case presentation and review of the literature. Spinal Cord Ser Cases 2018. [PMID: 29531797 DOI: 10.1038/s41394-018-0046-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Study design In this review, we present a case of Aspergillus spinal epidural abscess (ASEA) and review the literature. Objectives To provide further insight on a rare condition. Setting A description of a patient with ASEA in a 58-year-old woman that was successfully treated with conservative management is presented. Methods Following case presentation, a literature search (MedLine and PubMed) and assessment of epidemiology, presentation, diagnosis, treatments, and outcomes is performed. Results Review of the literature finds 26 reported cases. The infection occurs in males with a higher frequency (66.7%). The thoracic and lumbar regions are more likely afflicted (96.1%). Common symptoms are backache, neurological deficits, and fever. Most frequent comorbidities were malignancy, diabetes mellitus, and immunodeficiency. Complications were numerous and often catastrophic. Treatment entailed a combination of antibiotics and surgery. Overall, ASEA patients did poorly: death in majority (52%), minimal recovery in 22%, and others did attain full recovery (26%). Conclusions Generally, this infection has high morbidity and mortality. Early identification is important to a successful outcome. Appropriate management with antifungals is central and proves to be effective as seen in the reported case though surgical intervention is usually a necessity as the literature suggests. From an epidemiological and public health perspective, particularly with recent outbreaks, understanding the treatment of this rare CNS infection becomes even more imperative.
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Affiliation(s)
- Faris Shweikeh
- 1Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA USA.,2Summa Health System, College of Medicine, Northeast Ohio Medical University, Rootstown, OH USA
| | - Stephanie Zyck
- 3Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY USA
| | - Fadi Sweiss
- 4Department of Neurological Surgery, George Washington University, Washington, DC USA
| | - Ajleeta Sangtani
- 1Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Mohammed Shweikeh
- 5Family Medicine Center, St. Joseph's Hospital and Medical Center, Phoenix, AZ USA
| | - Husam Issa
- 6Memorial Hermann Hospital, University of Texas Health Science Center, Houston, TX USA
| | - Michael P Steinmetz
- 7Center for Spine Health, Department of Neurosurgery, Cleveland Clinic, Cleveland, OH USA
| | - Georges Z Markarian
- 1Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA USA
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Characteristics and surgical outcomes of tuberculous meningitis and of tuberculous spondylitis in pediatric patients at Dr. Hasan Sadikin Hospital, Bandung: A single center experience. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2017.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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148
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Management of spinal infection: a review of the literature. Acta Neurochir (Wien) 2018; 160:487-496. [PMID: 29356895 PMCID: PMC5807463 DOI: 10.1007/s00701-018-3467-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/08/2018] [Indexed: 12/17/2022]
Abstract
Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.
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149
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Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos. Neurocirugia (Astur) 2018; 29:64-78. [DOI: 10.1016/j.neucir.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/18/2017] [Accepted: 09/03/2017] [Indexed: 12/17/2022]
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150
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Dragsted C, Aagaard T, Ohrt-Nissen S, Gehrchen M, Dahl B. Mortality and health-related quality of life in patients surgically treated for spondylodiscitis. J Orthop Surg (Hong Kong) 2018. [PMID: 28639530 DOI: 10.1177/2309499017716068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess mortality, disability, and health-related quality of life (HRQL) in patients surgically treated for spondylodiscitis. METHODS A retrospective longitudinal study was conducted on all patients surgically treated for spondylodiscitis over a 6-year period at a single tertiary spine center. Indications for surgery, pre- and postoperative neurological impairment, comorbidities, and mortality were recorded. A survey was conducted on all eligible patients with the EuroQol 5-dimension (EQ-5D) questionnaire and Oswestry Disability Index (ODI). RESULTS Sixty-five patients were diagnosed with spondylodiscitis not related to recent spine surgery. One-year mortality rate was 6%. In all, 36% and 27% had pre- and postoperative neurological impairment, respectively, with only one patient experiencing deterioration postoperatively. At final follow-up (median 2 years), mean ODI was 31% (SD = 22) and mean EQ-5D time trade-off score was 0.639 (SD = 0.262); this was significantly lower than that in the normal population ( p < 0.001). Patients with neurological impairment prior to index surgery had lower EQ-5D scores ( p = 0.005) and higher ODI ( p = 0.02) at final follow-up compared with patients without neurological impairment. CONCLUSIONS Several years after surgery, patients surgically treated for spondylodiscitis have significantly lower HRQL and more disability than the background population. Neurological impairment prior to index surgery predicts adverse outcome in terms of disability and lower HRQL.
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Affiliation(s)
- Casper Dragsted
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Theis Aagaard
- 2 Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Ohrt-Nissen
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- 1 Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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