Pitfalls of computed tomography in diagnosis of discitis

Postoperative Lumbar Pyogenic Spondylodiscitis: An Institutional Review

Background   Postoperative discitis (POD) remains a dreaded complication in the present era of asepsis. The treatment has been traditionally conservative, but the safety of spinal implants in infective settings has prompted the surgeons to provide rigid immobilization for promoting healing. A major concern in a country like ours is huge patient inflow and long waiting list added to the woe of patient's refusal for a second operative intervention after a first undesirable outcome. Objectives  The aim of the study was to evaluate the functional and radiological outcome of conservative management of POD and determine the methods of prevention. Settings and Design   A retrospective case study series in a tertiary-level hospital. Materials and Methods   Between January 2015 and 2017, 12 cases of POD (10 own and 2 referred) were managed and followed up clinically, radiologically, and with laboratory investigation. Two cases were managed surgically-one with kyphotic deformity and the other with discharging pus. Rest were managed conservatively with analgesics and intravenously followed by oral antibiotics. At 1-year follow-up, patient satisfaction was evaluated using the MacNab outcome assessment. Statistical Analysis   The descriptive data were analyzed mainly by descriptive statistics using mean, median, standard deviation, and interquartile range. Results   Mean follow-up in our series was 15.2 months. Except for two operated cases, we did not go for the invasive procedure for isolation of organism in any of our cases. The total duration of antibiotic in our series was for the mean of 7.3 weeks. Visual analog scale score returned from8 initially to baseline and at final follow-up-4 excellent, 6 good, and 2 had fair outcome. There was no adverse outcome. Conclusions   The majority of POD can be managed conservatively. Surgery is reserved only for special cases. Magnetic resonance imaging is the investigation of choice for diagnosing discitis. Intraoperative use of gentamicin-mixed normal saline wash reduces the incidence of discitis.

Spondylodiscitis: standards of current treatment

BACKGROUND

Spinal infections are an important clinical problem that often require aggressive medical therapy, and sometimes even surgery. Known risk factors are advanced age, diabetes mellitus, rheumatoid arthritis, immunosuppression, alcoholism, long-term steroid use, concomitant infections, poly-trauma, malignant tumor, and previous surgery or invasive procedures (discography, chemonucleolysis, and surgical procedures involving or adjacent to the intervertebral disc space). The most common level of involvement is at the lumbar spine, followed by the thoracic, cervical and sacral levels: lesions at the thoracic spine tend to lead more frequently to neurological symptoms.

OBJECTIVE

The aim of the current paper is to describe current evidence-based standards of therapy in the management of SD by emphasizing pharmacological therapy and principles and indications for bracing and surgery.

METHODS

A PubMed and Google Scholar search using various forms and combinations of the key words: spondylodiscitis, spine, infection, therapy, surgery, radiology, treatment. Reference citations from publications identified in the literature search were reviewed. Publications highlighted in this article were extracted based on relevancy to established, putative, and emerging diagnostic and therapeutic standards, either conservative (antibiotic therapy and bracing) or surgical.

FINDINGS

To date, conservative therapy, based on targeted antibiotic therapy plus bracing, represents the mainstay in the management of SD. Proper diagnosis and tailored therapy can improve clinical results and decrease the chance of failure. Surgery should be an option only for patients with complications of this disease, namely deformity, neural compression and neurological compromise. Current standards in the setting of SD are continuously evolving, as can be seen in the recent advances in the field of radiological diagnostics, and the use of growth factors and cell-therapy strategies to promote infection eradication and bone healing after surgery.

Postoperative lumbar discitis

We analysed 13 cases of lumbar disc infection following surgical discectomy. Two groups of patients were identified. The six patients in group A reported that the initial symptoms of discitis had appeared a mean of 15 days after surgery; on average, antibiotic treatment was started 31 days following operation and continued for 62 days, and symptoms regressed after 3.9 months. Four patients showed moderate changes, while two had extensive osteolytic lesions of one or both vertebral bodies adjacent to the involved disc. In the 7 cases in group B, discitis was suspected a mean of 5 days and antibiotics were initiated a mean of 8 days following surgery; on average, symptoms regressed 1.8 months after operation. Only four patients showed vertebral radiographic changes and none had marked destructive lesions. In both groups erythrocyte sedimentation rate exceeded 70 mm/h in cases in which discitis was suspected. Tomograms and magnetic resonance studies were the most diagnostic imaging studies in the initial stages of the disease. All patients obtained satisfactory clinical results at the last follow-up. Careful observation of the early postoperative clinical course usually allows detection of disc space infection. Early and adequately prolonged antibiotic treatment may shorten the course of the disease and avoid extensive osteolytic vertebral lesions.

[Multistep surgery for spondylosyndesis. Treatment concept of destructive spondylodiscitis in patients with reduced general condition]

OBJECTIVE

Retrospective assessment of multistage surgery in the treatment of progressive spondylodiscitis in patients with critical physical status.

PATIENTS

A total of 34 patients (mean age 58.6 years) with 37 progressive spondylodiscitis foci and destruction of one to three vertebral segments (1.9 mean) were recorded within an 8-year period. Time between first complaints and operative treatment was 3 months (mean). Preoperative health status was critically reduced in 11 patients (ASA IV) and poor general condition (ASA III) was seen in 23 patients when vital indication was seen preoperatively. Considerable systemic disease (n=31), further infection focus (n=18), and nosocomial trauma (n=5) were causally related. Spondylodiscitis was seen more frequently in the lumbar (n=20) and thoracolumbar than in the thoracic (n=10) and cervical spine (n=1). Staphylococcus aureus was detectable from operative specimens and hemoculture in 15 cases, MRSA in 6 of these.

METHODS

In cases of monosegmentary involvement (n=7) ventral debridement, biopsy, and application of antibiotic chains were followed by autologous interbody bone grafting in a second stage operation. In 29 cases with destruction of two (n=27) and three (n=3) segments, posterior instrumentation including laminectomy in 4 patients was completed by anterior debridement and application of antibiotic chains during a first surgical intervention. After stabilization of physical condition and having reached a macroscopically indisputable implant bed, the ventral fusion with autologous interbody bone grafting or cage in combination with a plate or internal fixation system was performed as the last of several surgical steps.

RESULTS

No case of perioperative mortality was observed. Intensive care continued 9.1 days and hospitalization 49.5 days (mean). During a 37.6-month follow-up two late recurrences were observed.

CONCLUSION

A multistep surgical procedure under protection of dorsal instrumentation can limit perioperative mortality in patients in critical general condition by avoiding an extended one stage dorsoventral spondylodesis. After eradication of further infection foci and stabilization of physical condition, ventral instrumentation is completed under elective conditions.

Imaging of the postoperative spine

With the widespread prevalence of back pain, and approximately 200,000 lumbar spine operations annually in the United States, imaging of the postoperative lumbar spine has become a major diagnostic issue. The many causes of the failed back surgery syndrome make the diagnosis of the etiology of the patient's symptom complex very important to the treating physician. With the varied types of surgery, the increasing use of fusion hardware, and the myriad of complicating factors, the imaging strategy must be flexible enough to be comprehensive in the evaluation of these difficult patients. This article will address the normal and abnormal findings after lumbar spine surgery.

Espondilodiscites sépticas: diagnóstico e tratamento

Estudamos retrospectivamente 24 pacientes com espondilodiscite séptica de diferentes etiologias (hematogênica, primária e infantil) e os diferentes aspectos envolvidos em seu diagnóstico e tratamento. Constatamos que a velocidade de hemossedimentação é um bom parâmetro laboratorial para acompanhar a evolução da doença, mas deve ser sempre interpretada conjuntamente com o quadro clínico e os achados de neuroimagem. Biópsias devem ser reservadas para os casos de diagnóstico duvidoso e o tratamento clínico realizado sempre que afastadas as seguintes condições: sepse, déficit neurológico, deformidade severa, abscesso epidural e corpo estranho (discite primária). A abordagem cirúrgica deve ser planejada levando em conta o estágio da doença, sendo preferencialmente por via posterior nas fases supurativas e anterior nas demais. Baseados em nossa experiência e em revisão da literatura, propomos um algoritmo para orientar o diagnóstico e o tratamento das espondilodiscites sépticas.

Imaging of pyogenic infectious spondylodiskitis

The presence of infectious spondylodiskitis and its complications may present protean clinical and imaging findings. The frequent use of multi-imaging modalities has led to a greater sensitivity and specificity in the diagnosis of this ubiquitous disease.

Extradural causes of myelopathy

Myelopathy, the rapid or insidious onset of motor and sensory abnormalities referable to the spinal cord, occurs as a result of a variety of causes that may be classified on the basis of their location of origin (intramedullary, intradural-extramedullary, and extradural). The first goal of imaging is to appropriately assign the observed abnormality to its location of origin and, therefore, into the correct diagnostic list. This article focuses on the plain film, computed tomography, and magnetic resonance demonstration of extradural causes of myelopathy.

Spondylodiscitis after lumbar disk surgery

The value of perioperative prophylactic use of antibiotics in lumbar disc surgery is investigated, based on a retrospective study of the operative results of 5041 patients. The rate of occurrence of postoperative spondylodiscitis was significantly higher during the period in which no perioperative prophylaxis was carried out, than it was during the period, in which perioperative prophylaxis was routine. Thus the perioperative prophylactic use of antibiotics seems highly recommendable.

The role of early postoperative CT scan following surgery for herniated lumbar disc

40 patients underwent lumbosacral microdiscectomy in a 12 months period covering the years 1988-1989 in our center. For the purpose of the present study, we considered the 30 cases who underwent CT control of the operated interspaces and of the adjacent vertebral endplates. This was routinely carried out on the 3rd post-operative day. The present study failed to show correlations between early post-operative CT data and subsequent clinical results in this unselected series of patients. In fact an image suggesting persistent disc herniation was as a rule observed in spite of satisfactory clinical results, and other CT findings that have been considered of clinical significance, such as intraspinal air and low attenuation of disc space, were commonly observed in patients with an uncomplicated post-operative course. The present study suggests that early post-operative CT appears to be of no value in the management of potential early complications of low-back surgery. The introduction of MRI appears to offer other possibilities in the evaluation and management of failed back surgery syndrome (FBSS).