Systematic review of the incidence of discitis after cervical discography

Analysis of the efficacy of retrodiscal approach percutaneous epidural adhesiolysis with WHIP catheter® in patients with lumbar radiculopathy: A retrospective study

Percutaneous epidural adhesiolysis (PEA) is an effective treatment for patients with lumbar radiculopathy unresponsive to single steroid injections. Various approaches and instruments have been developed to access these lesions. This study aimed to evaluate the utility of a retrodiscal approach for epidural adhesiolysis using a WHIP catheter®. This retrospective study was conducted at Bundang Seoul National University Hospital, reviewing cases from January to December 2022. Forty-seven patients diagnosed with lumbar radiculopathy, aged 20 to 80 years, who underwent PEA with the WHIP catheter® were included. Outcomes assessed Numeric Rating Scale (NRS) for pain, Patients' Global Impression of Change (PGIC) scores, and the incidence of procedure-related complications. Follow-up evaluations occurred at 1, 3, and 6 months post-procedure. Among 47 patients, 41 completed the study, showing significant pain reduction at all follow-up points: 1 month (N = 41, 1.32 ± 1.68, P < .001), 3 months (N = 31, 1.90 ± 2.14, P < .001), and 6 months (N = 30, 2.50 ± 2.30, P < .001). PGIC scores indicated that 40% of the patients reported substantial improvement at one-month post-procedure. The complications were minimal, with only one case of intradiscal injection and 2 cases of vascular uptake. The retrodiscal approach PEA using the WHIP catheter® demonstrated significant efficacy in pain reduction with minimal safety concerns for patients with lumbar radiculopathy. These findings suggest that this procedure is a viable option for patients who are unresponsive to conservative treatment. However, the retrospective nature of this study and its small sample size necessitate further prospective controlled studies to confirm our results and establish long-term outcomes.

The association between low virulence organisms in different locations and intervertebral disc structural failure: A meta-analysis and systematic review

Many factors may trigger intervertebral disc (IVD) structural failure (intervertebral disc degeneration (IDD) and endplate changes), including inflammation, infection, dysbiosis, and the downstream effects of chemical factors. Of these, microbial diversity in the IVD and elsewhere in the body has been considered as one of the potential reasons for disc structural failure. The exact relationships between microbial colonization and IVD structural failure are not well understood. This meta-analysis aimed to investigate the impact of microbial colonization and its location (such as skin, IVD, muscle, soft tissues, and blood) on IVD structural failure and corresponding low back pain (LBP) if any. We searched four online databases for potential studies. The potential relationships between microbial colonization in different sample sources (such as skin, IVD, muscle, soft tissues, and blood) and IDD and endplate change were considered as primary outcomes. Odds ratio (OR) and 95% confidence intervals (CI) for direct comparisons were reported. Grading of Recommendations Assessment, Development and Evaluation (GRADE) scale was used to assess the quality of evidence. Twenty-five cohort studies met the selection criteria. Overall pooled prevalence of microbial colonization in 2419 patients with LBP was 33.2% (23.6%-43.6%). The pooled prevalence of microbial colonization in 2901 samples was 29.6% (21.0%-38.9%). Compared with the patients without endplate change, the patients with endplate changes had higher rates of microbial colonization of disc (OR = 2.83; 95% CI = 1.93-4.14; I ² = 37.6%; p = 0.108). The primary pathogen was Cutibacterium acnes which was present in 22.2% of cases (95% CI = 13.3%-32.5%; I ² = 96.6%; p = 0.000). This meta-analysis and systematic review found low-quality grade evidence for an association between microbial colonization of disc with endplate changes. The primary pathogen was C. acnes. Due to lack of enough high-quality studies and methodological limitations of this review, further studies are required to improve our understanding of the potential relationships and mechanisms of microbiota, dysbiosis, IVD colonization and IVD structural failure.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Discitis Following Radiofrequency Nucleoplasty: A Case Report

Introduction

Radiofrequency nucleoplasty is a minimally invasive procedure to treat chronic low back pain, especially mild degenerative disc diseases. Discitis after radiofrequency nucleoplasty is a rare case.

Case Presentation

A 62-year-old male patient with a chief complaint of 10 years low back pain, gradually worsening for the last two years, a history of hypertension, chronic kidney disease, and routine dialysis twice a week, referred to the center. He underwent a lumbar medial branch block using radiofrequency and radiofrequency nucleoplasty procedure of lumbar 4-5 (L4-L5). Three weeks after the intervention, he could not move his legs, associated with urinary and fecal incontinence. MRI (magnetic resonance imaging) of the lumbar spine was performed, and the results indicated hyperintensity in L4-L5, suspicious of discitis. Laminectomy at L4 and L5 was performed. Eight months after surgery, the patient could feel and lift legs, and urinary and fecal incontinence was also controlled.

Conclusions

Early diagnosis of discitis is critical and challenging. Delay in diagnosis may lead to treatment delay and the development of neurological deficits. Comprehensive treatment with bed rest, antimicrobial therapy, and sensible application of timely surgery are essentials to an optimal outcome.

Pyogenic discitis with an epidural abscess after cervical analgesic discography: A case report

BACKGROUND

Chronic neck pain is a common clinical problem. It has long been considered that degenerative cervical disc is an important source of chronic neck pain. In the clinic, cervical discography is thought to be a useful and safe method to distinguish aging discs from pathological discs, and the probability of complications caused by it is really rare. However, once complication occurs, it is likely to cause fatal consequences to patients. Therefore, accurate judgment and effective treatment are crucial.

CASE SUMMARY

A 45-year-old female was admitted to the department with a 5-year history of severe neck pain, dizziness, and tinnitus. In order to find the diseased disc, analgesic discography was performed on C4/5 and 6/7 discs successively. Unfortunately, Discitis with an epidural abscess was caused during the procedures. With the help of magnetic resonance imaging, an accurate diagnosis was made and an urgent anterior cervical operation was given subsequently. The patient ultimately recovered well.

CONCLUSION

Discitis with epidural abscess is a rare complication after cervical discography, which needs accurate diagnosis and effective antibiotic treatment.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Anterior or posterior approach of full-endoscopic cervical discectomy for cervical intervertebral disc herniation? A comparative cohort study

STUDY DESIGN

This is a retrospective comparative cohort study.

OBJECTIVE

To compare the outcomes of patients with symptomatic cervical intervertebral disc herniation (CIVDH) treated with full-endoscopic cervical discectomy (FECD) using the anterior approach with those treated with the posterior approach.

SUMMARY OF BACKGROUND DATA

The optimal FECD surgical approach for CIVDH remains controversial.

METHODS

From March 2010 to July 2012, a total of 84 consecutive patients with symptomatic single-level CIVDH who underwent FECD using the anterior approach (42 patients) or the posterior approach (42 patients) were enrolled. Patients were assessed neurologically before surgery and followed up at regular outpatient visits. The clinical outcomes were evaluated using the visual analogue scale and the modified MacNab criteria. Radiographical follow-up included the static and dynamic cervical plain radiographs, computed tomographic scans, and magnetic resonance images.

RESULTS

In both groups, shorter mean operative time (63.5 min vs. 78.5 min), increased mean volume of disc removal (0.6 g vs. 0.3 g), larger mean decrease in the final postoperative mean intervertebral vertical height (1.0 mm vs. 0.5 mm), and longer mean hospital stay (4.9 d vs. 4.5 d) were observed in the anterior full-endoscopic cervical discectomy group. Postoperatively, the clinical outcomes of the 2 approaches were significantly improved, but the differences between the 2 approaches were not significant (P = 0.211 and P = 0.257, respectively). Four surgery-related complications were observed among all enrolled patients (complications in each group were 2; overall 4 of 84, 4.8%).

CONCLUSION

In our study, the clinical outcomes between the 2 approaches did not differ significantly. Nevertheless, posterior full-endoscopic cervical discectomy may be preferable when considering the volume of disc removal, length of hospital stay, and the postoperative radiographical changes. As an efficacious supplement to traditional open surgery, FECD is a reliable alternative treatment of CIVDH and its optimal approach remains open to discussion.

LEVEL OF EVIDENCE

3.

Antibiotic penetration into rabbit nucleus pulposus with discitis

OBJECTIVE

To assess the penetration into nucleus pulposus (NP) of cephazolin and clindamycin in a discitis model.

MATERIALS AND METHODS

Twenty New Zealand white rabbits were inoculated with 103 Staphylococcus aureus at lumbar disc space. The rabbits with discitis confirmed by MRI 10 days after inoculation were divided into two groups. One was given cephazolin by intravenous (IV) at 80 mg/kg/day at 1.5 h interval for 5 half-lives; the other was given clindamycin by IV at 30 mg/kg/day at 2.5-h interval for 5 half-lives. Thirty minutes after completion of the last dose, NP and serum were sent to measure antibiotic concentration.

RESULTS

Two rabbits died during inoculation. After 10 days, 18 rabbits were confirmed discitis in the inoculated levels. The cephazolin and clindamycin can diffuse throughout the infected, sham-infected and normal NP. The serum concentration of cephazolin and clindamycin was 251.3 ± 40.5 and 21.6 ± 4.71 mg/l, respectively. The cephazolin concentration in infected NP (1.93 ± 0.84 mg/l) was higher than that in sham-infected (1.73 ± 0.61 mg/l) and normal NP (1.68 ± 0.65 mg/l), but the difference showed no statistically significant (P > 0.05). The cephazolin penetration into NP averaged 0.68-0.77 % of serum level. The clindamycin concentration in infected NP (4.32 ± 1.54 mg/l) was higher than that in sham-infected NP (2.63 ± 1.26 mg/l) and normal NP (2.59 ± 1.01 mg/l) (P < 0.05). The penetration into NP averaged 11.9-20 % of serum level. There was no significance difference between sham-infected and normal NP in clindamycin and cephazolin concentration (P > 0.05).

CONCLUSIONS

This study demonstrates cephazolin and clindamycin can penetrate the infected and normal NP. The antibiotics charge influences the delivery. Furthermore, infection condition selectively promotes antibiotic distribution within NP.

Epidural abscess and cauda equina syndrome after percutaneous intradiscal therapy in degenerative lumbar disc disease

BACKGROUND CONTEXT

Percutaneous intradiscal therapies are gaining popularity as a regenerative treatment option for spinal disc degeneration. The risks, benefits, and possible complications associated with such procedures have been poorly defined. As these procedures are performed with increasing frequency, the likelihood that clinicians will be faced with significant complications also increases.

PURPOSE

The purpose of this study is to describe a significant complication of a percutaneous intradiscal bone marrow and adipose tissue transplantation for symptomatic lumbar disc degeneration.

STUDY DESIGN

The study design is a case report.

METHODS

Two weeks after an injection of adipose cells, bone marrow aspirate and plasma into his L3-L4 and L5-S1 lumbar discs, a 64-year-old patient presented to the emergency room with cauda equina syndrome, fever, and back pain. Magnetic resonance imaging diagnosed L3-L4 disc extrusion, discitis with osteomyelitis, and epidural abscess, resulting in emergency decompressive surgery. An epidural abscess was drained, extruded disc material was removed, and cultures obtained. Five days later, once afebrile on antibiotics, he underwent a definitive interbody arthrodesis and stabilization.

RESULTS

Cauda equina syndrome resolved, osteomyelitis (methicillin-resistant Staphylococcus epidermidis) was treated, and instrumented arthrodesis stabilized the involved segment.

CONCLUSIONS

Complications associated with the intradiscal injection of agents, such as stem cells, fibrin glue, adipose tissue, or bone marrow, have been poorly defined. Given the nature of the degenerating disc, serious adverse events, including discitis, osteomyelitis, and extrusion of disc contents, may occur.

Progress in diagnosis and treatment of cervical postoperative infection

Postoperative infection is the commonest complication that causes failure of spinal surgery. Although the rate of infection after cervical surgery is lower than that after lumbar surgery, the absolute number of cases is increasing. In recent years, new techniques, such as serum amyloid A and fludeoxyglucose ((18) F) positron emission tomography (18F-FDG PET), have emerged and gradually been employed in the diagnosis of postoperative infection, updating the ability to identify the presence of infection. Most patients with cervical postoperative infection require re-operation. There are three principles for such surgery: thorough debridement, adequate drainage and ensuring stability of the spine. Some severe cases even need emergency surgery. This article aims to discuss the controversial issues in diagnosis and treatment of cervical postoperative infection, as well as progress in related studies.

Candida lusitaniae discitis after discogram in an immunocompetent patient

BACKGROUND CONTEXT

Discitis or epidural abscess after discogram is a rare but known complication. It is more commonly bacterial; however, fungal discitis has been previously reported in immunocompromised patients. The management of fungal discitis in immunocompetent patients is rarely presented or addressed in the literature.

PURPOSE

To present a rare atypical fungal discitis after routine discogram with a typical presentation in an immunocompetent host, review diagnostic and management guidelines for discitis, and provide recommendations for management of atypical discitis in immunocompetent patients.

STUDY DESIGN

Case report and review of the literature.

METHODS

A 40-year-old woman presented with a 3-week history of progressively worsening low back pain after a lumbar discogram. Magnetic resonance imaging revealed L3-L4 discitis without an epidural abscess. Left L3 and L4 hemilaminectomies with L3-L4 discectomy were performed. An inflammatory mass was seen in the L3-L4 disc space region extending to the left L3 foramen.

RESULTS

Culture specimens obtained during surgery from both the disc and epidural space speciated to Candida lusitaniae. The patient completed a 6-month course of fluconazole therapy. At 2-year follow-up, she continued to be asymptomatic, without any recurrence of infection or neurologic sequelae.

CONCLUSIONS

We report a case of C. lusitaniae spondylodiscitis after discography in an immunocompetent patient with long-term follow-up. Clinicians must maintain a high index of suspicion for discitis in patients who undergo this procedure. If discitis is suspected, culture specimens must be evaluated for fungal and mycobacterial organisms, even in the immunocompetent host. With proper surveillance, surgical intervention, and appropriate postoperative follow-up, this complication can be effectively managed with excellent long-term outcome.