Spinal brucellosis in South of Tunisia: review of 32 cases

Cervical Brucella Spondylitis: A Case Report on Diagnosis and Surgical Management

Background

Brucellosis is a zoonotic disease that can affect various organs, including the spine. Cervical spondylitis caused by Brucella is rare but can lead to significant morbidity if not diagnosed and treated promptly.

Case Presentation

We report a case of a 46-year-old female who presented with intermittent high fever and intractable neck, shoulder, and back pain for two months. She was diagnosed with Brucella cervical spondylitis based on clinical manifestations, Rose-Bengal Plate Agglutination Test (RBPT, positive), and cervical MRI findings. She was treated with a combination of antibiotics for at least two weeks, followed by surgical intervention including abscess clearance, partial vertebral resection, and titanium mesh bone fusion. Real-time Polymerase Chain Reaction (RT-PCR) confirmed the presence of sheep Brucella DNA. The patient recovered well postoperatively with significant pain reduction and restoration of full mobility in the right upper limb.

Conclusion

This case highlights the diagnostic value of RT-PCR and tissue biopsy in cervical brucellosis spondylitis. Our study found that anterior cervical subtotal corpectomy can restore cervical stability, clear abscess, and relieve spinal cord compression on the basis of drug treatment, with good clinical results.

Association Between Diagnostic Delays and Spinal Involvement in Human Brucellosis: A Retrospective Case-Control Study

Background

Spinal involvement is a common but serious complication of human brucellosis. However, information on the risk factors associated with spinal involvement in individuals with brucellosis is limited.

Methods

This retrospective case-control study aimed to determine the potential risk factors associated with spinal complications in inpatients with brucellosis.

Results

During the study period, brucellosis was diagnosed in 377 patients, of whom 108 (28.64%) showed spinal involvement. Those with spinal involvement were significantly older than patients in the control group (mean age [standard deviation], 53.25 [10.48] vs 43.12 [13.84] years, respectively; P < .001). The diagnostic delays were significantly longer in patients with spinal involvement than in the control group (mean delay [standard deviation], 11.17 [13.55] vs 6.03 [8.02] weeks; P = .001). Age >40 years (odds ratio, 5.42 [95% confidence interval, 2.65-11.05]; P < .001) and diagnostic delay >4 weeks (2.94 [1.62-5.35]; P < .001) were independently associated with spinal involvement in brucellosis. The lumbar spine at the L3-5 level was the most affected (152 of 249 [61.04%]). Back pain (92 of 108 in case patients vs 21 of 108 in controls; P < .001) and splenomegaly (23 vs 42 of 108, respectively; P = .005) differed significantly between the 2 groups.

Conclusions

Age >40 years and diagnostic delay >4 weeks increased the risk of spinal involvement in brucellosis. Therefore, the time from symptom onset to diagnosis should be shortened, using effective measures to reduce spinal involvement risk.

Clinical characteristic, management, and outcomes of cervical spinal brucellosis: a retrospective cohort study over 1-year postoperative follow-up

BACKGROUND

The incidence of cervical spinal brucellosis is low, only a few case reports have been published, and case series are not widely reported in the medical literature. Therefore, clinical features, management, and outcomes of cervical spinal brucellosis are relatively unknown. In this series, the authors report 15 cases of patients with cervical spinal brucellosis, including clinical characteristic, imaging findings, management plans, the institution's experience, and outcomes at 1 year postoperatively.

METHODS

The study reviewed the clinical and radiographic records of 15 patients who received antimicrobial pharmacotherapy, and anterior cervical debridement and fusion for cervical spinal brucellosis. The data collected included patient demographic characteristics, spinal level affected, abscess, neurology, pathological reports, duration and type of antimicrobial regimens, details of orthopedic management, and complications incurred during the procedure.

RESULTS

Neck pain (100%) and limb paralysis (86.7%) were the most common clinical presentations, and the disease had a rapid progression. The C6-7 segment was the most commonly affected segment, followed by C4-5 and C5-6. Imaging commonly revealed epidural or paravertebral abscesses (80%). There was a significant improvement in the VAS, JOA, and NDI scores three months after surgery, and the scores continued to improve until the final follow-up. There was a statistically significant difference between the pre- and postoperative scores (P < 0.05). The ESR and CRP levels returned to normal within three months postoperatively, being 7.7 ± 4.5 mm/h and 7.55 ± 3.48 mg/L, respectively. There were statistically significant differences between the pre- and postoperative levels (P < 0.05). The positive rate of bacterial culture testing of pus or lesion tissues was only 40%, but blood cultures revealed an even lower positivity rate (33.3%). The average antimicrobial pharmacotherapy regimen duration was 6.1 ± 1.9 months. All patients achieved intervertebral bone fusion within 8 months (4.8 ± 1.4 months) after surgery and were cured with non-recurrence.

CONCLUSIONS

Spinal brucellosis rarely affects the cervical region, but its impact is more dangerous due to potential complications such as paraplegia or tetraplegia arising from epidural abscesses that compress the spinal cord. Surgical debridement, along with essential antimicrobial therapy, is an effective strategy and can lead to satisfactory prognosis in managing cervical spinal brucellosis.

Magnetic resonance imaging features for differentiating tuberculous from pyogenic spondylitis: a meta-analysis

OBJECTIVE

To perform a meta-analysis comparing the MRI features of tuberculous and pyogenic spondylitis, using histopathological results and/or blood culture as the standard reference.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for English-language studies on the MRI features of tuberculous and pyogenic spondylitis published between January 2010 and February 2023. Risk for bias and concerns regarding applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled MRI features' proportions were calculated using a bivariate random-effects model.

RESULTS

Thirty-two studies met the inclusion criteria: 21 for tuberculous spondylitis, three for pyogenic spondylitis, and eight for both. Of the nine informative MRI features comparing tuberculous spondylitis to pyogenic spondylitis, involvement of ≥ 2 vertebral bodies (92% vs. 88%, P = .004), epidural extension (77% vs. 25%, P < .001), paravertebral collection (91% vs. 84%, P < .001), subligamentous spread (93% vs. 24%, P < .001), thin and regular abscess wall (94% vs. 18%, P < .001), vertebral collapse (68% vs. 24%, P < .001), and kyphosis (39% vs. 3%, P < .01) were more suggestive of tuberculous spondylitis, while disc signal change (82% vs. 95%, P < .001) and disc height loss (22% vs. 59%, P < .001) were more suggestive of pyogenic spondylitis.

CONCLUSION

Involvement of ≥ 2 vertebral vertebral bodies, soft tissue attribution, thin and regular abscess wall, vertebral collapse, and kyphosis were MRI features more common in tuberculous spondylitis, while disc signal change and height loss were more common in pyogenic spondylitis.

Brucella Spondylitis: Current Knowledge and Recent Advances

The most prevalent zoonotic disease is brucellosis, which poses a significant threat for worldwide public health. Particularly in endemic areas, spinal involvement is a major source of morbidity and mortality and can complicate the course of the disease. The diagnosis of Brucella spondylitis is challenging and should be suspected in the appropriate epidemiological and clinical context, in correlation with microbiological and radiological findings. Treatment depends largely on the affected parts of the body. Available treatment options include antibiotic administration for an adequate period of time and, when appropriate, surgical intervention. In this article, we examined the most recent data on the pathophysiology, clinical manifestation, diagnosis, and management of spinal brucellosis in adults.

MRI-based interpretable radiomics nomogram for discrimination between Brucella spondylitis and Pyogenic spondylitis

Background

Pyogenic spondylitis (PS) and Brucella spondylitis (BS) are commonly seen spinal infectious diseases. Both types can lead to vertebral destruction, kyphosis, and long-term neurological deficits if not promptly diagnosed and treated. Therefore, accurately diagnosis is crucial for personalized therapy. Distinguishing between PS and BS in everyday clinical settings is challenging due to the similarity of their clinical symptoms and imaging features. Hence, this study aims to evaluate the effectiveness of a radiomics nomogram using magnetic resonance imaging (MRI) to accurately differentiate between the two types of spondylitis.

Methods

Clinical and MRI data from 133 patients (2017-2022) with pathologically confirmed PS and BS (68 and 65 patients, respectively) were collected. We have divided patients into training and testing cohorts. In order to develop a clinical diagnostic model, logistic regression was utilized to fit a conventional clinical model (M1). Radiomics features were extracted from sagittal fat-suppressed T2-weighted imaging (FS-T2WI) sequence. The radiomics features were preprocessed, including scaling using Z-score and undergoing univariate analysis to eliminate redundant features. Furthermore, the Least Absolute Shrinkage and Selection Operator (LASSO) was employed to develop a radiomics score (M2). A composite model (M3) was created by combining M1 and M2. Subsequently, calibration and decision curves were generated to evaluate the nomogram's performance in both training and testing groups. The diagnostic performance of each model and the indication was assessed using the receiver operating curve (ROC) with its area under the curve (AUC). Finally, we used the SHapley Additive exPlanations (SHAP) model explanations technique to interpret the model result.

Results

We have finally selected 9 significant features from sagittal FS-T2WI sequences. In the differential diagnosis of PS and BS, the AUC values of M1, M2, and M3 in the testing set were 0.795, 0.859, and 0.868. The composite model exhibited a high degree of concurrence with the ideal outcomes, as evidenced by the calibration curves. The nomogram's possible clinical application values were indicated by the decision curve analysis. By using SHAP values to represent prediction outcomes, our model's prediction results are more understandable.

Conclusions

The implementation of a nomogram that integrates MRI and clinical data has the potential to significantly enhance the accuracy of discriminating between PS and BS within clinical settings.

Vertebral osteomyelitis caused by Campylobacter jejuni in an immunocompetent patient

BACKGROUND

Campylobacter jejuni is the leading cause of human bacterial gastroenteritis worldwide. However, systemic infection with C. jejuni is uncommon, and osteomyelitis caused by C. jejuni is extremely rare. Cultivation from spinal bone biopsies has not previously been reported in the literature.

CASE PRESENTATION

A 79-year-old immunocompetent male was admitted to the emergency department at Aalborg University Hospital in Denmark with lower back pain, fever and diarrhoea. A FecalSwab obtained upon admission was PCR-positive for Campylobacter spp, while an aerobic blood culture bottle was positive for C. jejuni (Time to detection: 70.4 h). A MRI of columna totalis showed osteomyelitis at L1/L2 with an epidural abscess from L1 to L2 with compression of the dura sack. The patient underwent spinal surgery with spondylodesis and decompression of L1/L2. The surgery was uncomplicated and the discus material was also culture positive for C. jejuni. The patient was treated with meropenem for a total duration of four weeks, followed by four weeks of oral treatment with clindamycin in tapered dosage. The patient recovered quickly following surgery and targeted antibiotic treatment with decreasing lumbar pain and biochemical response and was fully recovered at follow-up three months after end of treatment.

CONCLUSIONS

While C. jejuni osteomyelitis is rare, it should still be suspected as a possible causative bacterial aetiology in patients with vertebral osteomyelitis, in particular when symptoms of diarrhoea is involved in the clinical presentation. Susceptibility testing is crucial due to emerging resistance, and targeted treatment strategies should rely upon such tests.

A proposed management classification for spinal brucellosis from India

INTRODUCTION

The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopaedic and rheumatology specialists. Moreover, the lack of disease-specific symptomatology is the leading cause of the delay in diagnosing osteoarticular brucellosis. Given the increasing number of spinal brucellosis cases across the country, no literature is presented on the systematic management of spinal brucellosis. However, with our experience, we formulated a classification for managing spinal brucellosis.

METHODS

A single-centred prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analysed and graded clinically, serologically, and radiologically and were managed with antibiotics for 10-12 weeks, and if necessary, stabilisation and fusion were done based on the treatment classification devised. All patients were followed up to ensure disease clearance at serial follow-up with relevant investigations.

RESULTS

The mean age of the study participants was 52.16 ± 12.53 years. According to spondylodiscitis severity code (SSC) grading, four patients belong to grades 1, 12 to grade 2 and 9 to grade 3 at presentation. Erythrocyte sedimentation rate (p = 0.02), c-reactive protein (p < 0.001), Brucella agglutination titers (p < 0.001), and radiological outcomes improved statistically by six months. The treatment duration was individualised according to the patient's response to the treatment, with a mean time of 11.42 ± 2.66 weeks. The mean follow-up period was 14.42 ± 8 months.

CONCLUSION

High index of suspicion of patients from endemic regions, proper clinical assessment, serological evaluation, radiological assessment, appropriate decision-making (medical/surgical) in treatment, and regular follow-up were the key to successful comprehensive management of spinal brucellosis.

The Incidence, Changes and Treatments of Cervical Deformity After Infection and Inflammation

A healthy cervical spine with normal movement is the basis of many daily activities and is essential for maintaining a good quality of life. However, the alignment, fusion, and structure of the cervical spine can change for various reasons, leading to cervical deformity, mainly kyphosis. Approximately 5%‒20% of spinal infections in the cervical spine cause cervical deformity. The deformity can recover early; however, the disease's long-term existence or the continuous action of abnormal stress may lead to intervertebral fusion and abnormal osteophytes. Many gaps and controversies exist regarding infectious cervical deformities, including a lack of clear definitions and an acceptable classification system thereby requiring further research. Moreover, there is no consensus on the indications for postinfectious cervical deformity associated with <i>Mycobacterium tuberculosis</i>, <i>Staphylococcus aureus</i>, and Brucellosis. Therefore, we reviewed and discussed the incidence, clinical manifestations, changes, and treatment of infectious and inflammatory secondary cervical deformities from common to rare to provide a theoretical basis for clinical decision-making.

Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis

Objective

This study aims to investigate the effectiveness and feasibility of biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis (LBS).

Methods

The data of 13 patients with LBS were retrospectively analyzed, who underwent biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation from May 2020 to June 2022. The patients' clinical data, the duration of operation, the estimated blood loss (including postoperative drainage), and complications were recorded. Clinical outcomes include serum agglutination test (SAT) measures Brucella antibody titer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the visual analog scale (VAS) scores of low back and leg, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), American Spinal Injury Association neurological classification, and lordotic angle were analyzed. All patients were assessed using the modified Macnab criteria at the final follow-up. The intervertebral bone graft fusion was assessed using the Bridwell grading criteria.

Results

The mean operation duration was 177.31 ± 19.54 min, and the estimated blood loss was 176.15 ± 43.79 ml (including postoperative drainage was 41.15 ± 10.44 ml). The mean follow-up period was 13.92 ± 1.5 months. SAT showed that the antibody titers of 13 patients were normal 3 months after the operation and at the final follow-up. ESR and CRP levels returned to normal by the end of the 3-month follow-up. VAS scores of low back and leg, JOA score, and ODI significantly improved after the operation throughout the follow-up period (P < 0.05). Based on the modified Macnab criteria, 92.3% showed excellent to good outcomes. One patient had only a percutaneous screw internal fixation on the decompression side due to severe osteoporosis. One case suffered a superficial incision infection postoperatively that healed with dressing change and effective antibiotic treatment. Bony fusion was obtained in all patients at the last follow-up, including 12 cases with grade I and 1 case with grade II, with a fusion rate of 92.31%.

Conclusion

Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation is an effective, safe, and viable surgical procedure for the treatment of LBS.

Role of Surgery in Brucella Spondylodiscitis: An Evaluation of 28 Patients

Background A limited number of studies are available in the literature on the surgical treatment of brucellosis-related spondylodiscitis. This study aimed to define and discuss the role of surgery in brucellosis-related spondylodiscitis. Methodology A total of 28 patients who underwent surgical treatment due to brucellosis-related spondylodiscitis between February 2021 and August 2022 were included in this study. Medical records, radiological images, and laboratory data were collected. Surgical results were evaluated according to the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels, clinical findings, postoperative radiological imaging findings, and complications were evaluated. Results In total, 16 of the patients included in the study were male and 12 were female, with a mean age of 56.4 ± 7.2 years. The mean follow-up duration was 11.8 ± 5.4 months. Brucellosis involvement was in the lumbosacral region in all patients. Overall, 21 patients had a neurological deficit in the preoperative period. Posterior stabilization and fusion were done in 20 (71.4%) patients, while simple laminectomy (decompression) and debridement were done in eight (28.6%) patients. There was a decrease in the pain in the lower back and leg in all patients in the postoperative period. Neurological recovery was achieved in 18 patients with a neurological deficit. Two patients underwent wound drainage in the postoperative period. The patient who had morbid obesity and comorbidities died in the postoperative period. ESR and CRP levels returned to normal at the end of the six-month follow-up. There was a significant recovery in VAS and ODI scores (p < 0.05). In total, 24 (85.4%) patients were considered fully recovered both radiologically and clinically at the end of the follow-up. Conclusions Although long-term and specific antibiotic treatment constitute the main treatment in brucellosis-related spondylodiscitis, debridement, decompression, and stabilization (when required) of infection with a focus on neurological deficits and instability formation and non-stop severe pain are effective and safe treatment options.

Brucella spp. Contamination in Artisanal Unpasteurized Dairy Products: An Emerging Foodborne Threat in Tunisia

Brucellosis is a worldwide zoonotic disease transmitted to humans, predominantly by the consumption of contaminated raw milk and dairy products. This study aimed to investigate the occurrence of Brucella spp. in 200 raw milk, ricotta, and artisan fresh cheese samples, collected from individual marketing points in four districts in Tunisia. Samples were analyzed for the presence of Brucella spp. by IS711-based real-time PCR assay. Positive samples were further analyzed by qPCR for B. melitensis and B. abortus species differentiation. The DNA of Brucella spp. was detected in 75% of the samples, B. abortus was detected in 31.3%, and B. melitensis was detected in 5.3% of positive samples. A percentage of 49.3% of samples co-harbored both species, while 14% of the Brucella spp. positive samples were not identified either as B. abortus or B. melitensis. High contamination rates were found in ricotta (86.2%), cheese (69.6%), and raw milk (72.5%) samples. The study is the first in Tunisia to assess the occurrence of Brucella spp. contamination in artisanal unpasteurized dairy products and showed high contamination rates. The detection of both B. abortus and B. melitensis highlights that zoonotic high-pathogen agent control remains a challenge for food safety and consumer health protection and could represent a serious emerging foodborne disease in Tunisia.

Complicated Brucellosis With Multisystem Involvement: Two Case Reports

Brucellosis is a zoonotic infection caused by facultative intracellular bacteria of the genus Brucella. The ability of the organism to invade both phagocytic and non-phagocytic cells and survive in the intracellular environment makes brucellosis a systemic infection that can affect various organs of the body. Complications of brucellosis occur when the infection involves one or more focal body sites. Early identification of complications of brucellosis and initiation of appropriate treatment is the key to a better outcome.

Here we present two cases of complicated brucellosis, both having multiple body site involvement.

Surgical management for lumbar brucella spondylitis: Posterior versus anterior approaches

There has been no ideal surgical approach for lumbar brucella spondylitis (LBS). This study aims to compare clinical efficacy and safety of posterior versus anterior approaches for the treatment of LBS.From April 2005 to January 2015, a total of 27 adult patients with lumbar brucella spondylitis were recruited in this study. The patients were divided into 2 groups according to surgical approaches. Thirteen cases in group A underwent 1-stage anterior debridement, fusion, and fixation, and 14 cases in group B underwent posterior debridement, bone graft, and fixation. The clinical and surgical outcomes were compared in terms of operative time, intraoperative blood loss, hospitalizations, bony fusion time, complications, visual analog scale score, recovery of neurological function, deformity correction.Lumbar brucella spondylitis was cured, and the grafted bones were fused within 11 months in all cases. It was obviously that the operative time and intraoperative blood loss of group A were more than those of group B (P = .045, P = .009, respectively). Kyphotic deformity was signifcantly corrected in both groups after surgery; however, the correction rate was higher in group B than in group A (P = .043). There were no significant differences between the two groups in hospitalizations, bony fusion time, and visual analog scale score in the last follow-up (P = .055, P = .364, P = .125, respectively).Our results suggested that both anterior and posterior approaches can effectively cure lumbar brucella spondylitis. Nevertheless, posterior approach gives better kyphotic deformity correction, less surgical invasiveness, and less complications.

Identification, geographic distribution and risk factors of Brucella abortus and Brucella melitensis infection in cattle in Algeria

Brucellosis is an infectious disease of several terrestrial and marine animals and humans caused by bacteria of the genus Brucella. This study aimed to identify Brucella species and biovars circulating in cattle and to analyze their geographic distribution across Algeria. Two hundred ninety eight milk and lymph node samples from 161 seropositive cattle of different local and foreign breeds were collected from 97 dairy farms in 56 towns of 13 wilayas (states/ provinces) of the central, eastern, western and southern regions. The samples were cultured on selective media and the obtained isolates were identified using bacteriological and molecular tests. Eighty-five Brucella isolates (72 B. abortus and 13 B. melitensis) were recovered from 63 animals in 37 dairy farms. In total, 71 (83.5 %) B. abortus bv 3, 11 (12.9 %) B. melitensis bv 2, 2 (2.4 %) B. melitensis bv 3 and 1 (1.2 %) unidentified B. abortus biovar were detected. The identification of B. abortus biovar 3 and B. melitensis biovar 2 is a new finding for Algeria and the Maghreb, respectively. B. abortus (84.7 %) was the main etiological agent of brucellosis. B. abortus showed a scattered distribution across Algeria. The fact that 60 % of the seropositive cattle showed no clinical signs, but 36 % were culture positive is an alarming observation. These data will rise awareness for the current epidemiological situation of bovine brucellosis in Algeria. To the best of our knowledge, this is the first representative countrywide bacteriological investigation of Brucella species and biovars in cattle across Algeria, which is a developing country where resources might be limited and the working conditions might not be very friendly.

Lumbosacral spondylodiscitis complicated by sepsis, osteomyelitis, epidural abscess formation and deep vein thrombosis

A 71-year-old man presented with a 3-month history of low back pain radiating to his right hip and thigh associated with lower limb weakness and constitutional symptoms. Imaging confirmed a lumbosacral spondylodiscitis at L2-3 and L5-S1 as well as a right-side psoas abscess which was treated with urgent CT-guided drainage and intravenous antibiotics. His admission was complicated by a number of issues, including the development of osteomyelitis with vertebral body destruction at multiple sites, epidural abscess formation and deep vein thrombosis. Additionally, the patient developed severe sepsis which necessitated admission to the intensive care unit. The patient's clinical condition improved gradually with intravenous antibiotics until he was well enough for transfer to a rehabilitation centre, where he underwent regular occupational and physical therapy. Repeat imaging showed overall resolution of the aforementioned pathologies and is currently being followed up by the spinal surgeons on an outpatient basis.

Tuberculous and Brucellar Spondylodiscitis: Comparative Analysis of Clinical, Laboratory, and Radiological Features

Study Design

This was a retrospective study.

Purpose

The aim was to compare the clinical, laboratory, radiological, and evolutionary features of tuberculous spondylodiscitis (TS) and brucellar spondylodiscitis (BS).

Overview of Literature

Clinical presentation of spondylodiscitis varies according to the underlying etiology, among which brucellosis and tuberculosis represent the primary cause, in endemic countries. Only a few studies have compared the characteristics between TS and BS.

Methods

A retrospective study was conducted using the data of all patients hospitalized for TS and BS in the infectious diseases department between 1991 and 2018.

Results

Among a total of 117 patients, 73 had TS (62.4%) and 44 had BS (37.6%). Females were significantly more affected with TS than males (56.2% vs. 22.7%, p<0.001). Fever (72.7% vs. 45.2%, p=0.004) and sweating (72.7% vs. 47.9%, p=0.009) were significantly more frequent among patients with BS. The median erythrocyte sedimentation rate was significantly higher in the TS group (median, 70 mm/hr; interquartile range [IQR], 45–103 mm/hr) than in the BS group (median, 50 mm/hr; IQR, 16–75 mm/hr) (p=0.003). Thoracic involvement was significantly more frequent in the TS group (53.4% vs. 34.1%, p=0.04), whereas lumbar involvement was significantly more frequent in the BS group (72.7% vs. 49.3%, p=0.01). Initial imaging findings revealed significantly higher frequencies of posterior vertebral arch involvement, vertebral compaction, and spinal cord compression in the TS group. Percutaneous abscess drainage (20.5% vs. 2.3%, p=0.005) and surgical treatment (17.8% vs. 2.3%, p=0.01) were more frequently indicated in the TS group, with a significant difference.

Conclusions

A combination of clinical, laboratory, and radiological features can be used to distinguish between TS and BS while these patients await diagnosis confirmation.

Safety and efficacy of polyetheretherketone (PEEK) cages in combination with one-stage posterior debridement and instrumentation in Lumbar Brucella Spondylitis

OBJECTIVE

The aim of this study was to explore the efficacy and safety of surgical treatment of lumbar brucella spondylitis with PEEK cages combined with one-stage posterior debridement and instrumentation.

METHODS

We performed a retrospective study for adult patients with lumbar brucella spondylitis. Medical records, imaging studies and laboratory data were collected, back pain was measured by employing the visual analog scale (VAS) and the neurological status was evaluated by using the American Spinal Injury Association (ASIA) scale.

RESULTS

A total of 61 consecutive patients (42 males and 19 females) were enrolled with the mean age at presentation of 56.33 ± 9.16 years old. L3-4 and L4-5 were the most infected levels with the ratios of 21.31 % and 19.67 % respectively. Moreover, 12 (19.67 %) patients suffered multiple-level infection and 5 (5/12, 41.67 %) of them had non-contiguous spondylitis. In addition, epidural masses were found in 26 (42.62 %) cases and psoas abscesses were found in 14 (22.95 %) cases. The number of operative segment depended on operation indications (failure of conservative measures, instability, kyphosis, intractable pain and/or neurological impairment). VAS scores were significantly improved at 6-weeks and the last follow-up. Among the 23 (37.70 %) patients with neurological deficits, 19 (19/23, 82.61 %) obtained a full recovery and 4 (4/23, 17.39 %) had been improved incompletely during the last follow-up. All patients exhibited satisfactory bone fusion during the last follow-up. Local infection of surgical site was identified in 6 (9.84 %) cases and no other surgery-related complications were found.

CONCLUSION

Use of PEEK cages for interbody fusion is feasible and safe in patients suffering from lumbar brucella spondylitis.

Cervical Epidural Abscess due to Brucella Treated with Decompression and Instrumentation: A Case Report and Review of Literature

Brucella is caused by a Gram-negative bacillus and is a common disease in endemic areas where people are in close contact with animals and dairy products, but brucellar cervical epidural abscess is rare. We describe a rare case of a C5–6 brucellar epidural abscess in a veterinary doctor who was treated with decompression and instrumentation. We also review the cases of cervical brucellar epidural abscess treated with instrumentation in the literature.

Computed tomography imaging characteristics help to differentiate pyogenic spondylitis from brucellar spondylitis

PURPOSE

Both pyogenic spondylitis (PS) and brucellar spondylitis (BS) can cause deformities and permanent neurologic deficits without prompt diagnosis and treatment. However, differential diagnosis is challenging. The aim of this study was to compare the computed tomography (CT) imaging features of PS with those of BS.

METHODS

Thirty-two patients with PS and 44 with BS were enrolled in the study. CT images were obtained in all cases. Data on bone destruction and formation, vertebral wall destruction, and osteosclerotic changes were collected and compared using the Chi-square test or t test. A P value < 0.01 was considered statistically significant. Positive predictive values (PPV) for detecting PS or BS were reported.

RESULTS

Involvement of the lumbar vertebrae and multiple spinal levels was more common in the BS group than in the PS group. Bone destruction was significantly greater in the PS group than in the BS group (30.8 vs 18.0%; t = 3.920, P = 0.000), with more extensive destruction of the vertebral body (35.8 vs 12.5%, χ² = 12.672, P = 0.002, PPV = 63.16%). In the BS group, there was more osteosclerosis around erosions (70.5 vs 43.3%, χ² = 11.59, P = 0.001, PPV = 67.74%) and fan-shaped osteosclerosis (27.3 vs 19.4%, χ² = 18.556, P = 0.006, PPV = 64.86%), more bone formation around the vertebra (77.2 vs 34.3%, χ² = 33.608, P = 0.000, PPV = 76.83%), more bone formation under the anterior longitudinal ligament (63.6 vs 19.4%, χ² = 30.133, P = 0.000, PPV = 76.09%), more longer anterior bone formation (3.55 vs 0.78 mm, t = 3.997, P = 0.000), and more anterior and closed-bone formation with local erosion (42.0 vs 9.0%, χ² = 74.243, P = 0.000, PPV = 74.36%).

CONCLUSIONS

CT images have unique advantages of revealing the morphology of erosions, osteosclerosis, and bone formation around the vertebra and help to differentiate PS from BS. These slides can be retrieved under Electronic Supplementary Material.

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults

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.

Osteoarticular manifestations of human brucellosis: A review

Brucellosis is a common global zoonotic disease, which is responsible for a range of clinical manifestations. Fever, sweating and musculoskeletal pains are observed in most patients. The most frequent complication of brucellosis is osteoarticular involvement, with 10% to 85% of patients affected. The sacroiliac (up to 80%) and spinal joints (up to 54%) are the most common affected sites. Spondylitis and spondylodiscitis are the most frequent complications of brucellar spinal involvement. Peripheral arthritis, osteomyelitis, discitis, bursitis and tenosynovitis are other osteoarticular manifestations, but with a lower prevalence. Spinal brucellosis has two forms: focal and diffuse. Epidural abscess is a rare complication of spinal brucellosis but can lead to permanent neurological deficits or even death if not treated promptly. Spondylodiscitis is the most severe form of osteoarticular involvement by brucellosis, and can have single- or multi-focal involvement. Early and appropriate diagnosis and treatment of the disease is important in order to have a successful management of the patients with osteoarticular brucellosis. Brucellosis should be considered as a differential diagnosis for sciatic and back pain, especially in endemic regions. Patients with septic arthritis living in endemic areas also need to be evaluated in terms of brucellosis. Physical examination, laboratory tests and imaging techniques are needed to diagnose the disease. Radiography, computed tomography, magnetic resonance imaging (MRI) and bone scintigraphy are imaging techniques for the diagnosis of osteoarticular brucellosis. MRI is helpful to differentiate between pyogenic spondylitis and brucellar spondylitis. Drug medications (antibiotics) and surgery are the only two options for the treatment and cure of osteoarticular brucellosis.

One-stage surgical management for lumber brucella spondylitis with anterior debridement, autogenous graft, and instrumentation

Literature reporting on lumber brucella spondylitis (LBS) is rare, therefore, the purpose of this study was to evaluate the outcomes of one-stage surgical management for lumber brucella spondylitis by anterior debridement, autogenous grafts, and instrumentation. This was a retrospective cohort study including 16 patients with lumber brucella spondylitis by treated from January 2009 to October 2011 in our department. All cases underwent one-stage anterior internal fixation, debridement, and bone fusion; clinical and radiographic results were analyzed and compared. All patients were followed up for an average of 35.3 ± 8.1 months (range, 24-48 months). Brucella spondylitis was completely cured in all patients with bone fusion achieved in 4.8 ± 1.3 months. Visual analog scale (VAS) scores were significantly improved between the preoperative and last follow-up visit and neurological function classification showed significant improvement after surgical intervention. Preoperatively, the Cobb angle was 20.7 ± 9.8°, and measured 8.1 ± 1.3° at the last follow-up visit. The outcomes of follow-up demonstrated that one-stage surgical treatment with anterior debridement, fusion, and instrumentation can be an effective and feasible treatment method for lumber brucella spondylitis.

Discrimination of pyogenic spondylitis from brucellar spondylitis on MRI

Retrospective Cross-Sectional Study.The purpose of this study was to investigate the accuracy of magnetic resonance imaging (MRI) for distinguishing between pyogenic spondylitis and brucellar spondylitis.Although pyogenic spondylodiscitis (PS) and brucellar spondylitis (BS) are common causes of spinal infections, the variety of their clinical manifestations complicates differential diagnosis. MRI may be helpful in differential diagnosis and treatment.MRI images of 64 patients who underwent MRI of the spine and with confirmed spondylitis were retrospectively reviewed. After referring to the related medical literature, we compared 32 patients with pyogenic spondylitis and 32 patients with brucellar spondylitis regarding MRI findings. Statistical analysis was performed with the chi-square test. Statistical significance was defined as P < .05.The significant differences between PS and BS on MRI findings are listed as follows (P < .05): diffuse, partial and fan-shaped hyperintense signals on middle sagittal fat-suppressed weighted images (PS: 51, 11, 3/65 vs BS:35, 18, 19/72); focal endplate destruction (PS: 9/43 vs BS:27/35); extensive end plate destruction (PS: 29/43 vs BS:8/35); ballooning change of the intravertebral space (PS: 7/32 vs BS:0/32); an inflammatory reaction line from the end plate (PS: 30/65 vs BS: 1/72); a disc invasion sign (PS: 1/28 vs BS:12/33); an inflammatory reaction line in the disc (PS: 5/28 vs BS:25/33); and 8) severe intravertebral space destruction (PS: 17/28 vs BS:12/33);MRI imaging provides useful information for the differentiation between pyogenic spondylitis and brucellar spondylitis.

Real-time PCR assays for diagnosing brucellar spondylitis using formalin-fixed paraffin-embedded tissues

It is difficult to diagnose brucellar spondylitis because of its nonspecific clinical, radiological, and histological characteristics. This study aimed to determine whether real-time polymerase chain reaction (PCR) using formalin-fixed paraffin-embedded (FFPE) tissues was superior to conventional serum-based methods for diagnosing brucellar spondylitis.This retrospective study included 31 patients with brucellosis and a control group of 20 people with no history of brucellosis or exposure to Brucella spp. Samples from all patients with brucellar spondylitis were evaluated using Giemsa staining, the standard tube agglutination (STA) test, blood culture, and real-time PCR.The brucellar spondylitis was acute in 7 patients (22.6%), subacute in 15 patients (48.4%), and chronic in 9 patients (29%). Serological assays provided positive results for 25 patients (80.1%), real-time PCR provided positive results for 29 patients (93.5%), and blood cultures provided positive results for 11 patients (35.5%). The real-time PCR provided sensitivity of 93.5%, specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 100%. The corresponding values for the STA test were 80.1%, 100%, 100%, and 76.9%, respectively. Real-time PCR provided better sensitivity than Giemsa staining, the STA test, and blood culture, although the difference between PCR and STA was not statistically significant (P = .22). B melitensis was the only pathogen that was detected in patient with brucellar spondylitis using real-time PCR.These results suggest that real-time PCR provides a high sensitivity for diagnosing brucellar spondylitis. Furthermore, the real-time PCR results indicate that B melitensis was the causative pathogen in these cases.

One-stage Surgical Management for Lumbar Brucella Spondylitis by Posterior Debridement, Autogenous Bone Graft and Instrumentation: A Case Series of 24 Patients

STUDY DESIGN

Clinical case series.

OBJECTIVE

The aim of this study was to explore the efficacy and safety of one-stage debridement, autogenous bone graft, and instrumentation for lumbar brucella spondylitis (LBS) via a posterior approach.

SUMMARY OF BACKGROUND DATA

Reports on LBS are sporadic, and the therapeutic effect and safety of surgical interventions have not been assessed in clinical studies.

METHODS

Between January 2012 and January 2014, 24 consecutive patients with symptomatic LBS who underwent a one-stage operation that combined debridement, autogenous bone graft, and instrumentation via a posterior approach were enrolled. Back pain was measured using the visual analog scale (VAS). The neurological status was evaluated with the American Spinal Injury Association (ASIA) scale. Bone healing was evaluated based on postoperative plain x-ray or computed tomography.

RESULTS

All cases were followed up for an average of 14.3 + 3.5 months. The VAS scores were significantly improved at every follow-up interval. An improvement of at least one grade level was observed in the ASIA score of each patient. The average time of bone fusion was 6.8 + 1.6 months. Significant improvements of the average segmental Cobb angle was observed from a preoperative value of 18.4° + 4.6° to a last follow-up value of 21.1° ± 3.7°. At the last follow up, the titers of antibodies against the standard tube agglutination test, erythrocyte sedimentation rate, and C-reactive protein were negative for all patients.

CONCLUSION

For LBS, systemic antibrucellosis chemotherapy is the cornerstone of treatment. When cauda equine syndrome, radiculopathy, spinal instability, and severe back pain caused by extradural nonabsorbable abscess or progressive collapse are present, surgical intervention is inevitable. One-stage debridement, autogenous bone graft, and instrumentation via a posterior approach could represent an alternative treatment for LBS, and the efficacy and safety of these techniques are satisfactory.

LEVEL OF EVIDENCE

4.

Sixteen Chinese pediatric brucellosis patients onset of fever in non-epidemic areas and 8 developed with osteoarticular involvement

The purpose of this study is to summarize the manifestations, diagnosis, differential diagnosis, and treatment of childhood brucellosis in non-epidemic areas of China. A retrospective review of 16 admitted children patients with brucella's disease who were diagnosed of brucellosis during the period from 2011 to 2016 was performed. Diagnostic criteria, clinical presentations, and outcomes were recorded. The most common symptom was fever. Osteoarticular involvement was found in 50% of the patients. They were infected by contacting with infected animals or consuming of unpasteurized milk or meat of sheep or goats, also. Standard agglutination test was positive in all patients and blood culture in 10 (62.5%) patients as well as medulloculture in 3 (18.8%) patients were positive. A combination of antibiotic treatment with rifampin plus cotrimoxazole showed good response and all clinical manifestations improved. Brucellosis is misdiagnosed frequently and should be considered in the differential diagnosis when patients do not respond to standard treatment. Blood culture, together with brucella serology test, is important and helpful in the diagnosis. MRI is a good method in differentiating those with symptoms of arthritis.

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis

Background

Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis.

Methods

From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria.

Results

The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months’ follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up.

Conclusions

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.

Cervical Spondylitis and Epidural Abscess Caused by Brucellosis: a Case Report and Literature Review

Brucellosis is a zoonotic disease widely seen in endemic regions and that can lead to systemic involvement. The musculoskeletal system is frequently affected, and the disease can exhibit clinical involvements such as arthritis, spondylitis, spondylodiscitis, osteomyelitis, tenosynovitis and bursitis. Spondylitis and spondylodiscitis, common complications of brucellosis, predominantly affect the lumbar and thoracic vertebrae. Epidural abscess may occur as a rare complication of spondylitis. Spinal brucellosis and development of epidural abscess in the cervical region are rare. Development of epidural abscess affects the duration and success of treatment. Spinal brucellosis should be considered in patients presenting with fever and lower back-neck pain in endemic regions, and treatment must be initiated with early diagnosis in order to prevent potential complications.

Brucellar spondylodiscitis with rapidly progressive spinal epidural abscess showing cauda equina syndrome

Early diagnosis of Brucellosis is often difficult in the patient with only single non-specific symptom because of its rarity. We report a patient with Brucellar spondylodiscitis, in which the low back pain was the only symptom and the magnetic resonance imaging (MRI) showed not radiographic features about infection at initial stage. He was misdiagnosed as a lumbar disc herniation for inappropriate treatment in a long time. The delay in diagnosis and correct treatment led to rapid progression of the disease and severe complications. The patient was treated successfully with triple-antibiotic and surgical intervention in the end. Brucellar spondylodiscitis should always be suspended in the differential diagnosis specially when the patient comes from an endemic area or has consumed dairy products from animals in such an area and comprehensive examination should be done for the patent to rule out some important diseases like Brucellosis with sufficient reasons.