Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis: a preliminary study

PURPOSE

To access the feasibility and efficacy of percutaneous endoscopic debridement (PED) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis.

METHODS

Forty-five patients diagnosed as pyogenic spondylodiscitis underwent PPSF followed by PED. A drainage catheter was left in place for negative pressure drainage. Adequate systematic antibiotics were administered empirically or based on bacterial culture results. Clinical outcomes were assessed by physical examination, regular serologic testing, visual analog scale (VAS), Oswestry Disability Index (ODI), and imaging studies.

RESULTS

The mean operative time was 110.1 ± 21.2 minutes (range 80-165 minutes), with intra-operative blood loss 47.8 ± 21.0 ml (range 20-120 ml). All patients reported relief of back pain, able to sit up, and partially ambulate the next day. Causative pathogens were identified in 32 of 45 biopsy specimens, staphylococcal bacteria being the most prevalent strain. However, there were 13 patients with post-operative complications. During 6-12 months' follow-up, inflammatory markers showed infection controlled. VAS and ODI values were significantly improved.

DISCUSSION

Satisfactory clinical and functional outcomes were achieved in our patients post-operatively. It is recommended that PED plus PPSF can be another alternative for spondylodiscitis.

CONCLUSION

PED supplementing PPSF offers a valid option in treating spondylodiscitis, as it is minimally invasive, shortens hospital stay, and avoids prolonged bed rest with an optimistic outcome.

Unstable Lumbar Spine Osteomyelitis Caused by Trans-Foraminal Migration of Laparoscopic Adjustable Gastric Band Connection Tubing: A Case Report

BACKGROUND

Disconnection of the tubing between the port and LAGB is a well-known complication in general surgery and accounts for up to 17% of LAGB complications. Typically, when this complication occurs patients present with abdominal or pelvic complaints. A complication of spinal infection due to trans-foraminal migration has not been previously reported. The aim of this study is to highlight an unusual infection of the thoracolumbar spine due to laparoscopic adjustable gastric band (LAGB) intragastric erosion, and migration into the lumbar spine causing epidural abscesses, discitis, and osteomyelitis. This case underscores the importance of a thorough surgical history, complete imaging, and multi-disciplinary approach in management of complex spine infections.

METHODS

We report a case of LAGB tubing migration into the spinal canal through the left L2/L3 neural foramen resulting in symptomatic epidural abscesses and osteomyelitis.

RESULTS

Although dislodgement and migration of LAGB tubing has been reported previously, this is the first report of trans-foraminal migration and erosion of lumbar vertebrae, causing osteomyelitis of the spine and epidural abscess formation, subsequent instability and neurologic deficit requiring urgent operative intervention.

CONCLUSIONS

Dislodgement and migration of LAGB tubing is a known complication. While it most commonly leads to abdominal and pelvic sequelae, in rare circumstances it may acutely affect the spine. Careful history, imaging, and multidisciplinary approach are paramount for the successful management.Level of Evidence: V.

[Vertebral osteomyelitis in adults]

Back pain is a frequent reason for consultation. Although commonplace most of the time, back pain can sometimes be the only symptom of vertebral osteomyelitis, an infection that usually affects an intervertebral disc and the two adjacent vertebrae. Microbiology varies with the host's risk factors and local epidemiology. MRI is the preferred radiologic modality. Nevertheless, the definitive diagnosis is based on microbiological and histopathological elements. Antibiotic therapy alone may in some cases lead to cure, while in other cases the use of surgery is necessary. If it isn't diagnosed in time, vertebral osteomyelitis can have serious consequences. Thus, the physician must be familiar with the anamnestic, clinical and paraclinical elements that will bring him to actively look for this disease.

A rare aetiology of spinal epidural abscess

Spinal epidural abscess (SEA) due to Streptococcus pneumoniae is a rare entity, but it is associated with high mortality. Here, we describe a rare case of pneumococcal SEA in an immunocompetent adult who presented with fever, lower back pain and paresis. Central nervous system examination revealed a decreased power in bilateral lower limbs. Magnetic resonance imaging of the lumbosacral spine showed loculated pus collection in the epidural space at the level of L4-L5 vertebrae. Pus obtained following L4-L5 decompression along with blood cultures grew S. pneumoniae. The patient was treated with clindamycin and cefoperazone-sulbactam for 6 weeks, and no relapse was noted on 11 months follow-up.

A travel-loving woman in her eighties with lower back pain and weight loss

BACKGROUND

This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding.

CASE PRESENTATION

A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis.

INTERPRETATION

An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

Unilateral Septic Arthritis of a Lumbar Facet Joint Secondary to Acupuncture Treatment - a Case Report

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.

Unilateral percutaneous endoscopic debridement and drainage for lumbar infectious spondylitis

BACKGROUND

The treatment of lumbar infectious spondylitis is controversial. In this study, we attempted to demonstrate that unilateral percutaneous endoscopic debridement with physiologic saline and negative pressure drainage postoperatively may achieve a satisfactory result in lumbar infectious spondylitis.

METHODS

We retrospectively analyzed 17 patients with lumbar infectious spondylitis who underwent percutaneous endoscopic debridement and drainage (PEDD) through a posterolateral transforaminal approach. Each biopsy specimen was submitted without delay after surgery and examined for microorganisms and evaluated histopathologically. Patients were assessed by careful physical examination, MacNab criteria, Oswestry Disability Index (ODI), visual analog scale (VAS), regular serological tests, imaging studies for clinical function, and patient satisfaction.

RESULTS

Of the 17 patients, 14 (82.4%) had satisfactory relief of their back pain according to MacNab criteria at 1 week after PEDD. Three patients (17.6%) who had advanced infections with multilevel involvement and paraspinal abscesses underwent anterior debridement and autograft interbody fusion with instrumentation within 2 weeks. However, there were no other severe surgery-related complications. Causative bacteria were identified in most cases, and Staphylococcus aureus was the most prevalent strain.

CONCLUSIONS

Unilateral PEDD with physiological saline or empirical antibiotics did not disrupt lumbar stability and avoided the important intraspinal structures such as the dural sac and nerve roots. It not only had a high rate of identification of the causative pathogen, but also provided effective infection control and pain relief. PEDD may be a useful technique for treatment of lumbar infectious spondylodiscitis patients who have no severe deformities and are unable to undergo the conventional anterior surgery due to poor health or advanced age.

Effect of computer navigation-assisted minimally invasive direct lateral interbody fusion in the treatment of patients with lumbar tuberculosis: A retrospective study

The benefits of navigation-assisted technologies are not entirely understood. Therefore, this study aimed to examine the outcomes of patients with lumbar tuberculosis who received computer navigation-assisted minimally invasive direct lateral interbody fusion (DLIF).This was a retrospective study of 33 patients with lumbar tuberculosis who underwent minimally invasive DLIF at the Department of Spine and Orthopedics of Guigang People's Hospital (Guangxi, China) between January 2015 and December 2016. The patients were pathologically diagnosed as lumbar tuberculosis and grouped into the navigation-assisted fluoroscopy (NAV; n = 18) and non-navigation-assisted fluoroscopy (non-NAV; n = 15) groups. X-ray exposure and operation times were assessed in all patients.All surgical procedures were successfully completed. No case was converted into open surgery. The NAV group had longer surgical preparation time but shorter operation time compared with the non-NAV group (both P <.01). Total operation time showed no significant difference between the 2 groups (P = .1). The time of radiation exposure in the non-NAV group was longer compared with that of the NAV group (53.2 ± 9.9 vs 13.5 ± 2.6 s; P <.01). There were no significant differences regarding intraoperative blood loss, postoperative drainage volume, length of hospital stay, bone fusion and complications between the 2 groups (all P >.05).Computer navigation-assisted minimally invasive DLIF could significantly reduce intraoperative radiation exposure, with no increase in total operation time.

Minimally invasive direct lateral interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosisMini-DLIF for the thoracic and lumbar spinal tuberculosis

BACKGROUND

To investigate the clinical efficacy of minimally invasive direct lateral approach debridement, interbody bone grafting, and interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosis.

METHODS

From January 2013 to January 2016, 35 cases with thoracic and lumbar spinal tuberculosis received direct lateral approach debridement, interbody bone grafting, and interbody fusion. Of the 35 cases, 16 patients were male and 19 were female and the median age was 55.2 (range 25-83). The affected segments were single interspace, and the involved vertebral bodies included: 15 cases of thoracic vertebrae (1 cases of T5/6, 2 cases of T6/7, 4 cases of T7/8, 3 cases of T8/9, 5 cases of T9/10) and 20 cases of lumbar spine (2 cases of L1/2, 6 cases of L2/3, 6 cases of L3/4, 6 cases of L4/5). After MIDLIF operation, all the patients received medication of four anti-tubercular drugs for 12 to18 months.

RESULTS

The patients were followed up for 7 to 40 months with an average of 18.5 months. The visual analogue scale (VAS) at the last follow-up was 2.8 ± 0.5, which was significantly different from the preoperative VAS (8.2 ± 0.7). After MIDLIF, there was 5 cases occurred with transient numbness in one side of the thigh or inguinal region, and 10 cases suffered from flexion hip weakness. All the bone grafts were fused within 6~ 18 months (average of 11.5 months) after the operation.

CONCLUSION

Minimally invasive lateral approach interbody fusion technology have the advantage of less injury and quick recovery after surgery, which is the effective and safe treatment for thoracic and lumbar spinal tuberculosis.

[Research progress of surgical treatment of thoracolumbar spinal tuberculosis]

Objective

To review the progress of surgical treatment for the thoracolumbar spinal tuberculosis.

Methods

The related literature of surgical treatment for the thoracolumbar spinal tuberculosis was reviewed and analyzed from the aspects such as surgical approach, fixed segments, fusion ranges, bone graft, and bone graft material research progress.

Results

Most scholars prefer anterior or combined posterior approach for surgical treatment of thoracic and lumbar tuberculosis because it possessed advantage of precise effectiveness. In recent years, a simple posterior surgery achieved satisfactory effectiveness. The fixation segments are mainly composed of short segments or intervertebral fixation. The interbody fusion is better for the bone graft fusion range and manner, and the bone graft materials is most satisfied with autologous iliac Cage or titanium Cage filled with autologous cancellous bone.

Conclusion

The perfect strategy for treating the thoracolumbar spinal tuberculosis has not yet been developed, and the personalized therapy for different patients warrants further study.

Single posterior surgical management for lumbosacral tuberculosis: titanium mesh versus iliac bone graft: A retrospective case-control study

Recently, the one-stage posterior approach for treating spinal tuberculosis (TB) has gained popularity. However, large bony defects after debridement remain a major challenge in posterior surgery. The present retrospective study aims to compare the clinical outcomes of posterior-only surgical management by titanium mesh versus iliac bone grafts for treating lumbosacral TB. This was a retrospective cohort study. From January 2006 to April 2012, 36 patients with lumbosacral TB were treated at our department. The 36 cases were divided into 2 groups: 17 patients in Group A (titanium mesh) underwent one-stage posterior internal fixation, debridement, and titanium mesh bone fusion. The 19 patients in Group B (iliac bone graft) underwent posterior instrumentation, debridement, and iliac bone graft in a single procedure. The clinical and radiographic results for the 2 groups were analyzed and compared. The mean year of patients was 49.9 ± 15.4 months in group A and 55.5 ± 12.6 months in group B. All patients were followed up for an average of 47.3 ± 8.1 months (range 36-60 months). Spinal TB was completely cured and no intraspinal infection and central nervous system complications of TB infection occurred. Bone fusion was achieved 6.4 ± 1.9 months in group A and 7.8 ± 2.1 months in group B. There was no significant statistical difference in bone fusion between the 2 groups (P > .05). The Oswestry Disability Index score (ODI) significantly improved between the preoperative and the last visit in either group. However, no significant difference was observed between the 2 groups at last visit (P > .05). There were significant differences between groups regarding the postoperative lumbosacral angle and angle correction loss at the final follow-up (P < .05). The average operative complication rate of Group A was less than that of Group B. Both iliac bone and titanium mesh can effectively construct anterior column defects in posterior surgery. The titanium mesh has the advantage of minor surgical invasion, effective reconstruction of large defects, and ideal sagittal alignment in lumbosacral TB for patients with osteoporosis and poor iliac bone quality.

A medium-term follow-up of adult lumbar tuberculosis treating with 3 surgical approaches

Surgical intervention is an important option for treating lumbar tuberculosis. Previous studies have reported different surgical intervention procedures. To our knowledge, few studies have compared the clinical results of mid-term follow-up of 3 different surgeries in surgical treatment of spinal tuberculosis. This study's purpose is to evaluate the effectiveness of 3 different surgeries for the treatment of lumbar tuberculosis in adult and analyze the mid-term influence of the surgery on quality of life.Between June 2004 and January 2010, a total of 137 adult patients (54 women and 83 men) with lumbar tuberculosis were recruited for this study. The patients were divided into 3 groups based on administered surgeries: posterior, anterior, and combined posterior-anterior. The trauma index (operation time, blood loss, length of hospital stay, and complications), imaging parameters (segment kyphotic angle, correction rate, loss angle, and bone fusion time), and quality-of-life indicators, including Oswestry Disability Index (ODI), the Frankel grade, visual analog scale (VAS), and Macnab score, were collected.The posterior group experienced the lowest trauma index, whereas the combined group faced the highest trauma index. The anterior group's kyphosis correction rate of (52% ± 5.45%) was significantly inferior to the posterior group (74% ± 5.04%) and the combined group (69% ± 7.95%), whereas the loss of correction in the anterior group (2.5°) was higher than the losses of correction in the posterior group (0.8°) and combined group (1.1°). The mean bone fusion times of the 3 groups were similar. Postsurgery quality of life was markedly improved in all patients. The improvement rates of the ODI, VAS, and the excellent and good rate per the Macnab score were similar among the 3 groups at the final follow-up.Based on a retrospective study, for patients with lumbar tuberculosis, use of the anterior approach should be limited. Although the combined approach produced satisfactory outcomes, it remains more traumatic. Compared with the anterior surgery and the combined surgery, the posterior-only approach is safer and less invasive.

Abiotrophia defectiva endarteritis with infective spondylodiscitis in an adult patient with patent ductus arteriosus

Endarteritis is a major complication in patients with patent ductus arteriosus, causing significant morbidity and mortality. We report an adult patient with asymptomatic patent ductus arteriosus and endarteritis involving the main pulmonary artery and secondary infective spondylodiscitis at the L5-S1 intervertebral disc caused by Abiotrophia defectivaA. defectiva, commonly referred to as nutritionally variant streptococci, cannot be identified easily by conventional blood culture techniques from clinical specimens. Its isolation was confirmed by 16S ribosomal RNA sequencing. The patient was successfully managed with a combination of penicillin G and gentamicin, pending surgical repair of the patent ductus arteriosus.

Scintigraphic Patterns of Indium-111 Oxine-Labeled White Blood Cell Imaging of Gram-Negative versus Gram-Positive Vertebral Osteomyelitis

OBJECTIVE

The goal of the study was to investigate whether or not gram-negative organisms that secrete antichemotactic factors cause the nonaccumulation pattern of 111In-oxine-labeled white blood cell (111In-WBC) scans.

MATERIALS AND METHODS

Staphylococcus aureus (gram-positive) (group 1) was injected into 25 rabbits and Escherichia coli (gram-negative) (group 2) into another 25 to induce infection in the lumbar vertebrae or left thigh bone (femur). Sixteen successfully infected and surviving rabbits from each group were used for imaging and analysis. Of the 16 rabbits, each group included 8 with vertebral infection and 8 with femur infection. For imaging, each rabbit was injected intravenously with 11.1 MBq (300 μCi) 111In-WBC, and images were acquired 24 h later. Microscopic histopathology was performed after decalcification to confirm osteomyelitis.

RESULTS

The 111In-WBC accumulation was observed in 7 (87.5%) of the 8 rabbits infected with S. aureus in the vertebrae and thigh bone. Of the rabbits infected with the gram-negative vertebrae, 1 (12.5%) showed little accumulation of 111In-WBC. Of the 8 rabbits with gram-negative-infected femurs, 1 had high accumulation and another had low accumulation of 111In-WBC, while the rest did not show any uptake. Osteomyelitis was confirmed by histopathology in all the successfully infected rabbits used for imaging.

CONCLUSION

In the majority of the gram-positive-infected rabbit vertebrae there was high accumulation of 111In-WBC. However, no accumulation of 111In-WBC was observed in most of the vertebrae infected with gram-negative organisms, which release antichemotactic factors that prevent adequate accumulation of WBC at the infected area.

Unusual case of paediatric septic arthritis of the lumbar facet joints due to Kingella kingae

A 32-month-old boy presented with febrile limping that had developed over 6days, associated with right lumbosacral inflammatory swelling. Magnetic resonance imaging (MRI) showed joint effusion of the right L5-S1 zygapophyseal joint, complicated by destructive osteomyelitis of the L5 articular process and paraspinal abscess. Surgery was decided to evacuate the fluid accumulation and rule out differential diagnoses. The diagnosis of septic arthritis of the facet joint was confirmed intraoperatively; real-time quantitative PCR analysis identified Kingella kingae. This is the first substantiated paediatric case of zygapophyseal joint septic arthritis due to K. kingae. K. kingae is the most common pathogen responsible for invasive osteoarticular infection in children under 4years of age. Since empiric antibiotics are effective in early stages, physicians should consider the possibility of spinal infections due to K. kingae when a limping child under 4years of age presents with a fever.

The efficacy of local continuous chemotherapy and postural drainage in combination with one-stage posterior surgery for the treatment of lumbar spinal tuberculosis

BACKGROUND

The objective of this study was to compare the outcomes of one-stage posterior surgery involving debridement, bone grafting, and instrumentation with and without local continuous chemotherapy and postural drainage for the treatment of lumbar spinal tuberculosis.

METHODS

From January 2009 to January 2013, 109 patients with lumbar spinal tuberculosis were treated in our center using a posterior surgical approach. Patients underwent one-stage posterior debridement, bone grafting, and instrumentation, without (group A) and with (group B) local continuous chemotherapy and postural drainage. Clinical and radiographic results for the two groups were analyzed and compared. Clinical efficacy was evaluated based on surgery duration and blood loss. The Frankel scale was used to evaluate neurological function. A visual analog scale was used to assess low back pain. Bone graft fusion and instrumentation failure were monitored by radiography, and tuberculosis activity was monitored by erythrocyte sedimentation rate (ESR) and C-reactive protein testing.

RESULTS

Groups A and B contained 52 and 57 patients, respectively. Patients were followed for 18-36 (mean, 26.64 ± 4.2) months. All bone grafts ultimately fused, but the fusion rate was significantly more rapid in group B [6.4 ± 0.5 (range, 5-10) months] than in group A [8.9 ± 0.6 (range, 6-12) months; P < 0.05]. At 6 weeks postoperatively, ESR levels differed significantly between groups A and B (24.6 ± 1.5 vs. 16.3 ± 1.1 mm/h; P < 0.05). ESR levels normalized in both groups at 16 weeks.

CONCLUSIONS

Local continuous chemotherapy and postural drainage effectively eliminated infection foci caused by abscess remnants and accelerated interbody bone fusion in patients with lumbar spinal tuberculosis undergoing one-stage posterior surgery involving debridement, bone grafting, and instrumentation.

Thoracolumbar Scoliosis Due to Cryptococcal Osteomyelitis: A Case Report and Review of the Literature

Cryptococcus neoformans causes opportunistic infections in immunocompromised patients, with vertebral osteomyelitis being a very rare involvement.This study is to present a case of thoracolumbar scoliosis occurring in the setting of cryptococcal osteomyelitis.Pharmacological intervention with anticryptococcal medicine and medical management of immune hemolytic anemia were administered. After initial acute stabilization, she underwent spinal debridement and fusion on October 29, 2008. She eventually recovered fully from this episode with no subsequent mechanical instability or neurological deficits on subsequent clinic follow-ups.To the best of our knowledge, there have been no reports describing the onset of spinal cryptococcal osteomyelitis along with immune hemolytic anemia. We suggest a comprehensive algorithm for the diagnosis of vertebral cryptococcal osteomyelitis.

[Spondylodiscitis in children: a review. A propos of two cases]

Spondylodiscitis is defined as an infection of the intervertebral disc and the adjacent vertebral bodies. It represents, at the most, 2-4% of osteoarticular infections in children and its clinical presentation is often insidious. The specific condition of the young child (isolated discitis) is explained by some anatomical peculiarities. We report two cases of spondylodiscitis in children of different ages and review the pediatric characteristics, the role of imaging, the bacteriological diagnosis and the management of this disease.

Spontaneous septic arthritis of the lumbar facet caused by methicillin-resistant Staphylococcus aureus in an otherwise healthy adolescent

We report the case of a 16-year-old boy with isolated septic arthritis of a lumbar facet. This rare presentation of an infection in a lumbar facet joint occurred after minor trauma sustained in a football game. Septic arthritis of the spinal facet joint is an uncommon phenomenon. Only 5 cases have been reported in immunocompromised pediatric patients. To our knowledge, no case of septic arthritis in an immunocompetent pediatric patient has been reported. An otherwise healthy 16-year-old boy presented with 4 weeks of escalating back pain after a minor athletics-related trauma. Evaluation showed incapacitating pain, lumbar musculature spasms, and the absence of fever, hemodynamic, or neurologic changes. Laboratory values were within normal limits. Magnetic resonance images showed a fluid collection within the L3-L4 facet and a localized abscess. Computed tomographic-guided aspiration showed methicillin-resistant Staphylococcus aureus infection, for which the patient received 6 weeks of vancomycin with complete resolution of symptoms. Refractory lumbago in an adolescent requires careful evaluation.

Erysipelothrix rhusiopathiae bacteremia without endocarditis associated with psoas abscess: the first case report in Thailand

The authors report a patient with a rare manifestation of invasive septic Erysipelothrix rhusiopathiae infection without endocardial involvement. Our patient presented with progressive paraparesis and subacute fever for ten days. He had underlying diabetes mellitus and alcoholic cirrhosis. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a psoas abscess with vertebral osteomyelitis and discitis at level of L23 of the lumbar spine. His blood culture grew E. rhusiopathiae. Transthoracic echocardiography demonstrated normal endocardium. Surgical drainage and debridement with concomitant intravenous antibiotics administration resulted in clinical improvement, including neurological status. MRI showed resolution of the psoas abscess and osteomyelitis. Erysipelothrix infection should be considered as a causative pathogen of musculoskeletal infection in immunocompromised patients. To our knowledge, this is the first case report of psoas abscess caused by E. rhusiopathiae in Thailand.

Postoperative spondylodiscitis caused by Mycobacterium bovis BCG: a case study

BACKGROUND CONTEXT

Postoperative spondylodiscitis (PSD) is a known complication of lumbar disc surgery. The etiology of the disease is usually bacterial, but several uncommon infectious agents have also been described; however, there are no reports about postoperative colonization with Mycobacterium bovis bacille Calmette-Guérin after lumbar discectomy.

PURPOSE

To describe the case of PSD caused by M. bovis BCG, and to discuss diagnostic and therapeutic interventions as well as possible pathogenic mechanisms of the disease.

STUDY DESIGN

Case report and review of the literature.

METHODS

A 31-year-old man was operated on because of L4-L5 lumbar disc herniation. Two months later, the patient presented with gradual increase of back pain, and magnetic resonance imaging confirmed PSD. He started to receive antibacterial treatment and was reoperated on because of progressive neurological deficits due to epidural abscess. Neurological status improved, but a fistula developed with intermittent pus drainage from the operative scar.

RESULTS

Microbiological cultures were repeatedly obtained from the pus, but all the initial stains and cultures were negative. Four months after the reoperation, the culture for M. bovis BCG from the pus appeared to be positive. The patient received antituberculosis regimen, including isoniazid, rifampin, ethambutol, and ofloxacin. The clinical symptoms resolved, and antituberculosis treatment was discontinued after 14 months.

CONCLUSIONS

Mycobacterium bovis BCG must be considered in the differential diagnosis of PSD. Microbiological analysis and radiological studies are vital components in diagnosis; if there is any suspicion of BCG osteomyelitis, proper diagnostic and therapeutic management must be instituted without delay to avoid an unfavorable outcome.

Management of infectious discitis. Outcome in one hundred and eight patients in a university hospital

PURPOSE

The optimal management of pyogenic discitis is not agreed on. We conducted a retrospective, cross-sectional, observational study in which all patients with discitis who attended Hospital San Carlos Madrid from January 1999 to January 2009 were included.

METHODS

We identified 108 consecutive adult patients with infectious discitis. There were 49 men and 59 women with an average age of 67,5 (+/- 16,89) years in the study group. Mean follow-up interval was 6,06 (12,5-2) years. 78 patients had spontaneous discitis and 30 patients had postoperative discitis. Inclusion criteria for the review were illness compatible with vertebral infection and / or evidence of spinal involvement on magnetic resonance imaging (MRI).

RESULTS

In 56 percutaneous discal biopsy (52% patients) were positive in 28 cases. A single disc was infected in 100 patients. The segments involved were the cervical spine in four, the thoracic spine in 38 and the lumbar spine in 66. One or more comorbid diseases were present in 73 (68%) of 108 patients. Diabetes mellitus was the most common disease. Comorbid disease was rapidly fatal in four patients, ultimately fatal in seven patients, and nonfatal or not present in 97 patients (90 %).

CONCLUSION

Early diagnosis is a major challenge. Heightened awareness and the prompt use of MRI are necessary to avoid diagnostic delay. Prolonged antimicrobial therapy and the judicious application of timely surgical intervention are essential for an optimal outcome.

Outcomes of anterior and posterior instrumentation under different surgical procedures for treating thoracic and lumbar spinal tuberculosis in adults

PURPOSE

There are few articles in the literature comparing outcomes between anterior and posterior instrumentation in the management of thoracic and lumbar spinal tuberculosis (TB).

METHODS

Between January 2004 and December 2009, 217 adult patients, average age 39 (range 16-67) years with thoracic and lumbar spinal TB were treated by anterior radical debridement and fusion plus instrumentation, anterior radical debridement with fusion and posterior fusion with instrumentation, posterolateral debridement and fusion plus posterior instrumentation or transpedicular debridement and posterior fusion with instrumentation in a single- or two-stage procedure. We followed up 165 patients for 22-72 (mean 37) months. Of these, 138 underwent more than three weeks chemotherapy with isoniazid, rifampin, pyrazinamide and ethambutol, and the remaining 27 underwent operation for neurological impairment within six to 18 hours of the same chemotherapy regimen. In no case did relapse occur. Apart from eight patients with skip lesions treated by hybrid anterior and posterior instrumentation, anterior instrumentation was used in 74 patients (group A) and 83 patients (group B) were fixed posteriorly.

RESULTS

In both groups, local symptoms were relieved significantly one to three weeks postoperatively; ten of 14 patients (71%) in group A and 14 of 19 (74%) in group B with neurological deficit had excellent or good clinical results (P > 0.05). Erythrocyte sedimentation rates (ESR) returned from 43.6 mm/h and 42.7 mm/h, respectively, preoperatively to normal levels eight to 12 weeks postoperatively. Kyphosis degree was corrected by a mean of 11.5° in group A and 12.6° in group B, respectively (P < 0.01). Correction loss was 6.8° in group A and 6.1° in group B at the last follow-up (P < 0.01). Fusion rates of the grafting bone were 92.5% and 91.8%, respectively, at final follow-up (P > 0.05). Severe complications did not occur.

CONCLUSION

These results suggest that both anterior and posterior instrumentation attain good results for correction of the deformity and maintaining correction, foci clearance, spinal-cord decompression and pain relief in the treatment of thoracic and lumbar spinal TB providing that the operative indication is accurately identified. However, the posterior approach may be superior to anterior instrumentation to correct deformity and maintain that correction.

Spontaneous spinal epidural abscess

Spinal epidural abscess is an uncommon entity, the frequency of which is increasing. They occur spontaneously or as a complication of intervention. The classical triad of fever, back pain and neurological symptoms are not always present. High index of suspicion is key to diagnosis. Any delay in diagnosis and treatment can have significant neurological consequences. We present the case of a previously well man with a one month history of back pain resulting from an epidural abscess.

Vertebral osteomyelitis associated with Granulicatella adiacens

Granulicatella adiacens is a nutritionally variant streptococci. Only 3 cases of vertebral osteomyelitis due to these microorganisms have been reported. We experienced a 73-year-old male who consulted us due to fever and back pain of about 1-month duration. On examination, a presystolic murmur was heard in the apical region. Echocardiography showed prolapse of the mitral valve, but no vegetation was observed. MRI revealed osteomyelitis of lumbar vertebrae. As G. adiacens was detected in blood culture, it was determined as the cause of vertebral osteomyelitis, and combination antibiotics therapy was started. The condition improved, the patient underwent valvoplasty, and no trace of infective endocarditis was noted in the resected valve. All the previous cases had infection caused by G. adiacens and complicated with infective endocarditis. This is the first case without infective endocarditis. Vertebral osteomyelitis due to NVS is very rare. Since nutritionally variant streptococci do not grow in common culture media, and since the sensitivity of isolation by standard conventional biochemical methods is low, the condition may be misdiagnosed as blood-culture-negative vertebral osteomyelitis. Therefore, the possibility of nutritionally variant streptococci infection should be considered if a patient with vertebral osteomyelitis shows a positive Gram stain but negative blood cultures.

[Surgical treatment of thoracic and thoracolumbar spinal tuberculosis]

OBJECTIVE

To explore the surgical measurements and principles in the treatment of thoracic and thoracolumbar spinal tuberculosis.

METHODS

From 2001 to 2008, 232 cases of thoracic or thoracolumbar spinal tuberculosis were treated by operations in the study, including 148 males and 84 females with an average age of 37.8 years ranging from 20 to 76 years. Preoperative assessment displayed as follow: Cobb angles of kyphosis < 30 degrees in 65 cases, 30 degrees to 60 degrees in 147 cases, > 60 degrees in 20 cases; Frankel B grade in 13 cases, C in 12 cases, D in 41 cases, E in 166 cases. Among them, 48 cases were performed with one-stage transpedicular screw system and anterolateral debridement by single incision, 184 cases with one-stage anterior approach (debridement, fusion, and plate-screw fixation) routinely. The tissues and liquor puris debrided from focus were sent for pathological examination, Bacillus tuberculosis detection and culture, and drug sensitivity test. The patients were given anti-tuberculosis therapy according the results of drug sensitivity test for 1 to 1.5 years. The followed-up included relapse rate, fusion of the bone graft, the status of neurological restoring, kyphosis correction etc.

RESULTS

All 232 cases recovered from perioperation and 230 cases got primary wound healing, only 2 cases performed with single incision one-stage posterior instrumentation and anterolateral debridement got complications of wound healing problems and the sinus formation,which delayed healed by changing dressings. The complications included intercostals neuralgia in 135 cases and pneumothorax or hydrothorax in 13 cases, which needed not special handling. All the patients in this series got the followed-up ranging from 1.0 to 4.5 years (means 2.6 years). No recurrence within followed-up period and bone union was found in all cases. All 66 cases with the neurological deficits recovered partially or totally. Kyphosis correction were achieved by 27.5 degrees on average postoperatively and showed a mild loss of 4.2 degrees on average during followed-up period. All cases were confirmed with Bacillus tuberculosis infection by pathology. Bacillus tuberculosis was detected and culture successfully in 107 cases (46.1%), 40 strains (37.4%) were drug resistant and in which 8 strains (7.5%) were multi-drug resistant.

CONCLUSION

For the treatment of thoracic and thoracolumbar spinal tuberculosis, the best treatment include directional chemotherapy, one-stage anterior approach with thorough debridement, auto-rib or Ti-mesh fusion, and plate-screw fixation.

Non-contiguous multifocal Staphylococcus aureus discitis: involvement of the cervical, thoracic and lumbar spine

INTRODUCTION

Multilevel discitis is rare, and classically due to granulomatous organisms like Mycobacterium tuberculosis, brucella and fungal species.

CONCLUSION

We report a case of non-contiguous multilevel synchronous bacterial discitis involving cervical, thoracic and lumbar discs, attributable to Staphylococcus aureus.

Eggerthella lenta as a cause of anaerobic spondylodiscitis

Anaerobic organisms are a rare cause of spondylodiscitis. Eggerthella lenta is an organism that is not commonly associated with spondylodiscitis. We describe a case of spondylodiscitis due to Eggerthella lenta in an 82-year-old Chinese woman presenting with back pain. The organism was isolated from tissue cultures obtained via radiology-guided biopsy.

Aspergillus spondylodiscitis after multivisceral transplantation

BACKGROUND

Although spondylodiscitis is rare, it is increasingly described in patients with compromised immunity due to malignancy, chemotherapy or immunosuppression. Typical pathogens are staphylococcus aureus and enterobacteria; fungal spondylodiscitis is uncommon.

CASE REPORT

We present a case of aspergillus spondylodiscitis following pulmonary aspergillosis in a patient with multivisceral and kidney transplantation. Due to irreversible disc destruction, surgical restoration by autologous iliac crest graft was required in addition to intravenous antifungal therapy, which consisted of voriconazole, caspofungin and liposomal amphotericin B.

CONCLUSIONS

Aspergillus spondylodiscitis is a diagnostic and therapeutic challenge, a combination of surgical debridement and antifungal therapy is inevitable to prevent rapid progression of invasive aspergillosis and neurological damage.

Epidural tuberculosis involving the entire spine

We discuss an elderly male who developed severe back pain, rapidly progressing paraparesis and urinary retention consequent to L5-S1 spinal tuberculosis with dissemination of epidural tubercular abscess and granulation tissue to the cervical, thoracic, lumbar and sacral region. The initial diagnosis of lumbo-sacral pathology with high thoracic extension was tackled by an L5 laminectomy and decompression along with saline flushing and evacuation of the thoraco-lumbar and sacral epidural abscess with the aid of a catheter passed superiorly and inferiorly. He developed neck pain and upper limb weakness subsequently and was found to have extensive extradural cervical compression by granulation tissue. He underwent C4-7 laminectomy and decompression of the cord. He was started on four-drug anti-tubercular treatment. At 6-month follow-up, he had marked neurological improvement. MRI screening of the entire spine showed complete resolution of the disease. Contiguous epidural involvement of the entire spine by tubercular pathology has never been reported before. We suggest that screening of the entire spine should be considered in select cases of spinal tuberculosis based on symptomatology.

Pseudomonas mendocina spondylodiscitis: A case report and literature review

Pseudomonas mendocina is rarely recovered as a human pathogen. Only 2 human cases have been reported in the literature. Here, we report the third human case and possibly the first 1 to involve spinal infection caused by such an unusual bacterium.

Rupture of a nonaneurysmal abdominal aorta due to spondylitis

Contiguous arterial infections are extremely rare, and their actual rate of occurrence is not known. These infections occur as a result of direct invasion of an artery from an adjacent septic focus. Reaching the diagnosis of infected aorta is very difficult when there are contiguous infections from spondylitis or psoas abscess, because the clinical features are nonspecific. Although computed tomography is the most useful diagnostic tool in the detection of aortic infections, the most frequent findings mimic those of other diseases, such as retroperitoneal fibrosis, lymphoma, and periaortic lymphadenopathy. Diagnosis becomes even more challenging when an infected aorta is of normal diameter. Herein, we report the case of a 64-year-old man who experienced nonaneurysmal abdominal aortic rupture due to spondylitis and psoas abscess. Despite appropriate surgical management, the patient later died. We review the relevant medical literature and examine specific considerations that surround the diagnosis and treatment of this rare condition.

Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics

OBJECTIVES

Vertebral osteomyelitis is a cause of back pain that can lead to neurologic deficits if not diagnosed in time and effectively treated. The objective of this study was to systematically review the clinical characteristics of pyogenic vertebral osteomyelitis (PVO).

METHODS

The authors conducted a systematic review of the English literature. The inclusion criteria included studies with 10 or more subjects diagnosed with PVO based on the combination of clinical presentation with either a definitive bacteriologic diagnosis or pathological and/or imaging studies.

RESULTS

The 14 studies that met selection criteria included 1008 patients with PVO. Of them, the majority (62%) were men, with back pain and fever as the most common presenting symptoms. Diabetes mellitus was the most common underlying medical illness, while the urinary tract was the commonest source of infection. Staphylococcus aureus was the most commonly isolated organism. Computed tomographic guided or open biopsy yielded the causative organism more often than blood cultures (77% versus 58%). Plain radiography showed abnormalities in 89% of the cases, while bone scanning and computed tomography or magnetic resonance imaging were positive in 94% of the cases, revealing lumbar as the most commonly affected area. The attributable mortality was 6%, while relapses and neurological deficits were described in the 32% and 32% of the cases, respectively.

CONCLUSION

PVO is an illness of middle-aged individuals with underlying medical illnesses. Although the mortality rate is low, relapses and neurological deficits are common, making early diagnosis a major challenge for the physician.

Bacteroides fragilis bacteremia associated with vertebral osteomyelitis in a sickle cell patient

Osteomyelitis and septic arthritis are serious complications of sickle cell disease which occur at rates of 18% and 7%, respectively. In two small studies of osteomyelitis in sickle cell patients, the most common causative organisms were Salmonella spp. and Staphylococcus spp. Anaerobic infection is uncommon. Here, we report an 18-year-old girl with sickle cell disease and suspected spontaneous vertebral osteomyelitis due to Bacteroides fragilis. The diagnosis was based on multiple positive blood cultures. Despite extensive investigation, the port of entry could not be determined. The patient responded well to a four-week therapy with metronidazole, without the need for surgical debridement.

Successfully treatedCandida kruseiinfection of the lumbar spine with combined caspofungin/posaconazole therapy

Candidal vertebral osteomyelitis represents an extremely rare invasive mycosis and can be difficult to treat due to poor drug penetration into bony tissue. We report on a case of vertebral osteomyelitis caused by Candida krusei in a patient who had neutropenia as a result of chemotherapy for acute myelogenous leukaemia. The patient received prophylactic liposomal amphotericin B during chemotherapy but became febrile and experienced severe lumbar pain. Magnetic resonance imaging revealed vertebral osteochondrosis. C. krusei was recovered from blood cultures and voriconazole monotherapy was initiated but proved unsuccessful. The patient was then started on caspofungin monotherapy, which was discontinued after Candida krusei was no longer recoverable from blood cultures. However, as lumbar pain increased and spinal biopsy confirmed the presence of Candida krusei, caspofungin therapy was resumed. Oral posaconazole was added to the regimen when the patient did not improve after 30 days of caspofungin therapy. Combined antimycotic therapy resulted in a successful outcome.

Spontaneous pyogenic spondylitis caused by Klebsiella pneumoniae

A 72-year-old woman without a history of spinal injury was admitted to our hospital with prolonged severe back pain and high fever. Clinical laboratory findings and magnetic resonance imaging (MRI) revealed severe inflammation of the L2 and L3 lumbar vertebrae. Meropenem trihydrate administration improved her symptoms. Klebsiella pneumoniae isolated from the patient's blood indicated that the organism caused the spontaneous pyogenic spondylitis.

Pseudoaneurysm following vertebral biopsy and treatment with percutaneous thrombin injection

We present a case of a pseudoaneurysm within the lumbar musculature. This occurred following a computed tomography (CT)-guided vertebral biopsy in a 79-year-old male patient and was successfully treated with percutaneous ultrasound-guided thrombin injection. The patient initially presented with severe back pain. The plain radiographs and Magnetic resonance imaging (MRI) showed destruction of the L1 and L2 end plates, with marked narrowing of the disc space, suggestive of infective discitis. CT-guided biopsy was performed by the right paravertebral approach. Methicillin-resistant Staphylococcus aureus (MRSA) was grown, following culture of the specimen. Twenty days later, the patient developed a palpable swelling in the right lumbar region, with worsening of the back pain. MRI and ultrasound imaging showed a 3 cm pseudoaneurysm within the right lumbar musculature. The pseudoaneurysm was successfully treated following percutaneous ultrasound-guided injection of thrombin.

Advanced Multifocal Tuberculous Spondylitis without Disk Involvement and with Multidrug-Resistant Bacilli

In this brief report, we describe a 23-year-old immunocompetent Nigerian patient with extensive multifocal tuberculous spondylitis without disk involvement. Cultures of sputum samples and biopsy samples from the L4 vertebra were positive for tuberculosis; drug-susceptibility testing of the isolates revealed multidrug resistance. Treatment with second-line drugs resulted in an excellent interim outcome after 6 months, without the need for surgical intervention.

Vertebral osteomyelitis, epidural and psoas abscess after epidural catheter use

We report on a patient who developed persistent low back pain, pyrexia and neurological deficit soon after she underwent a laparotomy under combined general and epidural anaesthesia. The diagnosis of lumbar vertebral osteomyelitis, discitis, epidural and psoas abscesses was made one month later when she was referred to our institution. The patient was successfully treated with posterior decompression, drainage of the epidural abscess and fusion in combination with percutaneous, computed tomography-guided needle aspiration of the psoas abscesses.

Combined effect of Neridronate and specific antibiotic therapy in a case of tuberculous spondylodiscitis

Because of the increased incidence of tuberculosis (TB) in recent years, infective spondylitis is still a major problem in the world. In skeletal TB the spine is the most often involved and lumbosacral spine involvement is rare. Nowadays early diagnosis and new medical treatment can reduce the incidence of the serious skeletal sequelae and the number of surgery procedures in spinal TB. We present a case of TB spondylodiscitis characterized by a rapid and progressive clinical and radiological improvement after treatment with Neridronate and chemotherapic drugs. Our data suggest that in the treatment of the TB spondylodiscitis the combined use of these drugs is a good alternative to stimulate bone reparative process to the chemotherapy alone. To our knowledge this is first case of a patient with TB discitis treated with Neridronate. Further studies are necessary to confirm the effectiveness of Neridronate treatment added to antiTB drugs in spondylodiscitis.