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PubMed1993

[Aspergillus spondylodiscitis. Apropos of 5 cases].

Five cases of Aspergillus discitis in male patients are reported. Three patients had impaired immune responses as a result of immunosuppressive therapy following a heart transplant (two cases) or hairy cell leukemia (one case). Two patients had a recent history of mycobacterial infection. All five patients were hospitalized for severe spinal pain suggestive of an inflammatory disease with no neurological abnormalities. Erythrocyte sedimentation rate was elevated in every case. The diagnosis of discitis was suspected on spinal roentgenograms and established by computed tomography and/or magnetic resonance imaging. In three patients the spine was the only site of Aspergillus infection (lumbar discitis in two cases and thoracic discitis in one case). One patient developed Aspergillus infection of several disks (L1-L2, L2-L3, and L4-L5) after Aspergillus endocarditis with embolization to the left lower limb. Another patient developed discitis after an Aspergillus lung infection. In every case, Aspergillus fumigatus was recovered in cultures of specimens harvested by a percutaneous needle biopsy of the intervertebral disk. All five patients were treated by itraconazole which was given as single drug therapy in one case and in combination with 5-flucytosine and amphotericin B in four cases. Recovery was achieved in every case after four to six months of this drug therapy. In contrast to most previously reported cases, none of the five patients reported herein required surgical treatment. Efficacy of conservative treatment in this study may be related to the use of itraconazole in every case.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2006

Therapeutic use of cephazolin to prevent complications of spine surgery.

Discitis, caused by pyogenic organisms, is a potential complication of any procedure which involves entering the intervertebral disc during open or percutaneous procedures. While there are wide variations in the severity of symptoms, the characteristic feature of discitis is the development of increasingly severe back pain, which is not relieved by rest, or narcotic analgesics. While there is a tendency to spontaneous resolution over time, a self-limiting course does not always eventuate. Serious complications resulting from spread of the infective process can lead to vertebral osteomyelitis or to the formation of an epidural abscess with further risk of neural compression. Clinical and experimental evidence now supports the prophylactic use of a suitable antibiotic, but some uncertainties exist about the benefits of antibiotic therapy in treating established discitis. While cephazolin is a widely favoured choice of antibiotic, the timing of its administration to prevent or treat discitis has been complicated by the lack of suitable methods for detecting and measuring the concentration of cephazolin in the plasma and disc in experimental and clinical conditions. This paper describes a high-performance liquid chromatography technique for detecting the antibiotic cephazolin. The results conclude cephazolin can be detected in the plasma and disc after administering an intravenous bolus dose. However, concentration of cephazolin in the outer disc was 12 times greater than that of the inner disc.

Animals↗
PubMed1988

[Spondylodiscitis after surgery of lumbar disk hernia. Apropos of 12 cases in 1796 operations].

Discitis is a rare complication of disc operation. The incidence rate varies from 0.2 to 0.8% according to the series. During a 6 year period (1980-1986) 1,796 patients were operated for lumbar disc protrusion at our institution and twelve of them (0.66%) developed a post operative discitis. Bacteriologic verification due to the infection was ascertained in ten cases. Direct contamination during surgical time is likely far more frequent than hematogenous contamination because the liable germ was staphylococcus in 9 cases. Ascertaining the diagnosis is base upon clinical picture and some selected investigations. It may be earlier than it has been said before. Discitis may be suspected within a week after operation in two cases out of three. The most prominent clinical feature is back pain with muscle spasm but sometimes diagnosis may be misled to a psychiatric condition or a visceral disorder. Among conclusive investigations we range in the first place the needle aspiration of the disc which permitted to isolate a germ nine times out of eleven. Next the bone scan with H.M.D.P. Te 99 (8 Mbq/kg) which revealed a significant uptake pattern in eight cases out of eight. Finally the blood culture which grew five times out of ten. Risks of discitis, i.e septicemia, polysegmental infection or death justify in our opinion an appropriate antibiotherapy during at least 8 weeks. Moreover, in our experience, it is the best antalgic treatment that we can offer and back pain decreases as soon as the second day with antibiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Brucellar spondylitis: MRI findings.

This study was carried out to identify the distinguishing features of brucellosis on magnetic resonance imaging (MRI). MRI examinations were performed in 14 patients with spinal brucellosis. A 1-T Magnetom (Erlangen, Siemens) was used to obtain T1-weighted (TR/TE 500/30) and T2-weighted (TR/TE 2000/80/20) spin echo sequences, in both sagittal and axial planes. Thirty-three percent of the vertebrae and 18 levels of disc were involved in the 14 brucellar spondylitis cases. Eleven patients (79.8%) with discitis revealed anterior superior vertebral body involvement. Fourteen (77.7%) of the levels with discitis displayed soft tissue swelling without presence of abscess formation. Seven facet joints of five patients with discitis displayed signal increase after contrast enhancement. Vertebral body signal changes without morphologic changes marked signal increase in the intervertebral disc on T2-weighted and contrast-enhanced sequences, and soft tissue involvement without abscess formation can be accepted as specific MRI features of brucellar spondylitis. The facet joint signal changes following contrast enhancement is another MRI sign of spinal brucellosis, which has not been mentioned so far.

Adolescent↗
PubMed1997

Epidural spinal infection. Variability of clinical and magnetic resonance imaging findings.

STUDY DESIGN: This study evaluates the magnetic resonance characteristics of spinal epidural abscesses and their associated disc space infections. OBJECTIVES: The results were correlated with history, clinical, and laboratory findings to provide guidelines for early and appropriate diagnosis of epidural spinal infections. SUMMARY OF BACKGROUND DATA: Imaging signs of spinal infections have been reported before, but not with special attention to early clinical and imaging findings. METHODS: Thirteen patients (10 men, 3 women; age range, 32-64 years) with progressive sensorimotor deficit were studied. All patients had a neurologic examination after admission and a magnetic resonance imaging scan done within the first 48 hours. In all cases, T1-weighted images before and after administration of gadolinium were obtained. T2-weighted images were acquired in eight cases as well. Ten patients subsequently underwent open surgery; in three cases, a percutaneous biopsy and drainage was performed. RESULTS: Cervical discitis was found in five patients, and thoracic discitis was seen in another five cases. Three patients had an epidural infection without a concomitant discitis. Neurologic and clinical findings varied considerably. Despite clinical signs of spinal cord involvement, a spinal cord lesion was demonstrated only once. Signal change in T2-weighted images may be the first sign of disc space infection. Because a neurologic deficit may occur before any change is visible, follow-up examinations may be required if epidural infection is suspected on clinical grounds. CONCLUSIONS: Magnetic resonance imaging is the appropriate method for diagnostic work-up of progressive neurologic deficit resulting from epidural infection.

Abscess↗
PubMed2000

Hematogenous pyogenic spinal infections and their surgical management.

STUDY DESIGN: Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation. SUMMARY OF BACKGROUND DATA: Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised. OBJECTIVES: To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection. METHOD: All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed. RESULTS: Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%). CONCLUSIONS: Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.

Abscess↗
PubMed2005

Infections of the spine in patients with human immunodeficiency virus.

BACKGROUND: Musculoskeletal infections in patients with the human immunodeficiency virus (HIV) have been described. However, the prevalence, specific characteristics, and outcomes of spinal infections in these patients have not been studied in a large group of patients to our knowledge. METHODS: The computerized records of all patients discharged with the diagnosis of spinal osteomyelitis, discitis, epidural abscess, or tuberculosis from our institution from October 1994 through September 2000 were reviewed. Patients with the diagnosis of HIV were identified, and the charts were examined in detail. RESULTS: During the six-year period, 7338 unique patients who were HIV positive were admitted. Seventeen (0.23%) of them were treated for a spinal infection. The prevalence of spinal infection was 23.2 per 10,000 admissions of HIV-positive patients and 7.1 per 10,000 admissions of HIV-negative patients (p < 0.0001). Eight patients who had discitis and/or osteomyelitis had a mean CD4 T-cell count of 339.6 cells/mm(3), and all eight had clinical resolution of the infection after six to twelve weeks of appropriate antibiotic therapy. In contrast, six patients who had spinal tuberculosis had a mean CD4 count of 75.7 cells/mm(3) (p = 0.005), and one of them died during the hospitalization. The remaining three patients, who had epidural abscesses, had a mean CD4 count of 20.67 cells/mm(3) (p = 0.001), and two of them died. CONCLUSIONS: Discitis and/or osteomyelitis occurs in HIV-positive patients with a mild-to-moderate decrease (>/=200 cells/mm(3)) in the CD4 T-cell count, and the infection responds to appropriate antibiotics. Patients with a more severely decreased CD4 count (50 to 200 cells/mm(3)) may have spinal tuberculosis develop, and patients with the lowest CD4 counts are more likely to have epidural abscesses develop. The three fatalities in this study occurred in these two groups of patients. As a group, HIV-positive patients are significantly more likely to have a spinal infection develop than are HIV-negative patients (p < 0.0001). Although the CD4 count can be used as a predictor of the clinical course, identification of the organism remains paramount in the treatment of this complex patient population.

AIDS-Related Opportunistic Infections↗
PubMedDate not supplied

Vertebral osteomyelitis and psoas abscess occurring after obstetric epidural anesthesia.

BACKGROUND AND OBJECTIVES: Back pain and infectious complications occasionally occur after epidural anesthesia in obstetrics, and accurate diagnosis can be difficult. We report a patient who developed low back pain soon after obstetric epidural anesthesia and was diagnosed 6 months later with lumbar vertebral osteomyelitis, discitis, and a psoas abscess. CASE REPORT: A 34-year-old woman developed persistent low back pain after receiving epidural anesthesia for labor analgesia and cesarean delivery. After 6 months, a diagnosis of lumbar vertebral osteomyelitis, discitis, and psoas abscess was made, and surgery was performed. Because of the temporal and anatomical relationships between epidural catheterization and the development of symptoms, the preceding epidural anesthesia was initially suspected as a potential cause. However, because the posterior spinal elements were unaffected and the infectious agent was subsequently identified as tuberculous, the cause was eventually determined as unlikely to be related to the epidural procedure. CONCLUSION: Investigation of severe back pain after epidural anesthesia should include consideration of infectious causes, such as vertebral osteomyelitis and discitis, which may not be causally related to the epidural catheterization itself.

Adult↗
PubMed1994

[Diagnosis of arthritis in black Africa. Apropos of 473 cases in Congo].

A cross-sectional study of arthritis was conducted in the Rheumatology Department of the Brazzaville Teaching Hospital, Congo. A total of 473 patients with arthritis seen between 1989 and 1991 were subjected to the limited tests available. Gout was the leading diagnosis (n = 83). Septic arthritis (n = 82) and infectious discitis (n = 55) were the most common reasons for admission. Tests often failed to identify the causative organism; Staphylococcus was the most commonly recovered organism. Tuberculous discitis was less common than discitis due to pyogenic bacteria. HIV-related arthritis (n = 57) usually manifested as severe, febrile, asymmetrical, nonerosive, polyarthritis. Cases of rheumatoid arthritis (n = 29) fit the classical description of the disease. In 83 patients with monoarthritis, oligoarthritis, or polyarthritis, no etiology could be identified.

Adult↗
PubMed1997

Septic arthritis of lumbar facet joints. A review of six cases.

Hematogenous infection of the facet joints by pyogenic organisms is exceedingly rare. We report six cases of lumbar facet joint septic arthritis due to hematogenous spread of a pyogenic organism. A review of the literature identified ten anecdotal reports of similar cases. An analysis of these 16 cases showed that the diagnosis was based mainly on imaging study findings and that clinical data failed to discriminate between facet joint septic arthritis and infectious discitis. Increased uptake on the radionuclide bone scan was an early finding and the pattern of uptake was different from that seen in discitis. Computed tomography was the investigation that best delineated the facet joint lesions. Magnetic resonance imaging of the lumbar spine was superior over computed tomography in demonstrating spread of the infection to the epidural space and/or soft tissues and in some instances demonstrated enhancement of the infected facet joint on T1 images after gadolinium injection. Aspiration of the facet joint under fluoroscopic guidance was required only when blood cultures were negative or when the diagnosis of the septic nature of the arthritis was in doubt. Blood cultures yielded a Staphylococcus aureus in the six cases in our series. Appropriate antimicrobial therapy was successful in most cases. In our series, four of the six patients had posterior epiduritis, pyomyositis, or an abscess in the paraspinal muscles or psoas muscle, suggesting that some epidural infections or psoas muscle abscesses believed heretofore to be primary may in fact be complications of facet joint septic arthritis. Facet joint septic arthritis is a new aspect of pyogenic spinal infections that deserves to be considered in patients with febrile spinal syndromes not explained by discitis.

Abscess↗
PubMed1998

Prevalence and clinical presentations of arthritis in HIV-positive patients seen at a rheumatology department in Congo-Brazzaville.

OBJECTIVE: To determine the prevalence and clinical presentations of rheumatic manifestations in HIV-infected patients seen at a rheumatology department in Congo-Brazzaville. METHODS: Over a one-year period, all patients admitted to the Brazzaville Teaching Hospital's rheumatology unit underwent serologic testing for the HIV by ELISA confirmed by Western blot. Standard criteria were used to classify the inflammatory joint diseases seen during the study period. RESULTS: A total of 171 patients, 85 men and 86 women, were tested. The age range was 16 to 81 years, with a mean of 42.1 years. HIV tests were positive in 39 patients, 24 men and 15 women, with a mean age of 31.2 years, accounting for 22.8% of the overall patient population and for 35.1% of all patients with inflammatory rheumatic syndromes. HIV infection stage as determined based on Centers for Disease Control criteria was i.v. in 35 patients and II in the remaining four patients. Of the 39 HIV-positive patients, 32 had HIV-related arthritis, two had reactive arthritis, two had staphylococcal septic arthritis and three had infectious discitis. Of the 72 HIV-negative patients with inflammatory rheumatic syndromes, 22 had septic arthritis, 18 had infectious discitis, five had reactive arthritis, four had rheumatoid arthritis, four had gout, two had poststreptococcal rheumatic disease, one had juvenile chronic arthritis and 16 had unclassifiable arthritis. None of the remaining 60 HIV-negative patients had inflammatory joint manifestations. CONCLUSION: HIV infection was both the leading reason for admission and the leading cause of arthritis. Acute, febrile, asymmetric, nondeforming, nonerosive polyarthritis of the small and large joints responsive to nonsteroidal antiinflammatory drug therapy was the most common clinical pattern of arthritis in HIV-positive patients. Reactive arthritis, septic arthritis and infectious discitis were rarely seen and had no specific features as compared to HIV-negative patients. Patients with arthritis should be tested for HIV infection. It follows that rheumatologists need to know how to provide counselling about HIV testing and how to disclose the results to their patients. They also need to be familiar with the management of HIV infection and to direct careful attention to the prevention of HIV transmission in health care facilities.

Adolescent↗
PubMed2007

Prospective evaluation of contrast-enhanced MR imaging after uncomplicated lumbar discography.

OBJECTIVE: Postdiscography infection is an uncommon complication. Magnetic resonance (MR) imaging is often the modality of choice for evaluating spinal infection. Discography entails disc access and fluid injection that could alter the baseline MR imaging appearance of the spine and be confounded for infection. Our purpose was to describe the MR imaging findings of the lumbar spine subsequent to uncomplicated discography and to determine if this may mimic infection. DESIGN AND PATIENTS: In a prospective cohort study of eight adults (age 22-64 years, mean 45 years) with 22 intradiscal injections, all subjects underwent routine unenhanced and contrast-enhanced MR imaging during the 2-3 week interval postdiscography. A subset of four returned for additional MR imaging during the 4-8 week interval postdiscography. MR images were reviewed for intradiscal, endplate, marrow, and epidural findings and then compared with prediscography examinations. Infection was excluded by clinical documentation. RESULTS: Postdiscography MR imaging showed that almost all levels were similar to baseline prediscography examinations. No levels developed new vertebral marrow edema, fluid-like intradiscal signal, endplate irregularity, or epidural abnormality. Two subjects simulated potential discitis, but these findings were unchanged from prediscography and were related to prior surgery. CONCLUSIONS: Uncomplicated lumbar spine discography does not cause MR imaging changes that simulate discitis.

Adult↗
PubMed1998

Effects on the vertebral end-plate of uncomplicated lumbar discography: an MRI study.

The study aimed to identify and characterise changes occurring in the vertebral end-plate on MRI following uncomplicated lumbar discography. MRI was performed immediately before and within 2 h after uncomplicated lumbar discography in 20 consecutive patients undergoing the study as a precursor to possible spinal fusion. Of these, seven patients underwent a further MRI study at a mean of 72 days after discography (range 19-183 days). The MRI scans were assessed for the presence of any changes in the end-plates prior to and following discography. End-plate changes were identified in eight patients (40%) prior to discography. No new changes in end-plate signal intensity (SI) were identified in either the immediate or delayed MRI studies. The study suggests that any changes occurring in the vertebral end-plate following discography should be considered due to infectious discitis. There is no support for the concept of chemical discitis, chemical irritation of bone or microfracture of subchondral trabeculae as a cause of pain at discography.

Adult↗
PubMed1995

Brucellar spondylitis mimicking lumbar disc herniation. Case report.

In this paper, a patient with brucellar spondylitis who was initially diagnosed as having a lumbar disc herniation is presented. As the disc tissue enlarges in the early stages of discitis because of the inflammatory reaction, it may compress the related root(s) mimicking a disc herniation. For this reason infectious discitis, as in our case, should be kept in mind in the differential diagnosis of the radicular symptoms caused by a disc herniation. The crucial role of magnetic resonance imaging in making the differential diagnosis of the case is especially emphasized.

Adult↗
PubMed2003

A man with backache and renal failure.

Backache, a common symptom, is rarely caused by infection of the lumbar discs. The authors present the case of a 60-year-old man with a Staphylococcus aureus septicemia and associated lumbar discitis in whom a pauci immune crescentic glomerulonephritis and renal failure developed. Treatment with antibiotics and not immunosuppressive agents resulted in improved renal function with a discharge creatinine level of 1.87 mg/dL (165 micromol/L). This case highlights an association of pauci-immune crescentic glomerulonephritis with discitis that responded to antibiotic therapy alone.

Discitis↗
PubMed1988

Complications in the first 40 cases of microdiscectomy.

From 1984 to 1986, a single surgeon treated 40 patients suffering from lumbar disc herniation by the technique of microdiscectomy. While the advantages of working under magnification are endorsed, the complications encountered are analysed with the aim of giving warning to surgeons keen to start the technique. The complications included intraoperative dural tears (two cases), discitis (two cases), and recurrence of back pain (two cases). The intraoperative dural damage did not require specific treatment, while the patients with discitis responded readily with antibiotics. The recurrent cases were found to be caused by adhesion bands produced by hanging tags of incompletely removed yellow ligament. It is therefore concluded that in microdiscectomy prophylactic antibiotics should be given and a complete removal of the yellow ligament on the side of surgery should be ensured to avoid infection and recurrent root impingement.

Adult↗
PubMed2005

Effects of intervertebral disc infection on the developing ovine spine.

STUDY DESIGN: A prospective in vivo animal study. OBJECTIVES: To determine whether infection in the juvenile spine influences spinal development. SUMMARY OF BACKGROUND DATA: Discitis is thought to occur in children when blood-borne infection penetrates the highly vascular immature disc. The condition generally resolves without apparent complication, but little is known about the long-term effects on the growing spine. METHODS: Twenty-nine 6-week-old lambs underwent discography at multiple lumbar levels using radiographic contrast deliberately inoculated with Staphylococcus epidermidis. No antibiotics were given. Plain radiographs were taken at intervals up to 52 weeks after inoculation for morphometric analysis of the vertebral bodies and discs, and the lumbar spines were prepared for histology. RESULTS: Sixteen of 44 inoculated discs showed radiological evidence of discitis between 2 and 6 weeks after inoculation. Disc height and disc area were significantly reduced from 2 weeks, and did not recover during the study period. Vertebral body dimensions and overall lumbar spine length were not significantly affected. CONCLUSION: Infection of juvenile ovine discs impedes disc development but has no significant effect on vertebral body growth.

Animals↗