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PubMed1989

Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitals.

We determined the incidence of acute, major complications in a population of 28,395 patients who underwent lumbar laminectomy for discogenic radiculopathy in the United States in 1980. This population was drawn from a broad cross-section of community hospitals and represented 31% of all patients who underwent laminectomy that year for this condition. Our cohort excluded patients with a) operations exceeding two disc levels, b) fusion, c) previous lumbar laminectomy, or d) coexistent discitis, spondylosis, spinal stenosis, myelopathy, or arachnoiditis. The incidence of death was 5.9 per 10,000. The causes of death were septicemia, myocardial infarction, and pulmonary emobolus. The incidence of at least one major complication was 157 per 10,000. The incidences of specific complications were as follows: infection requiring intravenously administered antibiotics, 30.7; major neurological deficit, 29.8; pulmonary embolus, 10.7; and myocardial infarction, 5.6. We studied four additional categories of complication. Patients were counted only when a second operation was required to treat the complication. The categories and incidence per 10,000 were as follows: incisional hematoma, 8.7; cerebrospinal fluid fistula, 10.5; ventral perforation, 1.6; and retention of a foreign body, 0.7. Among the patients whose hospitalizations were otherwise normal, 6.7% received a blood transfusion; of the patients whose hospitalizations were complicated, 24% required transfusion. The demographic characteristics of transfusion. The demographic characteristics of patients with a normal hospitalization were tabulated separately from those whose hospitalizations were complicated. Neurosurgeons performed 60% of the operations, and orthopedic surgeons performed 40%. The speciality of the surgeon was not a factor in determining the risk involved in surgery. Spinal anesthesia was used in 7% of the cases, and no pattern of complications emerged that was uniquely related to that technique.

Demography↗
PubMed1978

Metastatic disc infection and osteomyelitis of the cervical spine. Surgical treatment.

Two cases of vertebral osteomyelitis and discitis in the cervical spine are presented, both having arisen from hematogenous spread to the spine. Bacteriologic diagnosis was established in 1 patient, but the infection had subsided in the other. Both patients were treated with anterior debridement and fusion, and a supplemental posterior wiring and fusion was performed in the second case to reduce kyphotic angulation. In the second case, both the anterior and posterior surgery were performed while the patient was under the same anesthetic. Satisfactory results were achieved in both cases.

Adult↗
PubMed1988

Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double-blind study.

A prospective, multiinstitutional, double-blind trial comparing the effect of chymopapain (Discase) vs. placebo (cysteine-edetate-iothalamate: CEI) for lumbar intervertebral disc rupture with sciatica was carried out on 173 patients, the largest such study reported to date. Patients were matched with respect to age, sex, physical habitus, and level of injection. The procedure was carried out under local anaesthesia. The success rate was superior in the chymopapain group regardless of the method used to assess outcome or the time over the first 6 months at which the two groups were compared: 71% vs. 45% if code breaks were analyzed at 6 months, and 67% vs. 44% if code breaks were defined as lost to follow-up. A single case of anaphylaxis and one case of septic discitis were the only serious complications noted. This study supports the role of chymopapain in the treatment of lumbar disc rupture with sciatica.

Adolescent↗
PubMed1994

Prevalence of incidental intraspinal lipoma of the lumbosacral spine as determined by MRI.

STUDY DESIGN: The prevalence and appearance on MRI of lipomas of the filum terminale was studied in a random population referred to MRI for evaluation of the lumbosacral spine. The MRI scans of 100 patients selected at random were retrospectively reviewed. OBJECTIVES: The study sought to determine the frequency and MRI appearance of incidental filum lipomas in a random population. SUMMARY OF BACKGROUND DATA: Postmortem studies have reported a 4%-6% incidence of occult fibrolipomas of the filum terminale in what were thought to be otherwise normal spinal cords. The improved resolution of MRI imaging allows the detection of small amounts of fat associated with the filum terminale that heretofore had not been demonstrated on radiologic imaging examinations. METHODS: The lumbosacral spine unenhanced MRI scans of 100 patients not previously operated upon were selected at random and were retrospectively reviewed by two of the authors (EB and JCM). RESULTS: Of the 100 MRI examinations reviewed, four patients were found to have small lipomas of the filum terminale. No spinal dysraphism or cord tethering were present in these four patients. Their clinical symptoms were related to disc herniation in two patients, spinal stenosis in one, and discitis in one. The lipomatous tissue was hyperintense to cerebrospinal fluid (CSF) on T1-weighted images and hypointense to CSF on T2-weighted images. CONCLUSIONS: Incidental lipomas of the filum terminale were present in 4% of 100 lumbosacral spine MRI examinations in a random population.

Adult↗
PubMed1994

Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch.

UNLABELLED: OBJECTIVES AND SUMMARY OF BACKGROUND DATA: Cerebrospinal fluid fistula after spinal surgery is associated with a definite risk of meningitis or discitis, and as a result, early active intervention usually is recommended. METHODS AND RESULTS: This report describes the successful use of an epidural blood patch after a more conventional intervention--namely, surgical re-exploration--had failed to control a postoperative cerebrospinal fluid leak. CONCLUSIONS: The techniques involved in performing a blood patch after spinal surgery may well differ from those usually recommended in the management of spinal headache resulting from other causes of dural puncture.

Aged↗
PubMed1995

The effect of prophylactic antibiotics on iatrogenic intervertebral disc infections. a rabbit model.

STUDY DESIGN: A rabbit model was used to test the efficacy of two commonly used prophylactic antibiotics, cefazolin and vancomycin, in preventing iatrogenically introduced Staphylococcus aureus intervertebral disc infections. OBJECTIVE: This study was performed to assess the efficacy of two prophylactic antibiotics in preventing iatrogenically introduced Staphylococcus aureus intervertebral disc infections. SUMMARY OF BACKGROUND DATA: Previous studies have had conflicting results regarding the penetration of antibiotics into the nucleus pulposus and their ability to eradicate infection. METHODS: In this study, 40 adult New Zealand White rabbits underwent inoculation of 10(1) or 10(3) Staphylococcus aureus/ml into 3-6 lumbar intervertebral discs under direct visualization. Either no antibiotics (control groups) or various preoperative and postoperative dosing schedules of cefazolin or vancomycin were given intravenously. Five days after surgery, the discs were harvested and cultured. RESULTS: All 40 discs inoculated in the control groups became infected. None of the 35 discs inoculated in the cefazolin groups became infected. Infection developed in 23 of 107 discs inoculated in the vancomycin groups. Most notable of these were 17 of 17 positive cultures in animals given vancomycin 8 hours preoperatively only. CONCLUSIONS: Based on these results, it was concluded that intravenous cefazolin or vancomycin given within 1 hour before surgery can effectively prevent postoperative discitis. No advantage was found with additional postoperative antibiotics.

Animals↗
PubMed1998

An unusual cause of low back pain. Osteomyelitis of the spinous process.

STUDY DESIGN: A case report of osteomyelitis of the spinous process. OBJECTIVE: To describe the diagnosis and successful treatment of a patient with spinous process osteomyelitis. SUMMARY OF BACKGROUND DATA: Spinous process osteomyelitis is exceedingly rare and may be misdiagnosed as paraspinal muscle strain, discitis, or vertebral body osteomyelitis. The clinical presentation of spinous process osteomyelitis is subtle, laboratory findings are nonspecific, and radiographs are often normal. METHODS: The diagnosis, treatment, and outcome of two patients with spinous process osteomyelitis (an adult and a child) with insidious, nonspecific lumbar pain and fever are reviewed. RESULTS: Magnetic resonance imaging with and without gadolinium enhancement demonstrated increased signal of the spinous process with paraspinous musculature enhancement, a finding consistent with spinous process osteomyelitis. Biopsy results demonstrated the presence of staphylococcus aureus in the child and no organisms in the adult. Treatment with intravenous antibiotics led to resolution in both cases. CONCLUSIONS: The use of magnetic resonance imaging technology permitted the early and accurate diagnosis of spinous process osteomyelitis.

Child↗
PubMed1998

Imaging of the cervical spine.

The emergence of multiplanar spiral computed tomography and high-resolution magnetic resonance imaging has resulted in the ability to see cervical spine anatomy and pathologic conditions in detail. Appropriately chosen and performed, these imaging studies can provide an anatomic basis for a clinical diagnosis and a therapeutic plan. In the evaluation of cervical spondylosis, magnetic resonance imaging is more commonly performed than computed tomography because of its superior depiction of soft tissue anatomy, including intervertebral discs and spinal cord disease. However, computed tomography still has a role, particularly in the assessment of osseous neural foraminal stenosis. In cervical spine trauma, routine radiography remains the procedure of choice. Computed tomography is performed in patients who have abnormal plain radiographs or in patients in whom there is a strong clinical suspicion of fracture with inconclusive radiographs. In the neurologically compromised patient, magnetic resonance imaging is useful in the diagnosis of cord and nerve root injury. Magnetic resonance imaging is the most sensitive and specific imaging study in the assessment of spinal infection, including osteomyelitis, discitis, and epidural abscess. Magnetic resonance imaging has also supplanted all other imaging methods in the evaluation of primary and secondary tumors of the spinal cord and spinal column. Despite the precise depiction of cervical spine anatomy provided by these imaging methods, the role of the clinician in determining the true cause of a patient's symptoms is in no way diminished. The presence of an imaging study abnormality does not automatically imply causality.

Cervical Vertebrae↗
PubMed2000

Effects of very high antibiotic concentrations on human intervertebral disc cell proliferation, viability, and metabolism in vitro.

STUDY DESIGN: Four antibiotics commonly used during spinal surgery (cefazolin, gentamycin, cefamandole, and vancomycin) were tested for their effects on cultured human disc cells from the anulus. OBJECTIVE: To determine the viability, proliferation, and metabolism of cells cultured from the human anulus after they were exposed to four antibiotics. SUMMARY OF BACKGROUND DATA: Previous studies concerning the effect of antibiotics on the disc have used animal models or explanted discs, but little is understood about the effect of antibiotics on the proliferation, viability, and metabolism of cells from the anulus. METHODS: In this study, 3H-thymidine incorporation, trypan blue exclusion, and cell metabolism were determined using cells from the human anulus grown in monolayer culture. The latter measurement used a cytosensor microphysiometer to monitor the rate at which cells acidified their microenvironment, an event that is proportional to cellular metabolism because it reflects the excretion over time of acidic products such as lactic acid from glycolysis and CO2 from cellular respiration. RESULTS: After 48 hours of antibiotic exposure, cell viability was significantly lower as a result of all four antibiotics at the highest concentration tested. Cell proliferation was lower after exposure to cefazolin and cefamandole. During a 6-hour antibiotic exposure, anulus cells in the highest concentration of cefamandole or vancomycin displayed a significantly decreased rate of cell metabolism. CONCLUSIONS: These findings show that high doses of antibiotics can have direct, deleterious effects on cultured disc cell survival, cell proliferation, and metabolic rates. Discitis is a serious primary or postoperative complication that often requires prolonged antibiotic treatment. Studies such as the current investigation with cultured cells from the anulus show the importance of a greater understanding concerning antibiotic effects on disc cell proliferation and metabolism.

Adult↗
PubMed2001

Pyogenic spondylitis in an S1-S2 immobile segment.

STUDY DESIGN: A case of pyogenic spondylitis in S1-S2 is presented. OBJECTIVE: To describe the diagnosis and management of this rare spondylitis. SUMMARY OF BACKGROUND DATA: The segment including the first and second sacral vertebrae is not mobile. Therefore, discitis of S1-S2 and adjacent spondylitis is very rare. To the authors' knowledge, this is the first reported case of infectious spondylitis in an immobile segment: S1-S2. METHODS: In addition to radiography and bone scintigraphy, magnetic resonance imaging was used to confirm the diagnosis. Changes consistent with infectious spondylitis were shown, including an epidural abscess. RESULTS: The patient was treated with laparoscopic drainage and biopsy. Staphylococcus aureus was cultured, and adequate antibiotics were administered. Repeat magnetic resonance imaging at approximately 4 months demonstrated normal signal intensity and disappearance of the abscess. CONCLUSION: Findings from this study show that pyogenic spondylitis can occur in immobile S1-S2.

Adolescent↗
PubMed2001

Zenker's diverticulum associated with multilevel cervical osteomyelitis.

STUDY DESIGN: A case report of cervical osteomyelitis possibly associated with a Zenker's diverticulum perforation. OBJECTIVES: To present clinical, radiologic, and surgical findings of a cervical osteomyelitis due to a Zenker's diverticulum perforation. SUMMARY OF BACKGROUND DATA: A 56-year-old patient was in an intensive care unit for a severe head injury. He was fed via a nasogastric tube. Four months later he developed a pyogenic cervical vertebral infection. METHODS: Plain films and magnetic resonance imaging showed a diffuse cervical osteomyelitis. Investigation of his dysphagia revealed a Zenker's diverticulum. RESULTS: After administration of antibiotics and surgical treatment of the diverticulum, the cervical infection resolved. Plain films and magnetic resonance imaging showed healing with vertebral fusion. CONCLUSIONS: Cervical osteomyelitis is uncommon. Only one case of direct contamination leading to cervical vertebral osteomyelitis after esophageal perforation has been previously described. Direct contamination of the prevertebral soft tissues by bacteria traveling through the fistula may have occurred. The development of vertebral osteomyelitis in this case is consistent with the hypothesis of direct contamination. Management relies on appropriate antimicrobial therapy and surgical management of the diverticulum. The association of Zenker's diverticulum with vertebral osteomyelitis and discitis is a unique, previously undescribed situation.

Anti-Infective Agents↗
PubMed2002

Nocardia farcinica spinal osteomyelitis.

STUDY DESIGN: A case of disseminated Nocardia farcinica infection with spine involvement is reported. OBJECTIVE: To describe the first case of Nocardia farcinica spinal osteomyelitis, and to propose spine instrumentation with debridement and multiple antibiotics for treatment of nocardia spinal osteomyelitis. SUMMARY OF BACKGROUND DATA: Only 11 cases involving Nocardia asteroides spinal osteomyelitis have been reported over the past 40 years. These case reports describe various presentations and treatments of nocardia spinal osteomyelitis. METHODS: A 54-year-old nonambulant, paraparetic man was admitted to the authors' hospital with acutely increased low back pain, fever, and signs of dementia. A disseminated Nocardia farcinica infection including spinal osteomyelitis at T11, T12, L1, L2, and L4; epidural abscess T10-L4, L5-S1 discitis, empyemas, cerebral abscess, and bilateral psoas abscess was noted. RESULTS: Antibiotic therapy, multiple debridements, and posterior instrumentation were performed to palliate the Nocardia farcinica infection. At a recent 3-year follow-up assessment, the patient was independent and ambulant. He had been off antibiotics for 5 months. CONCLUSIONS: Previous case reports of nocardia spinal osteomyelitis describe treatment with antibiotics, debridements, and arthrodesis with autologous bone graft. Prolonged recumbency ensued. In the reported case, a combination of antibiotics, debridements, arthrodesis, and posterior instrumentation for immediate stabilization of the spine resulted in a favorable outcome at 3 years.

Epidural Abscess↗
PubMed2001

Questioning the sensitivity of magnetic resonance imaging in early septic spondylodiscitis.

Septic spondylodiscitis is an uncommon disease, but one with serious complications and potentially high morbidity and mortality. The diagnosis is sometimes delayed, particularly in those patients with an insidious mode of onset and nonspecific symptoms. Several imaging methods are available to facilitate the early diagnosis of septic spondylodiscitis, and of these methods magnetic resonance imaging (MRI) has been reported to be the most sensitive, revealing abnormalities earlier than plain x-ray, gallium scan and bone scan. We report a case of septic spondylodiscitis in which MRI did not demonstrate evidence of discitis after a symptom period of seven days. The diagnosis was later confirmed by bone scan and repeat MRI. We suggest that a negative or equivocal MRI cannot exclude infective spondylodiscitis, especially in the early stages of the disease process. In such cases, it is important to note that the addition of a short tau-inversion recovery sequence will increase the sensitivity of MRI, and, additionally, gadolinium should be administered if the magnetic resonance study is negative and a strong clinical suspicion of spondylodiscitis exists.

Journal Article↗
PubMedDate not supplied

Superior hypogastric block: transdiscal versus classic posterior approach in pelvic cancer pain.

OBJECTIVE: The classic posterior approach of superior hypogastric block has several technical difficulties. The transdiscal approach is a novel and easier approach for superior hypogastric which overcome these technical difficulties. METHODS: Thirty patients were randomly allocated to two groups: The transdiscal group and the classic group; visual analog scale pain scores, daily morphine consumption, duration of the procedure and side effects were recorded. RESULTS: The duration of the procedure was significantly decreased in the transdiscal group (24.4+/-5.6 min) compared to the classic group (57.9+/-9.8 min). There were no significant differences between the 2 groups in daily morphine consumption and VAS pain scores. There was no discitis, disc rupture, or herniation in the transdiscal group. CONCLUSION: The transdiscal approach for superior hypogastric plexus block in pelvic cancer pain is easier, safer, and more effective with less side effects than the classic approach.

Aged↗
PubMed2006

Spinal infections: diagnostic tests and imaging studies.

UNLABELLED: Clinical signs and symptoms caused by spinal infections often are subtle and insidious; therefore, clinical suspicion in patients with nonmechanical pain is important in making the correct diagnosis in the early stage of disease. Serologic tests such as erythrocyte sedimentation rate and C-reactive protein are quite sensitive, but specificity is relatively low. Imaging tests include plain radiographs, radionuclide studies, computed tomography scan, and magnetic resonance imaging. Changes on plain radiographs appear at least 3 to 4 weeks after the onset of disease. Bone scan is a sensitive but not a specific test. Computed tomography provides structural details in the bone and intervertebral disc but magnetic resonance imaging is a superior imaging test for diagnosing infections earlier and more accurately. In many patients, percutaneous or open biopsy is required to make the definitive diagnosis of discitis or osteomyelitis and the organism responsible for the infection. Early and accurate diagnosis of spinal infections will lead to less invasive treatment for the patient. LEVEL OF EVIDENCE: Level V (Expert Opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Bacterial Infections↗
PubMed2006

Penetration of cephazolin in human lumbar intervertebral disc.

STUDY DESIGN: Levels of the antibiotic cephazolin were measured in disc and blood from a consecutive series of patients undergoing lumbar spinal fusion. OBJECTIVES: To determine if levels of cephazolin in the human disc reach the stated minimum inhibitory concentration against Staphylococcus aureus (1 mg/L) following intravenous administration, and to determine if there is a therapeutic relationship between serum concentration and disc concentration. SUMMARY OF BACKGROUND DATA: Disc space infection is a potential complication of surgical procedures that violates the intervertebral disc. Bacteria, often from normal skin flora, can be introduced into the disc space causing inflammation with destruction of the adjacent vertebral endplate. Although there is substantial evidence from animal studies that prophylactic antibiotics reduce the incidence of discitis, similar evidence in human beings is not strong. METHODS: A total of 30 patients, including 15 females and 15 males, with a mean age 42 years (range 21-63), received 1-g cephazolin (intravenous) during 1 or 2-level lumbar spinal fusion surgery. Venous blood was collected before administration of cephazolin and again at disc removal. Disc cephazolin concentrations were measured at the same time serum levels were measured for each patient. RESULTS: The interval between cephazolin administration and tissue sampling ranged from 7 to 137 minutes. Cephazolin concentration in the serum (range 31.1-148 mg/L) was higher than in the disc (range 0-9.5 mg/L). The concentration of cephazolin peaked in the serum at 7 minutes, and in the disc between 37 and 53 minutes. More than 70% of the disc samples had detectable levels of cephazolin at the time the disc was removed, although only half of these samples had cephazolin levels higher than 1 mg/L. All serum cephazolin concentrations were higher than 1 mg/L. Serum cephazolin concentration did not relate to disc concentration at a given time. CONCLUSIONS: The time when antibiotic concentration is highest in the disc varies among patients. More than 70% of disc samples had detectable levels of cephazolin, although only half of the discs contained cephazolin higher than the stated minimum inhibitory concentration for S. aureus(>1 mg/L). Factors such as molecular charge, degree of disc degeneration, and disc size may influence antibiotic penetration into the disc.

Adult↗
PubMed2006

Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center.

STUDY DESIGN: We performed a retrospective review of 48 cases of pyogenic spinal infection presenting over a 12-year period to the National Spinal Injuries Unit (NSIU) of the Republic of Ireland. The NSIU is the tertiary referral center for all adult spinal injuries and diseases of the spine warranting surgical intervention in the Republic of Ireland. OBJECTIVES: The objective of this study was to analyze the presentation, etiology, management, and outcome of nontuberculous pyogenic spinal infection in adults. SUMMARY OF BACKGROUND DATA: Pyogenic spinal infection encompasses a broad range of clinical entities, including spondylodiscitis, septic discitis, vertebral osteomyelitis, and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. METHODS: The medical records, radiologic imaging, and bacteriology results of 48 patients with pyogenic vertebral osteomyelitis from 1992 through 2004 were reviewed. The Hospital Inpatient Enquiry (HIPE) System and the NSIU Database were used to identify our study cohort. RESULTS: The average age of presentation was 59 years with an even distribution between males and females. Most patients (21 of 48) were symptomatic for between 2 and 6 weeks before presenting to hospital. The most frequently isolated pathogen was Staphylococcus aureus, in 23 of 48 cases (48%); 35 of 48 cases (73%) were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 13 of 48 cases (27%), surgical intervention was required because of neurologic compromise or mechanical instability. CONCLUSIONS: In the majority of cases, conservative management of pyogenic spinal infection with antibiotic therapy and spinal bracing is very successful. However, in a minority of cases, surgical intervention is warranted and referral to a specialist center is appropriate.

Adult↗
PubMed2006

Staphylococcal septic synovitis of the sternoclavicular joint with retrosternal extension.

Bacterial arthritis of the sternoclavicular joint is an uncommon disorder caused by a variety of microorganisms. Both Gram-positive and Gram-negative bacteria have been identified as etiologies of an acute suppurative arthritis, whereas a few other bacteria such as mycobacteria and treponemes have been incriminated in chronic disease of the sternoclavicular joint. We recently treated a patient with staphylococcal synovitis of the sternoclavicular joint, which is the 24th recorded in the literature. His illness was complicated by a retrosternal abscess, soft tissue abscess of the chest, septic bursitis, and lumbosacral discitis. He recovered after 6 weeks of nafcillin therapy without any residual infection. Six previous patients with extension into the substernal space and mediastinum have been described. Staphylococcal infection of the sternoclavicular joint, although usually confined to the joint, can be associated with sepsis and metastatic abscess formation as well as substernal extension even in immunocompetent individuals.

Abscess↗