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Twelve patients underwent biopsy of cervical vertebral bodies under CT guidance. An accurate diagnosis was obtained in 11. No complications were observed, except for a transitory recurrent laryngeal nerve palsy. Technical problems of the cervical spine biopsy are discussed and the utility of bone biopsy with a coaxial trephine system is emphasized.
A 10-year-old boy presented with a 7-day history of back pain and pyrexia. MRI showed an epidural abscess arising from septic arthritis in a lumbar facet joint. Whilst septic arthritis in a large joint is relatively common in children, epidural abscess is rare. This case illustrates how infection in a synovial joint may extend into the extradural space and might be the route of infection in more cases than has previously been recognised.
In a study the results recorded in 34 surgically treated patients with specific or unspecific spondylodiscitis after dorsoventral one-stage instrumentation with CDI and anterior grafting (group 1) were compared with those obtained in a group of 38 patients treated with anterior CDH instrumentation in combination with anterior grafting (group 2). The mean observation periods were 48.4 (19-82) months in group 1 and 29.0 (8-54) months in group 2. In both groups the infection healed after fusion without a secondary operation. In group 1 the mean values for blood loss, operating time, length of hospital stay and fusion length (3.5 segments) were significant higher than those in group 2; in particular, the fusion length was shorter (1.3 segments) in group 2. Only 8 patients in group 1 were treated with postoperative external support. The mean preoperative segmental angle of 18.2 degrees (group 1) was corrected by a mean of 11.9 degrees, and the reposition loss during follow-up amounted to an average of 2.7 degrees. Group 2 showed a mean preoperative segmental deformity angle of 13.4 degrees, which was corrected by 11.6 degrees, and the loss of reposition was 2.9 degrees on average. Even in florid spondylodiscitis a short-range anterior fusion of the affected spinal segment can be performed with a primary stable implant, avoiding a second operation without an increased risk of infection-related dislocation. In the authors' own experience a secondary dorsal operation can be avoided except in the case segment L-5/S-1, the fast mobilization without external support allows a up-to-date treatment in this severe spinal disease.
The operative results of 23 patients with a specific or unspecific spondylodiscitis were documented over 2 years after the focus of the inflammation had been eradicated, bone chip had been interposed and a CDH instrumentation had been performed by an anterior approach only. These outcomes were compared with the results of 32 patients in whom the focus had been removed and the defect had been filled with bone graft from an anterior approach, followed by stabilisation with CD instrumentation through an additional dorsal approach. In the cases where CDH instrumentation was applied, the range of fusion averaged 1.3 segments. This was clearly less extensive than in dorsoventral stabilisation, in which on average 3.5 segments were fused. In 47 of 55 cases mobilisation was achieved without orthesis. Eight months after the operations bony fusion could be observed radiologically in all patients. The mean preoperative kyphotic angle of the affected segments was 14.4 degrees, compared to 4 degrees after the operation. The mean loss of reposition was measured to be about 2.7 degrees in both groups. Average operation time and blood loss were about 50% higher in the patients treated dorsoventrally. We conclude that even in the case of florid spondylodiscitis, a short-range anterior fusion of the affected spinal segment may be performed by use of a stable-angle implant without an increased risk of infection-related loosening.
In 412 patients undergoing surgery for herniated lumbar discs from September 1986 to September 1987 and from January 1988 to July 1989 a microbiological specimen was taken from the intervertebral disc space and from the cover of the operating microscope. Also the tips of the wound drains were examined microbiologically after removal. 17% of the patients had a positive bacteriological culture from their intervertebral disc space; 12% of the specimen from the operating microscope were positive. These results favour the hypothesis that intra-operative contamination of the disc space, in contrast to haematogenous spread, causes spondylodiscitis. On the other hand we saw during this time course only one case of clinical spondylodiscitis, which implies a possible involvement of other predisposing factors such as pre- or perioperative infections or compromised patient immunologically. It is also possible, that the routine application of local antibiotic or antiseptic solutions into the disc space at the end of the operation could decontaminate the operative site and prevent clinical infection despite positive culture findings.
The diagnosis of spondylodiscitis after lumbar disc surgery has been based so far on clinical abnormalities, non-specific changes in chemical laboratory parameters [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)] and radiological examinations such as MRI. Such techniques do not enable any clear diagnosis to be made before the 3rd postoperative week. The PMN elastase released from stimulated polymorphonuclear granulocytes has been proved to be a good laboratory parameter by which it is possible to prognosticate bacterial and abacterial organ complications in surgical patients with a high degree of probability. Under investigation were 12 patients with spondylodiscitis out of 1162 operations on herniated lumbar discs. PMN elastase was determined on the 7th postoperative day. In patients with spondylodiscitis and a mean value of 110.5 micrograms/l, the elastase was on average higher by a factor of 2.6 as compared to 88 randomly selected control patients. Since spondylodiscitis is a rare complication, this results in a positive value of only 7%, which does not allow a reliable diagnosis of spondylodiscitis by the elastase assay. But because the negative predictive value is 100%, it is possible to exclude a postoperative spondylodiscitis already on the 7th postoperative day, if the elastase value is normal.
Five cases of Kingella kingae skeletal infections were diagnosed in children admitted to La Timone Hospital between 1992 and 1997. Patients were between 6 and 31 months old and presented with septic spondylodiskitis, calcaneus osteomyelitis, and hip-joint arthritis. All displayed either an upper respiratory tract infection or eczema during the month prior to their admission. Laboratory findings included an elevated leukocyte count and an elevated erythrocyte sedimentation rate. Standard radiography was unrevealing, but 99mTc bone scans and magnetic resonance imaging showed significant abnormalities. Isolation of Kingella kingae was achieved in all cases by culture of fluid aspirates using the Bactec blood culture system. This bacterium was sensitive to the most common antibiotics tested, and the outcome was favourable in all cases.
Spondylodiscitis due to Citrobacter diversus is rare. An unusual case of bifocal cervical spondylodiscitis following transurethral prostatectomy is reported. C. diversus was detected by urinary cultures and locally by intervertebral disc puncture. Satisfactory recovery occurred after treatment with imipenem and amikacin, and then imipenem alone. Citrobacter infections are still rare in adults but are increasing in immunocompromised patients and sometimes occur in healthy subjects following surgery.
Spondylodiscitis after lumbar disc surgery is a well-known complication with a frequency of 0.1 to 3%. According to the authors, the etiological factors are: combination of operated segment instability, damage to the lower and upper plates due to disc space curettage and transmission of germs. After treatment of 100 selected cases, all with increased risk of postoperative spondylodiscitis, distinct possibilities for prevention have been discovered. Basic treatment consisted of 3 x 80 mg perioperative doses of Gentamicin i.m. In addition a collagen sponge (Sulmycin Implant) containing 50 mg Gentamycin was inserted in the cleared disc spaces of 50 patients. Complications in this procedure were not observed. The following is recommended for prevention of postoperative spondylodiscitis: a careful operating technique, perioperative antibiotics, and in particularly endangered patients, insertion of Sulmycin Implant in the disc-spaces.
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MRI is routinely used in the evaluation and management of patients with failed back surgery syndrome (FBSS). However, its value is unclear in the early detection of signs that can negatively affect that later course of surgical cases. The purpose of the present study is to describe the MR images of early postoperative MRI at 3 days in 30 unselected patients who underwent lumbar microdiscectomy, and to correlate the findings with follow up MRI at 8 weeks and with final outcome. The findings are correlated with literature data. Early postoperative MRI findings were consisting of pseudohernia in 24 patients (80%), annular rent in 23 patients (80%), and other non-specific postoperative findings. On the late MRI the pseudohernia persisted in 12 patients (50%), the annular rent in 4 patients (15%) and asymptomatic pseudo-spondylodiscitis was apparent in 3 patients (10%) as was a case of true spondylodiscitis. Therefore, early postoperative findings have limited value in the management of patients after surgery for lumbar disc herniation, since the images were not correlated with the immediate clinical course after surgery nor with the late radiological and clinical outcome. The evident imaging changes in the early postoperative period after lumbar disc surgery limit the accuracy of the interpretation of MRI examinations.
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A 10-day-old girl who initially presented with fever developed over five days a complete paresis of both upper arms and swallowing difficulty. After emergency drainage of a retropharyngeal abscess, cervical US demonstrated a cervical anterior epidural mass compressing the cord. MRI confirmed the diagnosis of spinal epidural abscess secondary to C4-C5 spondylodiscitis. Surgical removal of the abscess was followed by complete disappearance of the neurologic symptoms after six months of follow-up. This is the first case of spinal epidural abscess in a newborn to be diagnosed by US and MRI preoperatively. The advantages of these non-invasive imaging modalities are discussed, and compared to myelography.
The MR aspects of spondylodiscitis in pediatric patients were studied with a 0.5-Tesla supraconductive magnet: 12 patients were divided in two groups; acute disease (9) and period of sequelae (3). The first group was divided into two subgroups according to the age and the clinical findings: infants (2) and children (7). In infants, MR gave good visualization of the destruction of vertebrae and discs. Presuppurative abscesses appeared as light signals, their extent and position relative to the cord being clearly visualized in frontal and sagittal planes in T1-weighted images. In older children, there were a low vertebral signal and disappearance of the disc-vertebra borders on T1-weighted images and a high vertebral signal with a decreased and flattened disc signal on T2-weighted images. Frontal and sagittal planes were used. During the first month of antibiotic therapy, the follow-up scans showed no changes, and even disclosed a spread of the abnormal signal in the vertebral body. At the stage of sequelae, on T1 the spinal signal was normal with a decreased disc width and on T2 the disc signal was low while the vertebrae appeared normal.
By the description of two cases of osteoarticular infections due to Kingella kingae in two young children we wish to draw the attention of clinicians to invasive infections due to this micro-organism. Since its biological characterization in 1976, K. kingae has been increasingly reported as a human pathogen. Most common presentations are endocarditis, bacteraemia, septic arthritis, osteomyelitis and spondylodiscitis. Interestingly, osteorticular involvement is largely predominant in previously healthy children. From the literature, we reviewed 51 cases of K. kingae bone and joint infections, representing 23 cases of septic arthritis, 17 of osteomyelitis and 11 spondylodiscitis. Of the cases 88% occurred in children below 5 years of age and in all cases only one bone or joint was involved. An underlying disorder could be found in only 4 patients. Since these infections have a favourable outcome with intravenous antibiotic treatment, proper isolation and identification of K. kingae is essential.
Vertebral osteomyelitis rarely mimics pancreatitis. However, the potential consequences of longstanding unrecognized disease, including neurological impairment and bony deformity, should make it an item in the differential diagnosis of chronic pancreatitis. In the evaluation of our patient, four items were of particular importance: awareness of his previously documented S. aureus bacteremia, a markedly elevated ESR, an abnormal chest radiograph, and the positive bone scan.
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