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A case of isolated brucella disk infection mimicking fragmented disk herniation is presented. MRI studies were performed two times in 6 months, both of which did not show any signs of spondylitis. Since brucella infections are seen along with spondylitis, this case has attracted our attention. We focused on radiological findings in this pure brucella disk infection.
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AIM: The present study on spondylodiscitis patients was carried out to compare prospectively and randomized the results of clinical and radiological outcomes of anterior versus posterior instrumentation after debridement and grafting. We aimed to make a recommendation concerning the optimum treatment of spondylodiscitis. METHOD: A total of 22 patients with spondylodiscitis were enrolled in the randomized trial to undergo an operation with anterior or posterior instrumentation after debridement and fusion with autologous bone transplant. 12 patients (group 1) were assigned to posterior Universal Spine System stabilization. 10 patients (group 2) were treated with anterior VentroFix instrumentation. In a prospective clinical investigation we have examined both operative therapies with regard to clinical and radiological outcome. The follow-up was one year. RESULTS: In patients with ventral Spondylodesis (group 2), prior recreation of patients was achieved in clinical examination and blood tests. Radiological results are even equivalent in both groups. Therefore we recommend ventral instrumentation as the superior surgical procedure. But the individual local situation has to enable ventral stabilization. CONCLUSION: We found advantages with anterior instrumentation in comparison to posterior stabilization in patients with spondylodiscitis. Advantages of ventral stabilization cause early mobilization postoperatively without any increase in complication rates. Except for operation time and intraoperative blood loss, no statistical difference were was seen. Important is the individual indication for each method depending on anatomical and clinical signs. Ventral instrumentation should be restricted to cases with sufficient bone stock.
HISTORY: A 56-year-old male patient has suffered from increasing pain in the left foot which limited the ability of walking since 18 months. There was a soft and painful swelling below the left inner ankle. In addition the patient reported back pain, but no neurological symptoms. Insulin dependent diabetes type II was known for 20 years, and a diabetic foot syndrome was suspected. 6 months prior the patient consulted his physician because of repeated acute bronchitis with expectoration and no improvement following antibiotic therapy. INVESTIGATIONS: Osteolytic destruction of the left middle foot and the tarsal with soft tissue infiltration according to MR, a spondylodiscitis of the lumbar vertebra I and II (MR) and mixed interstitial/alveolar infiltrates throughout the lung with a predominance in both upper lobes were found. The microbiological examination of sputum and biopsy of inflamed soft tissue of the left ankle revealed infection with mycobacterium tuberculosis. DIAGNOSIS: Open lung tuberculosis with concomitant bone tuberculosis and tuberculous arthritis of the left middle foot and spondylodiscitis. THERAPY AND CLINICAL COURSE: The antibiotic therapy consisted of a combination of five antibiotic drugs for 2 weeks and of a four drug combination for further 3.5 months. After that there will be a consolidation therapy with a two drug regime for 6 months. An orthopaedist is also involved. Surgical procedures with respect to the left foot will not be considered as long as the antibiotic therapy has not been finished. CONCLUSION: A combination of symptoms resulting from inflammatory bone processes and pulmonary symptoms is always suspicious for a hematogenic dissemination of a pulmonary tuberculosis.
AIM: The aim of this study was to evaluate the clinical and radiological results of surgical treatment of thoracic and lumbar vertebral osteomyelitis by means of one-stage extrafocal posterior stabilisation, anterior debridement, and anterior column reconstruction. METHOD: A retrospective analysis of the peri- and postoperative parameters of 62 patients with a clinical and radiographic follow-up of 2.6 years that were available for 46 patients was performed. In 42 cases, the anterior column was restored with structural bone grafts, in 20 patients, expandable titanium cages filled with morsellised autologous bone and antibiotic collagen sponges were used. To assess the course of spinal alignment a radiometric analysis was undertaken. Furthermore, the Roland-Morris score (RMS) was applied to evaluate the back pain-related disability. RESULTS: The diagnosis was made no earlier than 2.7 months after the first symptoms. Preoperatively, 40 % of the patients presented with neurological impairment, of these 76 % improved after surgery. Staphylococcus aureus was the most common pathogen isolated (32 %), Mycobacterium tuberculosis was found in 11 % of the patients. Except for one patient with revision for persistent infection and consecutive failure of the bone graft, primary eradication of the infection was achieved in all cases. At follow-up, bony fusion was radiographically observed in all patients. When using cages, the segmental loss of correction was significantly lower than when using bone grafts (1.0 vs. 4.1 degrees ). At follow-up the RMS averaged 6.6. CONCLUSION: One-stage extrafocal posterior stabilisation combined with anterior debridement and anterior column reconstruction with bone grafts or titanium cages is a safe and effective strategy for patients with vertebral osteomyelitis in need of surgery. Titanium cages have proven to be biomechanically advantageous, especially in cases of extensive destruction and are not associated with higher rates of persistence or recurrence of infection compared to autologous bone grafts.
AIM: The aim of this study was to investigate the effects of temporary distraction on a degenerated intervertebral disc to characterize regenerative changes associated with disc distraction. METHOD: New Zealand white rabbits (n = 32) were used for this experimental animal study. The rabbits were randomly assigned to one of five groups. 6 animals were loaded for 28 days using a custom-made external loading device to stimulate disc degeneration (G2). In 6 animals the discs were first loaded for 28 days and after 28 days loading time the discs in six animals were treated as dynamic distraction with an external distraction device (G1). In six animals the discs were distracted for 28 days without previous loading (G5) and in six animals the discs were loaded for 28 days and afterwards the loading device was removed for 28 days for recovery without distraction (G3). Six animals were sham operated (G4) without application of axial load. After 28 to 56 days loading and distraction time, the animals were sacrificed and the lumbar spine was harvested for histological and radiographic analysis. Histology was performed according to a degeneration score and disc height was calculated radiographically. For the cell viability examination, the number of apoptotic cells was determined. RESULTS: After 28 days of loading (G2), the discs showed a significant decrease in disc space of the treated segment. Histologically, a disorganization of the architecture of the annulus occurred. The number of dead cells increased significantly in the annulus and cartilage endplate. These changes were reversible after 28 days of distraction (G1). The disc thickness increased significantly to physiological levels as compared to the specimens from the 28 days loading group without distraction. Histologically, the discs showed signs of tissue regeneration after 28 days of distraction (G1). The number of apoptotic cells decreased significantly in comparison to the loaded discs without distraction (G2). CONCLUSION: The results of this study suggest that disc regeneration can be induced by axial dynamic distraction in the moderately degenerated rabbit intervertebral disc. The decompressed rabbit intervertebral discs showed signs of tissue recovery at the cellular and histological levels after temporary disc distraction.
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BACKGROUND AND OBJECTIVE: The involvement of the cervical spine in rheumatoid arthritis can be essential regarding prognosis and mortality. The cervical myelopathy due to pannus formation and/or subluxation can be fatal. Aim of this study was to demonstrate the possible changes seen by MRI, and to establish a risk-profile for the individual patient. PATIENTS AND METHOD: Within a period of 24 months 214 patients with active RA were included. Clinical and laboratory data were obtained and plain radiographs of the cervical spine were taken. In patients with pathological findings on X-ray an MRI was performed (36 patients). RESULTS: Within the group of 214 patients 36 were identified to get an cervical spine MRI. In all cases the MRI showed significant changes: in 7 (19.5 %) pannus surrounded the dens, with additional erosions in one patient (2.7 %). In 25 (69.5 %) atlanto-axial-subluxation was present, 7 (19.5 %) showed a spondylodiscitis below C2. In 10 (27.8 %) a cervical myelopathy due to pannus or subluxation was present. There was no correlation of the MRI-results with symptoms and findings by examination. The patients with cervical spine disease were in all stages of RA. The majority was rheumatoid-factor positive. 5 out of 10 patients with cervical myelopathy showed neurological deficits: 3 patients died in consequence of neural compression, 2 patients underwent surgery successfully. CONCLUSION: The early detection of a cervical spine involvement in RA is essential to avoid possibly fatal complications. The only reliable method to achieve this goal has to include radiographic diagnostic including MRI of the cervical spine. Only this approach can answer the question of the right time-point for surgery. In daily clinical practice the cervical-spine involvement in RA is still underestimated.
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MRI of proven spondylitis was performed in 39 patients. Acute spondylitis appeared hypointense on T1-weighted and hyperintense on T2-weighted images. Following intravenous application of Gd-DTPA, enhancement of the marrow and disk was seen. With progressive healing increasing signal was seen on T1-weighted images. This was caused by the presence of focal fat marrow representing the first sign of therapy response. Corresponding to the clinical healing process T1-signal increased due to fatty marrow, while the T2-signal decreased as well as the enhancement following Gd-DTPA application. Therefore, MR imaging can be recommended as the method of choice for early diagnosis of spondylitis and assessment of therapy response.
Pathogenically the erosive intervertebral osteochondrosis is the destructive form of the intervertebral osteochondrosis. This paper aims to define this acute variant by means of diagnostic criteria. In differential diagnosis a spondylodiscitis, an ankylosing spondylitis, a destructive spondylo-arthropathy and a morbus Scheuermann must be considered. Fifteen patients with erosive osteochondrosis were treated at the Department of Orthopaedic Surgery of the University of Mainz between 1990 and 1994. The diagnosis on admission into hospital was incorrect in all cases. Plain X-rays showed a decrease in height in the affected intervertebral room and bony erosions of the adjacent vertebral endplates. Distinction to spondylodiscitis was possible in MRT. In contrast to erosive osteochondrosis in spondylodiscitis edema cannot only be seen in the adjoining vertebrae but also in the affected disc. In later paravertebral inflammatory abscess often can be found. After conservative treatment four patients were free of complaints. 11 patients were operated on due to neurologic symptoms or increasing kyphosis of the lumbar spine. At average follow-up of 16 months intervertebral fusion was found in all operated patients. Lack of publicity and severance to spondylodiscitis seem to be major problems in diagnosing erosive osteochondrosis.
Correct treatment of destructive lesions in the vertebral column requires exact radiological evaluation with the traditional techniques of plain films, computed tomography and radionuclide scanning. With the development of magnetic resonance imaging the possibility of visualizing pathological changes of the bone marrow became apparent. To prove the value of MRJ in detecting destructive lesions of the spine 29 patients were investigated using plain radiographs, computertomographies, radionuclide scanning and MRJ. The findings were correlated to the intraoperative aspect of the lesion and the results of the histological investigation in 18 cases. MRJ showed to be a very sensitive manner of detecting bone marrow changes of different kind. Indeed characteristic changes in signal intensity were not to be observed in pathological lesions of inflammatory or tumorous genesis. So the distinction is based on morphological criterias.
Out of 144 patients with kyphotic deformities in Ankylosing spondylitis 33 (23%) had 45 disco-vertebral lesions of the spondylodiscitic type. They were characterized by osteolyses, scleroses and absence of syndesmophytes. 5 had additional arch fractures. All were localized in or below the apical vertebra in the lumber or the lower thoracic spine. Compared with the total collective strong pain, high sedimentation rates and extravertebral manifestations were more frequent, osteoporosis rare, and the degree of kyphosis and the types of ossification same. The radiology showed the lesions as inflammatory etiology. Functionally, however, they are pseudarthroses. All spines were lordosed by dorsal osteotomies and therewith statically corrected and for one year externally immobilized. The spondylodeses fusioned in this time. Complications did not occur on account of the spondylodiscites. The therapy of kyphosis had an influence on the spondylodiscites. They all healed except for one. After a follow up of two years 98% were completely fused, also those with non-identical levels of correction and lesion. The loss of correction in the segments of lesion was negligibly more than in the total collective. 91% of the patients were pain-free compared to 12% preoperatively. The spondylodiscites were no hindrance for dorsal lordosing osteotomies and can be treated successfully by means of this static correction and the immobilisation.
New aspects regarding the diagnosis of spondylodiscitis are shown by means of the casuistics of a severe immobilizing lumbar syndrome. In this special case only the MR-examination was able to make clear the diagnosis, at a time when all other diagnostic methods failed. The MR-examination was taken as primary and progressive diagnostic method and it also decided about therapeutic consequences.
In the time from 1980 to 1987 58 patients underwent a conservative or operative treatment of spondylitis and spondylodiscitis according to the individual clinical and radiological features. In early or moderately advanced stages of the disease conservative therapy was performed. Under bedrest and antibacterial or tuberculostatic drug therapy bony fusion of the affected vertebral bodies was achieved in 50% of the pyogenic cases. In tuberculous spondylitis fusion rate was 83%. Persistent septic changes, progressive neurological symptoms and gross vertebral damage are indications for surgery. In those cases removal of the focus and intercorporal spondylodesis was performed. Bony union occurred in every cases. At follow-up examination, 3 years after the onset of therapy on an average, 42 patients had no complaints according to the vertebral column. As the results of our study show spondylitis and spondylodiscitis should according to the clinical and radiological features be lead to a differentiated operative or conservative treatment. Then good clinical results are to be supposed.
Spondylodiscitis is a frequently unrecognized disease in childhood because of unspecific symptoms and late arising or radiological signs. The heterogeneous symptoms, the value of diagnostic procedures and the outcome of 8 patients suffering from spondylodiscitis in the time period of 1989 to 1995 are demonstrated. Guiding symptoms were back pain and refusal to walk or sit. Furthermore, abdominal pain and psoas abscess were the only symptoms in two cases. The pathogenomonical narrowing of the disc space arose in X-ray films earliest 3 weeks after onset of symptoms. The MRI was the best method for early diagnosis and detection of complications. In contrast to persistent radiological changes the clinical outcome was good in most of the patients.
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