Spinal subdural empyema complicating cervical discography.
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Discitis↗
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Pyogenic spinal sepsis in adults.
Twenty adult patients presented with bacteriologically and histologically proven nontuberculous spinal sepsis. Thirteen patients presented with varying degrees of neurologic impairment. All patients underwent spinal decompression; in 11 this was combined with an anterior fusion using autogenous tricortical iliac grafts. All patients have recovered and are ambulatory, and no patient's disorder was made worse by surgery. Twenty-three separate organisms were cultured, only five of which were Staphylococcus. The antibiotic courses were shorter and pain relief more rapid with anterior fusion. All anterior bone grafts incorporated rapidly, and there was no progression of kyphosis or sequestration of grafts, regardless of organisms or level. The rational treatment of adult spinal sepsis necessitates the securing of tissue from the spine for histologic and bacteriologic examination. Pain relief, stabilization, and neural decompression can best be achieved with anterior decompression and fusion. Autogenous iliac crest grafts incorporate in the presence of sepsis.
Back Pain↗
Aspergillus infection of the L3-L4 disc space in an immunosuppressed heart transplant patient.
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Adult↗
Vertebral collapse following spinal anesthesia.
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Anesthesia, Spinal↗
Erythrocyte sedimentation rate after lumbar spine surgery.
The erythrocyte sedimentation rate and total white cell count were measured in 110 patients who underwent lumbar spine surgery. Measurements were made before surgery; at 2 and 4 days; and at 1, 2, 6, and 16 weeks after surgery. A rapid increase of erythrocyte sedimentation rate was seen with peak value on the fourth postoperative day. After 2 weeks, the values were normalized for the majority of patients. Maximum mean peak value was seen 4 days after surgery for fusion (ESR = 102), which was higher than after disc surgery (ESR = 75). There was no corresponding change in total white cell count. No deep infection was noted in the study group. The erythrocyte sedimentation rate values and total white blood cell count at the time of diagnosis for five patients with postoperative deep infection were used for comparison. At the time of diagnosis, all patients with deep infection had an erythrocyte sedimentation rate value exceeding the corresponding mean value (+ 2 SD). Total white cell count was slightly elevated in one of the five infected patients; the remaining four had a normal count. Erythrocyte sedimentation rate determination shows a homogenous pattern with rapid increase and decline after lumbar spinal surgery in patients without postoperative infection, and patients with postoperative deep infection at the time of diagnosis show erythrocyte sedimentation rate elevation to a degree that usually makes the result diagnostic.
Blood Sedimentation↗
Cervical discography complications and clinical efficacy.
To determine the incidence and magnitude of complications of cervical discography as well as to assess the clinical results of operative treatment based on discographic findings, a series of 31 patients who underwent cervical discography was reviewed. Twenty-six patients (84%) experienced provocative concordant symptomatology and were considered positive. The overall complication rate was 13% (4/31), including the development of an acute epidural abscess that led to myelopathy and eventual quadriplegia. Of the twenty-two patients who underwent anterior cervical discectomy and fusion on the basis of cervical discography, one patient had an excellent result (5%), nine patients had good results (41%), and six patients each had fair and poor results (54%). Diagnostic cervical discography was found not to provide the degree of clinical predictive value necessary to substantiate its potential risks and complications.
Abscess↗
Observer variability in the assessment of disc degeneration on magnetic resonance images of the lumbar and thoracic spine.
STUDY DESIGN: Intraobserver and interobserver reproducibility study. OBJECTIVE: This study investigates the variability in the interpretation of degenerative disc findings using magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging has been used for years in clinical diagnostics, primarily to investigate disc herniation and spinal stenosis. Less attention has been paid to other disc findings and their assessment reliability. METHODS: Three independent readers evaluated magnetic resonance images of the lumbar and the lower and middle thoracic spines of 122 subjects by grading 12 aspects of the intervertebral discs and adjacent endplates using written definitions and example images. Images of 20 subjects were reevaluated for the assessment of intraobserver agreement. RESULTS: Agreement was highest in the lower lumbar and poorest in the middle thoracic spine. Intraobserver agreement was generally fair to excellent for almost all variables in the lumbar and lower thoracic spine (most intraclass correlation and kappa coefficients for these regions were above 0.70). Interobserver agreement was notably lower than intraobserver agreement, except for osteophytes and endplate defects in some regions. CONCLUSIONS: Intraobserver agreement in the evaluation of disc degeneration was at an acceptable level, in general, in the lumbar and lower thoracic spine. However, assessments were substantially more variable between readers, which limits comparisons of evaluations between different readers.
Adult↗
The North American Spine Society (NASS) on lumbar discography.
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Anti-Bacterial Agents↗
A controlled biochemical and immunohistochemical study of human synovial-type (group II) phospholipase A2 and inflammatory cells in macroscopically normal, degenerated, and herniated human lumbar disc tissues.
STUDY DESIGN: Group II phospholipase A2 enzyme activity was studied biochemically and immunohistochemically in tissue samples from disc prolapses, degenerated discs, and macroscopically normal discs. In parallel, phospholipase A2 and inflammatory cells were studied by indirect immunocytochemistry. OBJECTIVES: To compare phospholipase A2 activity in normal discs and abnormal discs by an identical assay for phospholipases A2, and to compare the occurrence of inflammatory cells with phospholipase A2 activity and immunoreactivity. SUMMARY OF BACKGROUND DATA: It has been suggested that a high phospholipase A2 enzyme activity in herniated disc tissue could be significant in abnormal states such as sciatica and discogenic pain. No comparison between healthy disc tissue and samples of abnormal discs (degenerated or herniated) has been carried out. In particular, an identical assay for phospholipase A2 for such tissue samples, supported by immunohistochemical staining data, has never been applied in parallel to normal and abnormal disc tissue, and neither have such results been compared with the demonstration of inflammatory cells. METHODS: Group II phospholipase A2 enzyme activity was determined, in parallel, using an identical assay for tissue samples from 11 macroscopically normal discs, 33 disc herniations, and six discs showing degeneration by discography. For determination of phospholipase A2 enzyme activity, a radioassay using 1-palmitoyl-2-(1-14C)linoleoyl-L-3-phosphatidylethanolamine as the phospholipid substrate was used. Total tissue DNA as an estimate of total tissue cell number was measured in parallel with phospholipase A2 activity. All tissue samples also were studied by indirect immunocytochemistry, locating phospholipase A2 and T and B lymphocytes. RESULTS: Neither degenerated nor herniated disc tissue samples demonstrated a higher phospholipase A2 activity than control disc tissue samples. Average phospholipase A2 activity was actually higher in the control samples than in herniated disc samples (Mann-Whitney test, P < 0.001), possibly a result of a higher total DNA (P < 0.005). The observed level of phospholipase A2 activity was lower than that of inflammatory human synovial fluid. Neither was there marked immunoreactivity for phospholipase A2, which was observed in chondrocytes in areas of cartilage and occasional disc cells, supporting the biochemical results. Lymphocytes were more numerous only in herniated disc samples (15%), and their presence showed little overlap with phospholipase A2 immunoreactivity. CONCLUSIONS: Synovial-type (Group II) phospholipase A2 enzyme activity is not particularly high in disc tissue and does not appear to be higher in herniated or degenerated discs than control disc tissue. Immunoreactivity to phospholipase A2 is seen only occasionally and is strong only when cartilage tissue is present. Neither are inflammatory lymphocytes commonly observed.
Adult↗
The prolapsed intervertebral disc. The high-intensity zone with discography correlation.
STUDY DESIGN: The study compared the presence of the high-intensity zone on magnetic resonance imaging with the results of awake discography. OBJECTIVES: To see if there was a correlation between the results of awake discography and the presence of a high-intensity zone on magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: The evaluation of discogenic pain has proved to be somewhat elusive. Recent studies have indicated the high-intensity zone as being highly sensitive in the diagnosis of the painful discogenic segment. The present study was designed to investigate whether the presence of a high-intensity zone is associated with a concordant pain response on awake discography. METHODS: Magnetic resonance images were obtained in 29 patients with low back pain with and without radiculopathy. Consecutive patients were considered for surgical intervention after falling to respond to conservative treatment. The presence of a high-intensity zone was specifically looked for within the posterior anulus. Each patient subsequently underwent awake discography with computed tomography. Computed tomography was classified according to the Dallas Discogram Scale and the presence of a concordant pain response. Chi-square analysis was used to calculate the presence of a high-intensity zone versus disc disruption and the correlation of high-intensity zone and concordant pain response. RESULTS: There was no statistically significant correlation between the presence of a high-intensity zone and a concordant pain response at any level. The high-intensity zone was, however, never seen in a morphologically normal disc. CONCLUSIONS: Although the high-intensity zone is present within the posterior anulus of some abnormal discs, it is not necessarily associated with a concordant pain response.
Adult↗
Spondylodiscitis. Clinical and magnetic resonance diagnosis.
STUDY DESIGN: This study reviews 65 patients with spondylodiscitis, both spontaneous and postoperative and of different etiology, studied by magnetic resonance imaging. OBJECTIVES: To define the magnetic resonance imaging characteristics of infections of the spine in acute and chronic stages and to evaluate the role of magnetic resonance imaging in defining their etiology. BACKGROUND DATA: Early diagnosis of spondylodiscitis is often difficult because of the long latent period. Radiographs of the spine, bone scan, and computed tomography scan provide insufficient data. METHODS: Among 65 patients with spondylodiscitis studied by magnetic resonance imaging, 24 were examined in the acute stage (clinical evolution between 7 days and 20 days), and 41 were examined in the chronic stage (3-6 weeks). The etiologic agent was staphylococcus in eight cases, Brucella in 13, Mycobacterium tuberculosis in 29, Salmonella in four, and unknown in 11. RESULTS: In cases observed in the acute stage, the disc and the vertebral bodies were hypointense in T1 and hyperintense in T2; this relatively constant finding was not correlated with the etiologic agent. In the chronic stage, cases caused by Brucella or of unknown etiology showed long T1 and T2 relaxation times, with precocious contrast enhancement of the disc; in cases of tubercular etiology there was slight shortening of T1, with inhomogeneous enhancement of the involved vertebral bodies and late disc enhancement. CONCLUSIONS: Magnetic resonance imaging is the investigation method of choice in diagnosing spondylodiscitis, especially in very early stages of the disorder, when other investigations still yield negative results. In chronic stages, magnetic resonance imaging also allows tubercular spondylodiscitis to be distinguished from cases of different etiology.
Adult↗
Super-acute aseptic spondylitis as the first manifestation of round calcifying nucleopathy in a 77-year-old man. A case report.
STUDY DESIGN: This is a report of an unusual case of very late onset, symptomatic, round calcifying nucleopathy. OBJECTIVE: To describe this unusual case of calcifying nucleopathy in a 77-year-old man who had no previous back problems, but had a history of diffuse skeletal hyperostosis. SUMMARY OF BACKGROUND DATA: The resorption of calcifying nucleopathy associated with reactional spondylitis is a classic occurrence in children but is rare in adults. METHODS AND RESULTS: Spondylitis was diagnosed on the basis of pain, a transient Babinski's sign, and systemic inflammation. Radiographs, a bone scan, and magnetic resonance imaging revealed a large calcified nucleopathy of the T12-L1 disc associated with spondylitis of T12. The calcification disappeared within 3 weeks, and recovery was clinically and biologically complete after treatment consisting of only rest and analgesics. CONCLUSION: A diagnosis of resorption of a round calcifying nucleopathy is not to be excluded in the elderly patient. This event can mimic an infectious spondylitis clinically and biologically.
Aged↗
Murine nucleus pulposus-derived cells secrete interleukins-1-beta, -6, and -10 and granulocyte-macrophage colony-stimulating factor in cell culture.
STUDY DESIGN: Cultures established from murine disc-derived cells were stimulated by lipopolysaccharide. The cells' capacity to secrete proinflammatory cytokines and interleukin-10 with and without lipopolysaccharide stimulation was determined using enzyme-linked immunosorbent assays. OBJECTIVES: To determine the capacity of disc-derived cells to secrete proinflammatory cytokines, and the effect of lipopolysaccharide stimulation on such secretion. SUMMARY OF BACKGROUND DATA: The pathophysiology of compressive radiculopathy is unclear. Inflammation is a possible explanation. Proinflammatory cytokine secretion was demonstrated in herniated nucleus pulposus. It is unknown whether these cytokines are secreted from disc-derived cells or from infiltrating inflammatory cells in the herniated nucleus pulposus. METHODS: Discs were microsurgically harvested from inbred mice and cut to allow the nucleus pulposus to establish cell culture. A study group was exposed to lipopolysaccharide stimulation. Media were harvested from the study and control groups 24 hours later. Secretion of interleukins-1-, -6, and -10, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor-alpha were determined using enzyme-linked immunosorbent assays. RESULTS: Basal secretion of interleukins-6 and -10, but no basal secretion of interleukin-1-, granulocyte-macrophage colony-stimulating factor, or tumor necrosis factor-alpha was detected. Secretion of interleukin-1- rose from zero to 27.69 pg/10(5) cells, and granulocyte-macrophage colony-stimulating factor secretion rose from zero to 9.77 pg/10(5) cells after lipopolysaccharide stimulation. A 75-fold increase in interleukin-6 secretion and a 150-fold increase in interleukin-10 secretion were detected after stimulation with lipopolysaccharide. No tumor necrosis factor-alpha secretion was detectable. All result had high statistical significance (all P < 0.001). CONCLUSIONS: Cultured murine disc-derived cells have the capacity to secrete proinflammatory cytokines and interleukin-10 in the absence of inflammatory cells. This finding supports the hypothesis that disc-derived cells are capable of initiating or amplifying an inflammatory process.
Animals↗
Spondylodiscitis after lumbar discectomy. Incidence and a proposal for prophylaxis.
STUDY DESIGN: An analysis of the incidence of spondylodiscitis after lumbar disc surgery in 1642 patients. In 508 patients no prophylactic antibiotics were given. In 1134 patients a collagenous sponge containing gentamicin was placed in the cleared disc space. OBJECTIVES: To report the incidence of postoperative spondylodiscitis in cases in which no antibiotic prophylaxis was used, and to define the value of a collagenous sponge containing gentamicin in preventing disc space infections. SUMMARY OF BACKGROUND DATA: Spondylodiscitis is considered to be a rare complication of lumbar disc surgery. The retrospective design of most studies and the rare use of magnetic resonance imaging for early radiologic diagnosis suggest that the reported incidence rates may be underestimates. Postoperative spondylodiscitis is the result of intraoperative contamination and, theoretically, could be prevented by treating these patients with prophylactic antibiotics. METHODS: In 1642 patients, 1712 discectomies were performed. In 508 of these patients no prophylactic antibiotics were given; in 1134 of these patients a collagenous sponge containing gentamicin was placed in the cleared disc space. Clinical reexamination and, in cases of unsatisfactory results, laboratory and radiologic investigations were performed 4-8 weeks after surgery. RESULTS: In nineteen of the 508 patients who were not treated with antibiotic prophylaxis (3.7%) a postoperative spondylodiscitis developed, whereas none of the 1134 patients who received antibiotic prophylaxis became symptomatic (P < 0.00001). CONCLUSION: In the current study, a 3.7% incidence of postoperative spondylodiscitis was found in the absence of prophylactic antibiotics. Gentamicin-containing collagenous sponges placed in the cleared disc space were effective in preventing postoperative spondylodiscitis.
Administration, Topical↗
The involvement of matrix metalloproteinases and inflammation in lumbar disc herniation.
STUDY DESIGN: Surgically obtained herniated lumbar disc specimens were stained with hematoxylin-eosin or toluidine blue (for detection of proteoglycans) or were immunostained with monoclonal antibodies (CD68), antihuman interstitial collagenase (matrix metalloproteinase [MMP]-1) and antihuman stromelysin (MMP-3). OBJECTIVE: To investigate the possible correlation of matrix metalloproteinase activity to granulation tissue formation and lumbar disc herniation, depending on the type of herniation. SUMMARY OF BACKGROUND DATA: Interstitial collagenase and stromelysin have been implicated in the degradation of the matrix of articular cartilage in rheumatoid arthritis, osteoarthritis and degenerated disc tissues. However, their role in the herniation of the intervertebral disc has received little study. METHODS: Twenty-one specimens of lumbar disc herniation (classified as protrusions, subligamentous extrusions, transligamentous extrusions, and sequestrations) and four nonherniated discs were stained with hematoxylin-eosin or toluidine blue or were immunostained with monoclonal antibodies to CD20, CD45RO, and CD68, anti-MMP-1, and anti-MMP-3, using the avidin-biotin-peroxidase complex method. The amount of granulation tissue and results of staining were graded to examine differences in histology among the four herniation types. RESULTS: In sequestration and transligamentous extrusion specimens, granulation tissue containing many CD68-positive macrophages was commonly observed. Most cells in granulation tissue, as well as chondrocytes, stained positively with anti-MMP-1 and anti-MMP-3 antibodies. Granulation tissue was less commonly observed in subligamentous extrusions and was absent from most protrusion specimens and all nonherniated specimens. B and T lymphocytes could not be demonstrated in granulation tissue. CONCLUSIONS: The increased staining of MMP-1 and MMP-3 associated with inflammatory cells of granulation tissue in herniated discs suggests a causal correlation of these proteinases to tissue degradation in herniation.
Adolescent↗
Is there a clinical correlate to the histologic evidence of inflammation in herniated lumbar disc tissue?
STUDY DESIGN: The presence of inflammatory cells was examined immunohistochemically in routinely processed resection specimens of the lumbar disc. The histologic results were compared with prospectively obtained clinical data. OBJECTIVES: To assess the clinical relevance of inflammatory cells in herniated lumbar disc specimens. SUMMARY OF BACKGROUND DATA: It is postulated that in addition to nerve root compression, an inflammatory stimulus of the herniated lumbar disc is responsible for sciatic pain and radiculopathy. However, the clinical relevance of the histologically described inflammatory infiltrates is not defined clearly. METHODS: Disc specimens from 44 patients who underwent surgery for lumbar disc herniation were studied immunohistologically. Before surgery, severity of pain was classified in each patient according to a visual analog scale, and general clinical data were recorded prospectively. RESULTS: Varying amounts of inflammatory cells could be demonstrated in the resected disc tissue. In the statistical analysis, no statistically significant correlation between the histologic evidence of macrophage infiltrates and the pain grading scale or the clinical data was noted. CONCLUSIONS: There is no statistically significant correlation between macrophage infiltrates in herniated lumbar disc specimens and the obtained clinical data.
Adult↗
Cervical spondylodiscitis after removal of a fishbone. A case report.
STUDY DESIGN: A case report of cervical spondylodiscitis after removal of a lodged fishbone. OBJECTIVES: To present a rare case of cervical spondylodiscitis and to inform the readers that a lodged fishbone can give rise to this complication after its removal. SUMMARY OF BACKGROUND DATA: In the literature, only one mention of this complication was found. METHODS: The literature, clinical presentation, technical examinations, and treatment are reviewed. RESULTS: Prolonged antibiotic treatment and immobilization of the cervical spine resulted in a cure of the spondylodiscitis. CONCLUSIONS: After removal of a lodged fishbone, a cervical spondylodiscitis is possible, but this is a very rare complication. In this patient, conservative treatment resulted in a cure of the infection. Successive magnetic resonance imaging investigations showed the extent of the destruction of the vertebral bodies and disc very well, as well as the curation of the spondylodiscitis after 5 months.
Aged↗
The role of mast cells in disc herniation inflammation.
STUDY DESIGN: A study of herniated lumbar disc tissue samples and control disc material to determine the presence of mast cells in disc herniations. OBJECTIVES: To analyze whether mast cells have any involvement in disc herniation pathophysiology and lumbar pain, because mast cells may have an important role in acute and chronic inflammatory responses. SUMMARY OF BACKGROUND DATA: Studies of inflammatory cells, biochemical mediators of inflammation, and tissue degrading enzymes have suggested that these factors may be involved--and perhaps play an important role--in the pathophysiology of lumbar pain and radiculopathy. Mast cells are known to play an important role in acute and chronic inflammatory responses. It was therefore of interest to clarify their possible role in intervertebral disc herniation inflammation. METHODS: Fifty herniated lumbar discs from 50 patients who had undergone disc surgery and three normal control discs were obtained. Sections from every disc then were examined histologically and immunocytochemically for mast cells by using monoclonal antibodies to either of two types of specific proteases of mast cells, tryptase and chymase. RESULTS: By none of the methods could any mast cells be observed in any of the control disc samples. With toluidine blue staining, mast cells were observed in 9 of 50 (18%) of discs. Mast cells immunoreactive to either tryptase or chymase were observed in 10 of 50 disc samples (20%) and immunoreactive for tryptase and chymase simultaneously in 4 of 50 disc samples (8%). However, the majority of the samples studied (80%) demonstrated immunoreactivity to neither tryptase nor chymase. Among the samples studied were five disc protrusions that totally lacked mast cells. CONCLUSIONS: A minority of disc herniations exhibited mast cells, as verified by toluidine blue staining and immunocytochemistry. The results may suggest a role of mast cells in intervertebral disc herniation inflammation, but only in a subset of these cases. Massive infiltration by mast cells never was observed.
Adult↗