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PubMed2001

Spondylodiscitis and infective endocarditis: case studies and review of the literature.

STUDY DESIGN: This study evaluated the association between infective endocarditis and infective spondylodiscitis and its clinical features. OBJECTIVES: To report case studies of patients with spondylodiscitis complicating infective endocarditis. SUMMARY OF BACKGROUND DATA: Early diagnosis of infective endocarditis as the source of the spondylodiscitis is often difficult because clinical and radiologic patterns are similar to those present in spondylodiscitis alone. METHODS: The case records of the patients with infective endocarditis admitted to our Department from 1991-1998 were reviewed. The diagnosis of spondylodiscitis was made on the basis of clinical features and of typical radiologic signs. RESULTS: Among 30 patients affected by infective endocarditis, three also were affected by spondylodiscitis. All patients fully recovered after appropriate antibiotic therapy. CONCLUSIONS: In all patients with spondylodiscitis, infective endocarditis should be excluded, particularly in patients with a history of heart valve disease.

Adult↗
PubMed2001

Immunophenotypic analysis of the inflammatory infiltrates in herniated intervertebral discs.

STUDY DESIGN: The herniated portion of the lumbar disc was analyzed immunohistochemically for inflammatory infiltrates to determine their immunophenotype. OBJECTIVE: To investigate the pathomechanism behind spontaneous regression of herniated discs. SUMMARY OF BACKGROUND DATA: Spontaneous regression of herniated intervertebral discs has been increasingly reported. The inflammatory response of the host has been suggested as a factor in this phenomenon. However, whether the inflammation is induced from direct chemical irritation of the nucleus pulposus material or whether it is secondary to an autoimmune response to the nucleus pulposus remains controversial. METHODS: The herniated portion of the disc was collected from 38 patients who underwent surgery for lumbar disc herniation. Thin cryostat sections were made, and the extent to which inflammatory cells had infiltrated the disc specimen was defined. Then the immunophenotype of cellular infiltrates in the herniated disc specimens was assessed by immunostaining using a series of antibodies for lymphocyte, monocyte, macrophage, and dendritic cell markers. RESULTS: The inflammatory infiltrates in 14 of the 38 herniated discs were subjected to immunohistochemical analysis. None of them expressed the immunophenotypic markers of the lymphocyte (CD20, CD45RO, CD4, CD8, TCRgammadelta), mature monocyte (CD33), or dendritic cell (CD1a, CD80, CD86, S100). Abundant infiltration of CD68-positive cells that lacked CD33 but had a variable amount of CD11b, CD11c, and CD40 likely represents a process of differentiation from monocytes to macrophages. CONCLUSIONS: These findings are consistent with an immunophenotype of inflammatory responses to tissue injury or chemical irritation rather than antigen-specific immune responses. Therefore, understanding the mechanism of tissue repair is fundamentally important in the management of patients with disc herniations.

Adult↗
PubMed2001

Vertebral osteomyelitis secondary to epidural catheter use: a case report.

STUDY DESIGN: A case of vertebral osteomyelitis secondary to epidural catheter use is reported. OBJECTIVE: To investigate the occurrence of vertebral osteomyelitis after the use of an epidural catheter. SUMMARY OF BACKGROUND DATA: Vertebral osteomyelitis is a rare but serious complication of epidural catheter use that apparently has not been reported previously in orthopedic literature. METHODS: A patient underwent abdominal surgery, and an epidural catheter was used for postoperative pain relief. He presented 3 months later with severe midlumbar pain. Magnetic resonance imaging and microbiologic examination of a specimen obtained at open biopsy were used in the investigation. RESULTS: Magnetic resonance imaging suggested vertebral osteomyelitis involving L1-L3. The patient underwent open debridement and posterior instrument stabilization. Biopsies taken from L3 pedicles yielded Pseudomonas aeruginosa, which had been recovered earlier from the epidural catheter tip. CONCLUSION: Vertebral osteomyelitis is a rare but serious complication of epidural catheter use.

Acute Disease↗
PubMed2002

Polysegmental spondylodiscitis and concomitant aortic aneurysm rupture: case report with 3-year follow-up period.

STUDY DESIGN: A case report describing a patient with spondylodiscitis of the thoracic and lumbar spine complicated by rupture of an abdominal aortic aneurysm and aggravation of neurologic symptoms is presented. OBJECTIVE: To present a cardiovascular complication worsening the clinical condition during conservative spondylodiscitis therapy, and to describe a minimally invasive treatment regimen for both spondylodiscitis and aortic aneurysm rupture in multimorbid patients at high risk for complications or refusal of surgery. SUMMARY OF BACKGROUND DATA: Few articles describe minimally invasive treatment of spondylodiscitis. Some available reports describe neurologic symptoms resulting from spinal cord ischemia in aortic aneurysm rupture. No data were found describing simultaneous therapy for spondylodiscitis and rupture of aortic aneurysm. METHODS: Therapy consisted of CT-guided percutaneous drainage of the spondylodiscitis and parenteral antibiotic treatment combined with immobilization and minimally invasive endoluminal exclusion of the aortic aneurysm with a bifurcated stent graft. RESULTS: Effective therapy for polysegmental spondylodiscitis on the one hand and contained rupture of aortic aneurysm on the other are presented. The successful clinical outcome after conservative orthopedic therapy and vascular intervention has been followed for 3 years. CONCLUSIONS: In older patients, spondylodiscitis may be complicated by other underlying diseases. Pain and neurologic symptoms may occur secondarily to concomitant illnesses instead of being caused by the inflammation itself. Minimally invasive therapy is shown to be an effective alternative to surgery in older and multimorbid patients with spondylodiscitis and contained aortic aneurysm rupture.

Aged↗
PubMed2002

Serratia spondylodiscitis after elective lumbar spine surgery: a report of two cases.

STUDY DESIGN: This report describes two cases of acute spondylodiscitis, caused by, complicating two different conditions: microdiscectomy for herniated nucleus pulposus and decompressing laminotomy for spinal stenosis. OBJECTIVE: To describe a rare and life-threatening spinal infection and discuss its successful management. SUMMARY OF BACKGROUND DATA: To our knowledge, no published reports in the English language have described this potentially devastating infection as a complication of elective noninstrumented discectomy or decompressive laminotomy. METHODS: Two cases of a very early onset of acute spondylodiscitis, caused by, after minimally invasive lumbar spine surgeries are presented. The elapsed time between these two complications was 1 week. The clinical presentation was characteristically stormy in both cases. On postoperative day 2, the patients developed high fever with intense chills and concomitant acute low back pain rapidly increasing in severity. The overall clinical appearance was alarming. The patients were carefully investigated immediately and scrutinized for possible origin of the infection. Treatment consisted of prompt intravenous antibiotics and surgical debridement. RESULTS: The history and clinical manifestations of postoperative spondylodiscitis were corroborated with magnetic resonance imaging findings and bacteriologic and hematologic laboratory examination. Blood cultures revealed as the responsible pathogenic microorganism. The source of the pathogens was contaminated normal saline used for surgical lavage. Both patients were able to completely resume their previous occupations after aggressive surgical debridement/irrigation and 3 months of antibiotic treatment. CONCLUSIONS: may become a potential pathogen, causing severe spinal infection after elective surgery. For prompt diagnosis and effective treatment of this life-threatening infection, one should maintain high index of suspicion and should not procrastinate in initiating treatment, which should consist of appropriate intravenous antibiotics and surgical debridement.

Aged↗
PubMed2004

Innervation of the lumbar intervertebral disc by nerve growth factor-dependent neurons related to inflammatory pain.

STUDY DESIGN: We used anatomic tracers and immunoreactivity in rats to define dorsal root ganglion neuron populations innervating the lumbar discs in physiologic and inflammatory states. OBJECTIVES: To investigate the percentages of calcitonin gene-related peptide-immunoreactive (CGRP-ir) and isolectin B4 (IB4)-binding neurons innervating lumbar discs. SUMMARY OF BACKGROUND DATA: Small neurons are classified into two types. One contains CGRP and expresses the nerve growth factor receptor. The other binds IB4 and expresses the glial cell line-derived neurotrophic factor receptor. METHODS: A neurotracer, Fluoro-Gold, was applied to the L5-L6 disc in rats. Five days later, 50-microL saline (control group: n = 8) or Complete Freund's adjuvant (inflammatory group: n = 8) was applied to the disc. Seven days after the second operation, T13-L5 dorsal root ganglions were processed for double staining of CGRP and IB4. RESULTS: Of the Fluoro-Gold-labeled neurons, 50.1 +/- 4.6% (mean +/- SEM) were positive for CGRP and 0.7 +/- 0.6% positive for IB4 in the control group, while 65.6 +/- 4.7% were positive for CGRP and 1.0 +/- 1.0% positive for IB4 in the inflammatory group. The percentage of CGRP-ir neurons was significantly higher than that of IB4-binding neurons in both groups (P < 0.001, each). The percentage of CGRP-ir neurons in the inflammatory group was significantly higher than in the control group (P < 0.05). CONCLUSIONS: We found that most small neurons innervating the disc were CGRP-ir. Furthermore, disc inflammation caused an increase in CGRP-ir neurons but not IB4-binding neurons, suggesting that CGRP-ir, nerve growth factor-dependent neurons are more responsible for discogenic pain.

Animals↗
PubMed2004

Interleukin-6 production is upregulated by interaction between disc tissue and macrophages.

STUDY DESIGN: Interleukin (IL)-6 production was investigated using a coculture system of disc tissue and macrophages. OBJECTIVES: The purpose of this study was to investigate the interaction between intervertebral disc tissue and macrophages in terms of IL-6 production. SUMMARY OF BACKGROUND DATA: IL-6 production is observed in human herniated disc specimens, and there is a correlation between IL-6 production and neurologic symptoms. However, the mechanism of IL-6 production in the herniated disc is not clear. MATERIALS AND METHODS: Coccygeal intervertebral discs and exudated peritoneal macrophages were obtained from male Sprague-Dawley rats. Macrophages and intervertebral disc without endplates were cocultured in a serum-free medium. Fat tissue culture with or without macrophages, intervertebral disc alone, and macrophages alone were used for controls. The supernatant fluid of the culture was utilized for the enzyme-linked immunosorbent assay. The precipitations of macrophages and disc coculture were used for semiquantitative RT-PCR for IL-6. Immunohistochemical staining for IL-6 and the macrophages marker (ED2) were also carried out using disc tissue cultured with macrophages. RESULTS: IL-6 production level was significantly increased in the coculture of intervertebral disc and macrophages (P < 0.01). However, there was no significant production of IL-6 in the control groups. The precipitations from coculture of macrophages and disc expressed IL-6 mRNA in semiquantitative RT-PCR. Immunohistochemical staining revealed most IL-6 producing cells were also positive for ED2, which adheres to or infiltrates the peripheral area of the nucleus pulposus. CONCLUSIONS: Our results demonstrated that interaction between disc tissue and macrophage is necessary for upregulation of IL-6 production. Immunohistochemical staining also indicated that infiltrated macrophages played a major role in production of IL-6, suggesting that infiltration of macrophages into herniated disc material may be a trigger for IL-6 production and associated neurologic symptoms.

Animals↗
PubMed2000

Aspergillus osteomyelitis after liver transplantation: conservative or surgical treatment?

We report on a liver transplant recipient who developed coxarthritis and lumbar spondylodiscitis due to Aspergillus flavus. He was treated with high-dose liposomal amphotericin B for 2 months followed by itraconazole. Because of intractable pain and severe, irreversible damage of the left hip, a Girdlestone resection was performed. The spondylodiscitis was treated successfully with anti-fungal agents only, which indicates that, in the absence of neurological impairment, good clinical outcome can be achieved without surgery. This case demonstrates that surgical therapy, which is often proclaimed as unavoidable for the treatment of Aspergillus osteomyelitis, should be considered in particular in the case of intolerable pain due to irreversible joint damage or involvement of vital organs.

Adult↗
PubMed2004

Abdominal sacral colpopexy mesh erosion resulting in a sinus tract formation and sacral abscess.

BACKGROUND: Complications associated with the use of synthetic mesh during an abdominal sacral colpopexy procedure include mesh infection and erosion into the vaginal vault and sacral osteomyelitis. CASE: This case report describes the management of an abdominal sacral colpopexy procedure that was complicated by postoperative vaginal mesh erosion, formation of a fistulous tract from the vaginal apex to the sacrum, and development of diskitis, osteomyelitis, and a sacral abscess. CONCLUSION: Treatment of a vaginal mesh erosion complicated by the formation of a sinus tract after abdominal sacral colpopexy should include extensive sinus tract resection in addition to complete mesh removal.

Abdomen↗
PubMed2005

Salmonella spondylodiscitis in patients without sickle cell disease.

The optimal treatment of salmonella spondylodiscitis is controversial. The cases of eight patients who had salmonella spondylitis without sickle cell disease were reviewed. Back pain (100%), fever (75%), and elevated C-reactive protein levels (100%) were common, but gastrointestinal symptoms were not (0%). Six patients had positive blood cultures, and the other two had positive tissue cultures. Group C1 salmonella was the most common serotype. Two patients with coexisting aortic mycotic aneurysms had immediate aneurysm resection. Three others responded favorably to appropriate antibiotics, and three required subsequent surgical reconstruction because of neurologic impairment or osseous instability. Clinical outcomes were significantly better than those of 46 previously reported patients. Salmonella spondylodiscitis usually responds favorably to appropriate antibiotics; consequently, a tissue diagnosis is important. Operative interventions are necessary only for patients with coexisting aneurysms or ongoing osseous instability. A ruptured aortic aneurysm with pseudoaneurysm may mimic a paravertebral abscess, and surgery at the site of an unsuspected aneurysm may precipitate life-threatening hemorrhage. Satisfactory results may be depend on early surgical intervention for a mycotic aneurysm and also are related to host immunity.

Adult↗
PubMed2003

Psoas abscess: the spine as a primary source of infection.

STUDY DESIGN: Case report, literature review, discussion. OBJECTIVES: To emphasize the role of the spine as primary source of infection for psoas abscess. SUMMARY OF BACKGROUND DATA: Spine-associated psoas abscesses increase with more frequent invasive procedures of the spine and recurring tuberculosis in industrialized countries. Diagnosis is often delayed by misinterpretation as arthritis, joint infection, or urologic or abdominal disorders. METHODS: We present six cases of psoas abscesses associated with spinal infections that were treated in our hospital from January to December 2001. Diagnostic and treatment concepts are discussed. RESULTS: Our data emphasize the importance of the spine as primary source of infection and suggest an increase in the incidence of secondary psoas abscess. Treatment includes open surgical drainage and antibiotic therapy. In patients with high operative risk and uniloculated abscess, a CT-guided percutaneous abscess drainage can be sufficient. It is essential to combine abscess drainage with causative treatment of the primary infectious focus. Related to the spine, this includes treatment of spondylodiscitis or implant infection after spinal surgery. Usually, several operations are necessary to eradicate bone and soft-tissue infection and restore spinal stability. Continuous antibiotic therapy over a period of 2-3 weeks after normalization of infectious parameters is recommended. CONCLUSION: The spine as primary source of infection for secondary psoas abscess should always be included in differential diagnosis. Because the prognosis of psoas abscess can be improved by early diagnosis and prompt onset of therapy, it needs to be considered in patients with infection and back or hip pain or history of spinal surgery.

Anti-Bacterial Agents↗
PubMed2003

Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis.

STUDY DESIGN: A retrospective clinical study investigated patients undergoing surgery for destructive pyogenic and tuberculous spondylodiscitis. OBJECTIVE: To compare anterior debridement and bone grafting with a combined anterior and posterior procedure in terms of the physiologic alignment of the segmental sagittal spinal profile. SUMMARY OF BACKGROUND DATA: There is considerable agreement in the literature on the indications for surgical treatment of destructive spondylodiscitis. An anterior approach usually is recommended for debridement and bone grafting. Additional posterior instrumentation is applied to reduce kyphotic deformities and to prevent a correction loss. No comparison has been made so far in the literature between repositioning results obtained after surgery for destructive spondylodiscitis and physiologic segmental sagittal angles. METHODS: The surgical results of 49 patients treated by anterior debridement and bone grafting were compared with those of 22 patients who received additional posterior instrumentation. A comparison between the segmental kyphotic angles obtained and the standard values reported in the literature enabled an assessment of the segmental spinal alignment in the sagittal plane. Data were obtained from medical record review, imaging procedures, and patient follow-up examinations. RESULTS: All the subgroups submitted to a combined procedure had a greater preoperative segmental kyphosis angle than those undergoing anterior fusion alone. In marked segmental kyphotic false positioning, good postoperative repositioning was achieved by the combined procedure, and an increase in segmental kyphosis was permanently prevented. CONCLUSIONS: In single-level spondylodiscitis with no major substance loss, anterior debridement and bone grafting alone seem to be adequate, especially in the lumbar spine. Additional posterior instrumentation is indicated in multiple-level spondylodiscitis, extensive kyphotic deformity, or both.

Adolescent↗
PubMed2004

Two-year fusion rate equivalency between Grafton DBM gel and autograft in posterolateral spine fusion: a prospective controlled trial employing a side-by-side comparison in the same patient.

STUDY DESIGN: Multicenter, prospective equivalency trial with each patient serving as his/her own control. OBJECTIVES: To compare the effectiveness of a Grafton DBM gel composite with iliac crest autograft in posterolateral spine fusion. SUMMARY OF BACKGROUND DATA: While autograft remains the preferred graft material to facilitate spine fusion, the supply is limited and harvesting produces undesirable clinical consequences. METHODS: A total of 120 patients underwent posterolateral spine fusion with pedicle screw fixation and bone grafting. Iliac crest autograft was implanted on one side of the spine and a Grafton DBM/autograft composite was implanted on the contralateral side in the same patient. An independent, blinded reviewer evaluated anteroposterior and lateral flexion-extension radiographs. The fusion mass lateral to the instrumentation on each side was judged fused or not, and the mineralization of the graft was rated absent, mild, moderate, or extensive. The degree of correspondence in outcomes between sides was estimated by computing the percentage agreement and kappa statistic. RESULTS: Nearly 70% of patients (81 of 120) provided complete 24-month radiographic studies. The bone graft mass was fused in 42 cases (52%) on the Grafton DBMside and in 44 cases (54%) on the autograft side. The overall percentage agreement for fusion status between sides was approximately 75% (61 of 81), indicating moderately strong statistical correspondence (kappa = 0.51, P < 0.0001). Bone mineralization ratings also were similar between treated sides. Perfect agreement was realized in almost 60% of patients (48 of 81) with moderate statistical correspondence (weighted kappa = 0.54, P < 0.0001). CONCLUSIONS: Grafton DBM can extend a smaller quantity of autograft than is normally required to achieve a solid spinal arthrodesis. Consequently, a reduced amount of harvested autograft may be required, potentially diminishing the risk and severity of donor site complications.

Bone Matrix↗
PubMed2004

Colony formation and matrix production by human anulus cells: modulation in three-dimensional culture.

STUDY DESIGN: Human intervertebral disc cells from the anulus were tested in a study of colony formation and extracellular matrix (ECM) production during long-term three-dimensional culture with exposure to selected cytokines. Experimental studies were approved by the authors' Human Subjects Institutional Review Board. OBJECTIVES: To quantitatively evaluate colony formation and qualitatively assess ECM production (using immunohistochemistry and in situ hybridization) in cells derived from Thompson Grades I to V discs and tested in culture with cytokines and nutrient supplementation. SUMMARY OF THE BACKGROUND DATA: Human intervertebral disc cells offer special in vitro challenges because of the slow-growing nature of these cells and their need for specialized three-dimensional in vitro conditions, which permit the expression and production of proteoglycans and Type II collagen, two ECM products that are important for disc cell biology. METHODS: Discs from 9 human subjects (2 control donors and 7 surgical patients, Thompson Grades I-V), mean age 35.8 years, were used to obtain anulus cells to be tested in three-dimensional agarose culture. Tests of specialized growth conditions included treatment with ITS (insulin-transferrin-sodium selenite supplement), insulin-like growth factor I (IGF-I), and transforming growth factor-beta1 (TGF-beta1). Cultures were evaluated after 14 to 36 days of culture for % colony formation and cell numbers/colony; immunocytochemistry, in situ hybridization, and quantitative histology were used to evaluate colony formation and ECM production. RESULTS: : Data showed that compared with the average 17.5% colony formation observed in controls, ITS, TGF-beta1 and ITS with IGF-I significantly increased colony formation (28.4%, 30.4%, and 30.4%, respectively, P < or = 0.04). Even cells derived from Thompson Grade V disc showed responsiveness to cytokines and improved production of ECM in vitro. CONCLUSIONS: : Findings indicated that cells derived from discs with advanced degeneration were still responsive to cytokines and could be modulated to produce Type II collagen and proteoglycans in three-dimensional culture by the addition of enriched media and selected cytokines. Such findings are important since they advance our understanding of how to modulate disc cell behavior in vitro, and may have application to potential future biologic therapies for disc degeneration.

Adult↗