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We describe a case of spondylodiscitis caused by Campylobacter fetus in a previously healthy patient. This is the first report of this agent causing discovertebral infection, which generated cellular immune deficiency, reversible with the cure.
Bacterial osteitis of the discs and the vertebrae is rare after fixing the uterus to the promontary of the sacrum. Only 30 cases have been reported in the literature. Twelve cases were found in a Rheumatology Unit over a period of 12 years from 1975-1987. The initial symptoms of septic osteitis were low back pain or sciatica, and fever. They were confirmed by radiological evidence. Bacteriological diagnosis was obtained in every case by fine needle aspiration of the disco-vertebral space retrieving staphylococci or gram-negative bacilli. The same agent was found in blood cultures in four or five cases. Potentiating pathogenic factors include urinary tract infections, prosthetic material, and surgical errors.
The magnetic resonance (MR) imaging findings in patients after surgery for degenerative disc disease in the lumbar and cervical spine are discussed. In the lumbar spine, changes seen in the immediate postoperative period, use of Gd-DTPA in distinguishing scar and disc and postoperative complications are reviewed. In the cervical spine, operative approaches and types, the appearance of bony stenosis, and disc herniations are demonstrated.
Three patients are reported in whom on days 10-14 after the operation for lumbar intervertebral disc prolapse symptoms of lumbago developed. In all cases radiological examination revealed signs characteristic for spondylodiscitis. The analysis of these cases and other ones collected from the literature suggested the conclusion that spondylodiscitis occurring after operations for lumbar disc prolapse is a self-limiting infection in the development of which a role may be played, apart from bacterial factors also by immunological mechanisms.
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The role of antibiotics in the treatment and prevention of postoperative spondylodiscitis is still controversial. In a group of 15 patients operated on account of lumbar discopathy, the authors investigated the penetration of antibiotics into the intervertebral disc, in correlation to serum levels, when antibiotics were administered during operation. Despite high serum levels rolitetracycline was not detected in extirpated material of the disc, gentamycin reached 2-6% serum levels. The authors give an account of views on the role of antibiotics in the prophylaxis of postoperative spondylodiscitis and recommend their administration in particular in risk groups. They recommend antibiotics in case of early diagnosis of postoperative spondylodiscitis, in the later stages of the disease the role of antibiotics is controversial.
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A 12-year-old female (HLA-B27 negative) presented with unilateral low back pain and sterno-clavicular arthritis. Six months after onset the clinical and radiological findings determined spondylodiscitis L1/2. On the basis of the clinical findings (oligoarthritis, symptomatic sacroilitis, spondylodiscitis), juvenile ankylosing spondylitis was suspected. The diagnosis was corroborated 18 months after the first occurrence of symptoms by the appearance of typical changes in the sacroiliac joint that are indicative of juvenile ankylosing spondylitis. Because of persisting antibodies against Borrelia burgdorferi, the possibility of B. burgdorferi-induced reactive arthritis with involvement of the axial division of the skeletal system was considered. After 3.5 years of observation the condition showed a benign course with radiologically observable consolidation of the spondylodiscitis. To our knowledge, this is the second case described of juvenile ankylosing spondylitis with spondylodiscitis as a dominating feature.
A case of staphylococcus spondylodiscitis with vertebral collapse and recurrent bacterial colonizations at pulmonary and gluteal level consequent on a septicaemic condition that arose as a result of a missed diagnosis is reported. The misleading factor was the pre-existing spondylarthrosis and marked osteoporosis.
The usefulness of indium-111 white blood cell (WBC) scintigraphy in the detection of spine sepsis was studied in 22 patients who had open or percutaneous biopsies for microbiologic diagnosis. The indium images in 18 patients with vertebral infection were falsely negative in 15 (83%) and truly positive in 3 (17%). All four patients with negative cultures and histology had true-negative scans. The indium-111 WBC imaging results yielded a sensitivity of 17%, a specificity of 100%, and an accuracy rate of 31%. Prior antibiotic therapy was correlated with a high incidence of false-negative scans and photon-deficient indium-111 WBC uptake. The usefulness of indium-111 WBC scintigraphy for the diagnosis of vertebral infection may be limited to those patients who have not been treated with antibiotics previously.
The nucleotome, a recently developed instrument for percutaneous disc excision, was used for suction aspiration in two cases of osteomyelitis of the spine. The technique obtained significant amounts of pus, serosanguinous material, and tissue, which provided adequate samples for histologic examination and culture. Both patients obtained immediate relief of pain after a significant amount of pus and infected material was removed. Appropriate antibiotics were used for subsequent control of the infections. The risk and morbidity of this technique are no greater than with conventional needle biopsy.
Thirty-six patients diagnosed with diskitis from 1978 to 1988 and followed for an average of 29.2 months were reviewed. The study included 23 boys and 13 girls with an average age of 5.3 years. The initial symptoms varied, but distinct clinical patterns emerged and were identifiable in different age groups. Both the leukocyte count and sedimentation rate were elevated. Routine roentgenograms were positive for intervertebral disk space narrowing in 82% of cases, technetium bone scans positive in 72%, and magnetic resonance imaging positive in all recent cases. Treatment consisted of bed rest for all patients, plaster casts for 50%, antibiotics for 40%, and traction for 23%. Regardless of the treatment combination, the course of the disease in most children is benign. At the completion of the study, all patients were asymptomatic including three children who had recurrences. In spite of being asymptomatic, 74% had persistent roentgenographic changes. The administration of antibiotics appears to be appropriate when indicated, i.e., failure to respond to immobilization. Disk space aspiration or biopsy should be reserved for those cases that are refractory to immobilization and antibiotics.
Infectious and inflammatory processes of the spinal column are discussed, including disc space infection, osteomyelitis, epidural abscess, arachnoiditis, and rheumatoid arthritis. The relative sensitivity and specificity of various imaging modalities, as well as the imaging characteristics and utility of these various modalities are given. Emphasis is placed on the use of magnetic resonance imaging.
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The extent of bone marrow edema seems relevant in assessing the activity of discovertebral destructions in ankylosing spondylitis using highly T2-weighted images. Twenty-one patients showing 32 discovertebral lesions in total were examined by MR-imaging. Radiological progression of destruction is significantly connected with the extent of bone marrow edema. Areas of probable progression can be visualized, which is especially valuable in polysegmental distribution. MR-imaging of discovertebral lesions facilitates the planning of therapy, particularly concerning surgical stabilization.
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Ceramic interspinous block (CISB) assisted anterior fusion system was developed. The system is recommended for patients with symptomatic disc degeneration and destructive lesions of the lumbar spine. One hundred and six patients who underwent CISB-assisted anterior fusion by one doctor (H.T.) from 1981 to 1987 were followed-up 2-6 years after the operation. A comparative study of the results between the CISB-assisted group and the CISB-unassisted anterior fusion group, performed by the same doctor during 1979-1981 for deranged disc, was also done. Satisfactory relief of back and leg pains, marked ADL recovery and early bone union were obtained in all of the CISB-assisted anterior fusion cases. The union rate was 98.9% in the CISB-assisted anterior fusion group, whereas in the CISB-unassisted group, it averaged 79%. The efficacy of CISB for anterior interbody fusion was also verified using a computer simulation. CISB implementation appears to create equalization of stress distribution on the graft-vertebra interface.