Vertebral infection

Vertebral infection represents 2-4% of all cases of osteomyelitis. An increase in the incidence of pyogenic as well as granulomatous spondylitis has been noticed. Early radiological diagnosis is of great importance for prompt treatment and prevention of clinically significant consequences which include neural compromise and late spinal deformities. The most frequent causative pyogenic micro-organisms are gram-negative bacteria especially Staphylococcus aureus. An important form of nonpyogenic granulomatous infection is tuberculous spondylitis which represents the most common form of extrapulmonary tuberculosis. The routes of spinal infection include hematogenous spread, postoperative infections, direct implantation during spinal punctures and spread from a contiguous focus. The role of imaging is an early diagnosis, evaluation of extent of infection with special regard to potential neural compromise, differential diagnosis, guidance of diagnostic biopsy, planning of eventual operative procedures and assessment of therapeutic response. Imaging modalities include bone scintigraphy, radiography, CT and MRI. In practice, usually a combination of a sensitive and a specific method is utilised. The only imaging modality which combines high sensitivity with satisfactory specificity is MRI. This is the reason that MRI frequently has become the first imaging modality in clinically suspect spinal infection. The MRI is the method of choice for direct demonstration of extension of infection, especially of eventual epidural abscess or phlegmon and consecutive neural compression. Using MRI monitoring of therapeutic efficiency is possible.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

99mTechnetium-ciprofloxacin scintigraphy for the evaluation of spinal infections: a preliminary report

Currently available laboratory and imaging tests have limitations diagnosing and following patients with spinal infections. We evaluated 17 Technetium-99m labeled ciprofloxacin scintigraphy studies in 11 patients who had the diagnosis of a spinal infection based on the Centers for Disease Control and Prevention criteria. Three of the 17 studies were performed in three patients within 2 months from the onset of the symptoms. All of these three studies showed increased uptake of the radiopharmaceutical in the area of the spinal infection. Fourteen studies were performed during the followup period (from 210 to 690 days after the onset of symptoms) in nine patients with spinal infections. Ten of the 14 studies performed in five patients with an active spine infection showed positive results while the patients had evidence for active spinal infection at the time of the testing. Four studies were performed during the followup period in four patients who at the time of the nuclear imaging testing had no symptoms, signs, or laboratory or other imaging evidence for active infection. All four studies showed negative results. The results of this preliminary study show that scintigraphy with 99mTc-ciprofloxacin may be useful in the diagnosis of active spinal infections.

LEVEL OF EVIDENCE

Diagnostic study, level II-1 (Testing of previously developed diagnostic criteria on consecutive patients [with universally applied reference "gold" standard]). Please see Guidelines for Authors for a complete description of levels of evidence.

[Recovery of the support capacity of the vertebral column in patients with tuberculous spondylitis]

The paper presents the results of anterior spine fusion in 250 patients with tuberculous spondylitis involving 2 to 8 vertebrae, by using free and non-free autologous bone grafts, carbonaceous implants, and revascularized transplants. Anterior spine fusion added to posterior spinal fixation with a CD-type metal construction. A tuberculous process in the spine was cured in 96.1% of cases; the spinal support capability recovery rate was 95.2% in the early postoperative period and in 93.5% in the late one.

[Sarcoidosis as seronegative spondyloarthropathy]

Two cases were presented with initial symptoms of inflammatory low back pain and alternate buttock pain. They developed a progressive dyspnea with bilateral mediastinal and hiliar lymphadenopathy and pulmonary interstitial disease as visualized with chest CT scan. Sarcoidosis diagnosis was confirmed by biopsy in both cases--in one case by skin biopsy and in the other by open lung biopsy. These clinical forms of spondyloarthropathy and sarcoidosis were unusual and were compared with similar cases present in the literature.

[Vertebral and spinal cord hydatidosis: contribution of imaging]

The authors report the case of a vertebromedullary hydatidosis revealed by medullar compression in a 40-year-old male patient. Magnetic resonance imaging showed lesions of the seventh and eighth dorsal vertebras, cystic lesions in the epidural space and in the perivertebral soft tissues. Surgical excision lead to clinical cure. Vertebromedullary hydatidosis is rare and severe. Modern techniques of imaging are very helpful for the diagnosis and the follow-up of patients after treatment.

Video-assisted thoracoscopic decompression of tubercular spondylitis: clinical evaluation

STUDY DESIGN

A prospective, observational study using a novel procedure of video-assisted thoracoscopy and conventional, long spinal instruments for decompression of dorsal tubercular spondylitis.

OBJECTIVES

To assess the efficacy of video-assisted thoracoscopic decompression of dorsal tubercular spondylitis and compare it with the published data of classic thoracotomy procedures.

SUMMARY OF BACKGROUND DATA

Surgical decompression of dorsal tubercular spine with the transpleural transthoracic method is a standard procedure. It is a major surgery with significant morbidity in terms of blood loss, intensive care unit (ICU) and hospital stay, postoperative incision pain, and chest tube insertion. A procedure that has the potential to achieve comparable recovery in patients with dorsal tubercular spondylitis but with a surgery of lesser magnitude and morbidity has immense potential.

METHODS

There were 16 patients with mid-dorsal tubercular spondylitis with paraplegia/paraparesis requiring surgery who were included in the study. Every patient had a recent paradiscal disease at a single level. A soft tissue shadow was visible on plain radiographs of the spine, and conservative treatment for at least 3 weeks had shown no recovery. Patients with obvious respiratory insufficiency and likely to have significant pleural adhesions were excluded from the study. Single lung anesthesia and ipsilateral lung collapse using a double-lumen tube were administered. A 3-portal thoracoscopy approach was used, and conventional but long spinal instruments were used through an open port to decompress the spine. Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of chest tube insertion, ICU and hospital stay, and neurologic recovery. Patients were observed for a minimum of 6 months.

RESULTS

Of 16 patients, 14 (88%) had good neurologic recovery. In 1 patient, thoracoscopy was abandoned, and open thoracotomy was performed because of persistent bleeding. Another patient did not recover, and anterolateral decompression was performed 10 weeks after thoracoscopy. She recovered subsequently. Other complications included fracture of the sixth rib in 1 patient and breakage of suction tip in another. Adequate tissue biopsy for histopathologic examination could be obtained in all patients. Duration of surgery was 223 minutes (+/-56), blood loss was 497 ml (+/-302), and blood transfusion was required in 3 patients (3 U in 1 and 1 U in 2). Postoperative analgesic (tramadol) was 243 mg (+/-70) for 2-4 days (median 3), median hospital stay was 5.5 days (range 4-9), chest tube requirement was 3 days (range 2-7), and 2 patients were required to stay in the ICU for 1 day each.

CONCLUSION

Video-assisted thoracoscopic decompression of tubercular dorsal spondylitis is a viable option to achieve significant neurologic recovery with less morbidity, blood requirement, and hospital stay compared to the open thoracotomy procedures.

Infectious spondylitis

Infection of the spine is a rare but serious cause of back pain. Conventional radiographs remain the initial screening procedure. Typically two adjacent vertebral bodies and the intervening disk space are affected. Early in the course of the disease, radiographs may be normal or nondiagnostic. Magnetic resonance imaging or radionuclide bone scan will establish pathology centered in the vertebral body. Because of the ability to image soft tissues, magnetic resonance imaging is particularly helpful in detecting paravertebral and extradural abscesses. Four other conditions may mimic infectious spondylitis: degenerative disk disease associated with Modic type 1 changes, pseudoarthrosis in ankylosing spondylitis, dialysis spondyloarthropathy, and neuropathic spondyloarthropathy. Advanced imaging studies in combination with radiographs and clinical information are essential in determining the correct diagnosis.

Examination of the Effects of Degeneration on Vertebral Artery by Using Neural Network in Cases With Cervical Spondylosis

The scope of this study is to diagnose vertebral arterial inefficiency by using Doppler measurements from both right and left vertebral arterials. Total of 96 patients' Doppler measurements, consisting of 42 of healthy, 30 of spondylosis, and 24 of clinically proven vertebrobasillary insufficiency (VBI), were examined. Patients' age and sex information as well as RPSN, RPSVN, LPSN, LPSVN, and TOTALVOL medical parameters obtained from vertebral arterials were classified by neural networks, and the performance of said classification reached up to 93.75% in healthy, 83.33% in spondylosis, and 97.22% in VBI cases. The area under ROC curve, which is a direct indication of repeating success ratio, is calculated as 92.3%, and the correlation coefficient of the classification groups is 0.9234. It is also demonstrated that those medical parameters of age and systolic velocity, which were applied into the neural networks, were more effective in developing vertebral deficiency.

Tuberculosis of the spine: CT and MR imaging features

Tuberculosis (TB) remains endemic in most of the developing countries. However, a resurgence of tuberculosis has also been reported in the past decades in developed countries, not only in the lungs, but also in extrapulmonary sites, e.g. the vertebral column. Vertebral TB is most often found in the lower thoracic and upper lumbar regions. Diagnosis is often difficult; clinical findings are usually non-specific and radiologic features may mimic those of other bacterial, fungal, inflammatory and neoplastic diseases. However, recognition and understanding of the radiological findings may help in diagnosis. Two distinct patterns of vertebral tuberculosis may be seen: the classic finding of spondylodiscitis, characterized by destruction of two or more contiguous vertebrae and opposed end plates, disk infection, and commonly a paraspinal mass or collection. The second pattern, increasing in frequency, is a atypical form of spondylitis without disk involvement.The value of CT and MR imaging are discussed in the diagnostic workup of vertebral tuberculosis. A positive culture or histopathologic analysis of CT-guided needle aspiration or biopsy specimens is required in the absence of pulmonary manifestations of tuberculosis for definitive diagnosis and adequate treatment.

[Differences between anteroposterior and posterior spondylodesis in clinical scores]

The present study on spondylitis patients was carried out to compare prospectively results of clinical scores of patients treated with anteroposterior or anterior spondylodesis. A total of 22 patients with spondylitis were enrolled in the randomized trial to undergo an operation with anteroposterior or posterior spondylodesis. For quality of life adjustment, the SF-36 health survey was applied. Pain and disability were measured using the Oswestry low-back pain disability questionnaire and visual analogue scales (VAS). Twelve patients were assigned to undergo anteroposterior spondylodesis and ten patients anterior spondylodesis. Postoperative improvement of spinal function, general health, well being, back pain, and mobility could be observed in both groups of patients. Better results of patients treated with anterior spondylodesis compared with anteroposterior spondylodesis were seen. No statistical difference was found between the two groups at any time. The less invasive nature of anterior spondylodesis could be responsible for that result.Anterior spondylodesis should used if possible and deemed adequate because it causes less discomfort.

Use of sulesomab in the diagnosis of brucellar spondylitis

Twenty-two patients with suspected brucellar spondylitis were investigated to evaluate the possible diagnostic role of Sulesomab, a (99m)Tc-antigranulocyte antibody Fab' fragment. Sensitivity and specificity were compared with those of magnetic resonance imaging (MRI). Skeletal involvement was detected by MRI in 11 cases, while leukoscintigraphy indicated normal vertebral uptake in seven of these patients, increased uptake in two patients, and decreased uptake in two patients. Leukoscintigraphy of the 11 patients negative by MRI demonstrated increased uptake in two cases. The sensitivity and specificity of leukoscintigraphy were 27.2% and 81.1%, respectively. Based on these results, leukoscintigraphy is not indicated for the management of patients with suspected brucellar spondylitis.

Massive intracerebral air embolism associated with meningitis and lumbar spondylitis: case report

BACKGROUND

Massive intracerebral air embolism is a rare pathologic state and never in association with meningitis and lumbar spondylitis. To the best of our knowledge, our presented case is the first of a massive intracerebral air embolism associated with meningitis and lumbar spondylitis of Klebsiella pneumonia.

CASE DESCRIPTION

A 55-year-old man presented with a high fever and low back pain. Blood culture showed Klebsiella pneumonia. Lumbar computed tomography (CT) revealed discitis at L1-2 and L2-3 levels and paraspinal abscess in which air was found. Despite management with antibiotics, patient's consciousness deteriorated, and brain CT revealed diffuse intravenous air embolism and severe brain swelling. Cerebrospinal fluid (CSF) examination demonstrated bacterial meningitis, and the CSF culture showed Klebsiella pneumonia. Later, septic shock occurred and patient expired.

CONCLUSION

Intracerebral air embolism can occur in the Klebsiella pneumonia meningitis that resulted from lumbar spondylitis and sepsis.

[The prevalence of radiographic sacroiliitis in patients affected by inflammatory bowel disease with inflammatory low back pain]

Inflammatory bowel diseases (IBD), as Crohn's disease (CD) or ulcerative colitis (UC), are frequently complicated by joint complaints with prevalence that varies between 10 and 28%. The IBD related arthropathy may be expressed as peripheral arthritis or axial one frequently indistinguishable from the classical ankylosing spondylitis (AS). According to ESSG criteria for spondyloarthropathy, the presence of synovitis or the inflammatory back pain (IBP) in IBD patients is diagnostic for spondyloarthropathy, but for diagnosis of ankylosing spondylitis also radiological criteria must be fulfilled. There are few studies regarding the radiological prevalence of sacroiliitis in patients with IBD. We examined, by plain film radiograms of pelvis, 100 sacroiliac joints (SJ) of 50 IBD patients with IBP. The New York (1984) SJ radiological score with gradation from 0 to 4 was applied. Total sacroiliac score (SJS) was summarized between left and right side (from 0 to 8). Fourteen patients fulfilled New York modified criteria for AS and 8 patients had unilateral 2nd grade sacroiliitis. Only 4 of 14 AS patients (28%) were HLA B27 positive. Thirty patients had localized IBP, 10 extended to buttock and 4 extended to sacrum. Sixteen patients had sciatica-like extension of back pain. A difference in SJS between left and right side was observed only in CD patients (1.3 +/- 0.8 and 0.8 +/- 0.9 respectively; p < 0.05), but not in UC (1.5 +/- 1.2 vs 1.5 +/- 1.3; p = ns) nor in total IBD patients (1.4 +/- 1.0 vs 1.2 +/- 1.2; p = ns). Total SJS was higher in UC respect CD, but not significantly (2.9 +/- 2.3 vs 2.1 +/- 1.5; p = ns). Our data confirm the importance of these symptoms in patients with IBD, who need to be carefully investigated also for these aspects.

Radiological sacroiliitis, a hallmark of spondylitis, is linked with CARD15 gene polymorphisms in patients with Crohn's disease

BACKGROUND

Sacroiliitis is a common extraintestinal manifestation of Crohn's disease but its association with the HLA-B27 phenotype is less evident. Polymorphisms in the CARD15 gene have been linked to higher susceptibility for Crohn's disease. In particular, associations have been found with ileal and fibrostenosing disease, young age at onset of disease, and familial cases.

OBJECTIVES

To investigate whether the presence of sacroiliitis in patients with Crohn's disease is linked to the carriage of CARD15 polymorphisms.

METHODS

102 consecutive patients with Crohn's disease were clinically evaluated by a rheumatologist. Radiographs of the sacroiliac joints were taken and assessed blindly by two investigators. The RFLP-PCR technique was used to genotype all patients for three single nucleotide polymorphisms (SNP) in the CARD15 gene. Every SNP was verified by direct sequencing. The HLA-B27 phenotype was determined.

RESULTS

Radiological evidence of sacroiliitis with or without ankylosing spondylitis was found in 23 patients (23%), of whom only three were HLA-B27 positive. In contrast, 78% of patients with sacroiliitis carried a CARD15 variant v 48% of those without sacroiliitis (p = 0.01; odds ratio 3.8 (95% confidence interval, 1.3 to 11.5)). Multivariate analysis (logistic regression) showed that the association between sacroiliitis and CARD15 polymorphisms was independent of other CARD15 related phenotypes (ileal and fibrostenosing disease, young age at onset of disease, familial Crohn's disease) (p = 0.039).

CONCLUSIONS

CARD15 variants were identified as genetic predictors of Crohn's disease related sacroiliitis. An association was demonstrated between these polymorphisms and an extraintestinal manifestation of Crohn's disease.

Clinical feasibility of two-step streptavidin/111In-biotin scintigraphy in patients with suspected vertebral osteomyelitis

PURPOSE

Streptavidin accumulates at sites of inflammation and infection as a result of increased capillary permeability. In addition to being utilised by bacteria for their own growth, biotin forms a stable, high-affinity non-covalent complex with avidin. The objective of this investigation was to determine the diagnostic performance of two-step streptavidin/111In-biotin imaging for evaluating patients with suspected vertebral osteomyelitis.

METHODS

We evaluated 55 consecutive patients with suspected vertebral osteomyelitis (34 women and 21 men aged 27-86 years), within 2 weeks after the onset of clinical symptoms. Thirty-two of the patients underwent magnetic resonance imaging (MRI) and 24, computed tomography (CT). DTPA-conjugated biotin was radiolabelled by incubating 500 microg of DTPA-biotin with 111 MBq of 111In-chloride. Two-step scintigraphy was performed by first infusing 3 mg streptavidin intravenously, followed 4 h later by 111In-biotin. Imaging was begun 60 min later.

RESULTS

Streptavidin/111In-biotin scintigraphy was positive in 32/34 patients with spinal infection (94.12% sensitivity). The study was negative in 19/21 patients without infection (95.24% specificity). The corresponding results for MRI and CT were 54.17% and 35.29% (sensitivity), and 75% and 57.14% (specificity), respectively. All statistical parameters of diagnostic performance (Youden's J index, kappa measure of agreement with correct classification, accuracy, sensitivity, specificity, positive likelihood and negative likelihood) were clearly better for streptavidin/111In-biotin scintigraphy than for either MRI or CT.

CONCLUSION

Streptavidin/111In-biotin scintigraphy is highly sensitive and specific for detecting vertebral osteomyelitis in the first 2 weeks after the onset of clinical symptoms, and is potentially very useful for guiding clinical decisions on instituting appropriate therapy.

Diagnostic value of 99mTc-HMDP bone scan in atypical osseous tuberculosis mimicking multiple secondary metastases

STUDY DESIGN

A case of atypical osseous tuberculosis (TB) mimicking multiple secondary metastases on radiologic and nuclear imaging is presented.

OBJECTIVES

To emphasize the contribution of nuclear bone scanning for the assessment of osseous tuberculosis in typical and atypical presentations.

SUMMARY AND BACKGROUND DATA

Skeletal locations of TB mostly involve the dorsolumbar spine and diagnosis is often delayed. The presence of multiple TB sites can mimic secondary metastases and biopsy remains the mainstay for final diagnosis.

METHODS

Clinical symptoms, lab tests, and imaging data are presented. Possible diagnoses are discussed. A review of imaging characteristics in cases of typical and atypical presentations of osseous TB is proposed.

RESULTS

A dorsal spine spondylitis was first diagnosed on a 56-year-old patient presenting neurologic deficit of the left arm. Fine needle aspiration identified bacterial infection but was negative for Mycobacterium tuberculosis. Whole-body bone scan allowed the identification of an asymptomatic sacroiliac lesion, which was accessible to biopsy and gave a final diagnosis.

CONCLUSION

Nuclear bone scanning should be kept in mind when assessing spinal pain in patients at high risk of TB infection or reactivation.

99mTc ciprofloxacin imaging for the diagnosis of infection in the postoperative spine

BACKGROUND

The non-invasive assessment of postoperative spinal infections can pose a substantial diagnostic challenge, especially in the presence of orthopaedic devices. In contrast to white blood cell scanning, which is of limited use in the spine, the low uptake of 99mTc ciprofloxacin into normal bone marrow, combined with its claimed bacterial specificity, makes it, theoretically, an ideal candidate for evaluating postoperative spinal infections.

AIM

This study aimed to evaluate 99mTc ciprofloxacin planar and single photon emission tomography (SPET) imaging in relation to microbiological diagnosis in the postoperative spine.

METHODS

Only patients with a microbiologically confirmed diagnosis were included in this analysis. Planar imaging was performed at 1, 3 and 24 h, and SPET was performed at 3 h post-injection of 370 MBq 99mTc ciprofloxacin. Images were scored by two independent, certified, nuclear medicine physicians, blinded for the final diagnosis.

RESULTS

Within the first 22 consecutive patients with microbiological diagnosis, there were nine deep infections. Sensitivity, specificity and accuracy at visual scoring were, respectively, 67%, 77%, 73% (1 h), 78%, 69%, 73% (3 h), and 56%, 92%, 77% (24 h) for planar imaging, and 100%, 54%, and 73% for SPET.

CONCLUSION

In contrast to white blood cell scanning, SPET with Tc ciprofloxacin is sensitive in evaluating infections in the postoperative spine. Sensitivity is higher for SPET than for planar imaging. However, the results presented prove that its specificity is limited, especially in patients who have recently (< 6 months) undergone surgery. Taken this limitation into account, we advise planar and SPET imaging at 3 h post-injection and at an interval of at least 6 months after surgery to minimize the chance for false positives.

[Percutaneous laser denervation of the zygapophyseal joints in the pain facet syndrome]

Percutaneous laser denervation of archoappendicular joints in spinal pain was made in 15 patients from a study group. Percutaneous high-frequency denervation of archoappendicular joints was performed in a control group consisting of 15 patients with facet syndrome. A preoperative protocol for each patient included at least two diagnostic segmental blocks. A surgical intervention was morphologically substantiated during an experiment; the most optimum surgery protocol was chosen. Destruction was performed by 0.97-micron laser radiation for 4-6 sec at 5-10 W. The number of cases of a complete or partial pain regression, the duration of its impact, side effects and complications were determined. Of the 15 patients from the study group, 8 and 6 patients were observed to have a complete and significant pain regression (more than 50% of the baseline). No effect was achieved in one patient. The similar results were obtained in the control group. There were no postoperative infectious complications in the patients of both groups; transient pain dysesthesia was registered in one case. The findings have led to the conclusion that laser denervation of archoappendicular joints is effective in the pain facet syndrome.

99mTc-Ciprofloxacin planar and tomographic imaging for the diagnosis of infection in the postoperative spine: experience in 48 patients

The non-invasive assessment of postoperative spinal infections can pose a substantial diagnostic challenge, especially in the presence of orthopaedic devices. Whereas white blood cell scanning is of limited use in the spine, the low normal bone marrow uptake of technetium-99m ciprofloxacin combined with its claimed bacterial specificity makes it theoretically an ideal candidate for the evaluation of postoperative spinal infections. This study aimed to evaluate 99mTc-ciprofloxacin planar and single-photon emission tomography (SPET) imaging in relation to microbiological and clinical diagnosis in the postoperative spine. Planar imaging was performed at 1, 3 and 24 h and SPET was performed at 3 h post injection of 370 MBq 99mTc-ciprofloxacin. Images were scored by two independent certified nuclear medicine physicians, blinded to the final diagnosis. Within the 48 patients, there were 13 deep infections. Sensitivity, specificity and accuracy at visual scoring were respectively 54%, 71% and 67% (1 h), 62%, 77% and 73% (3 h), 42%, 91% and 77% (24 h) for planar imaging and 100%, 74% and 81% for SPET. When recently operated patients (< 6 months) were excluded, the specificity of the SPET imaging rose to 81%. In conclusion, unlike white blood cell scanning, 99mTc-ciprofloxacin SPET is sensitive in evaluating infections in the postoperative spine. Sensitivity is much higher for SPET than for planar imaging. However, the results presented prove that its specificity is limited, especially in recently operated patients. Taking this limitation into account, we advise planar and SPET imaging at 3 h post injection and an interval of at least 6 months after surgery to minimise the likelihood of false positives.

Mykotisches Aneurysma der infrarenalen Aorta

The mycotic aneurysms of the infrarenal aorta (MAIA) are extremely rare and the associated morbidity and mortality is very high. The classification of infected aneurysms considers four types: a) true mycotic aneurysms, b) secondary mycotic aneurysms due to bacterial arteritis, c) infected preexisting abdominal aortic aneurysms and d) post-traumatic infected false aneurysms. The prognosis of true MAIA’s is better than the other forms of infected aneurysms. The standard treatment includes the resection of the aneurysm and infectious surrounding tissues and the restoration of the flow using ex situ (axillobifemoral) bypass or in situ replacement with autologous vein or a rifampicine-bonded graft. We present a case of mycotic aneurysm of the infrarenal aorta and a brief discussion of the alternative treatments from the relevant literature.

[Spiral computed tomography in the diagnosis of inflammatory diseases of the vertebral column]

A Somatom Plus 4 spiral computed tomograph was used to examine 40 patients with purulent spondylitis and 8 patients with tuberculous spondylitis. Analysis of the primary examination, postoperative status, and follow-up of patients on medical therapy identified the main signs of an inflammatory process from a great variety of the computed tomographic (CT) signs of a lesion. They made it possible not only to reveal the inflammatory nature of a lesion, but also to differentiate purulent and tuberculous spondylitis. The main CT signs that allow a purulent spondylitis to be differentiated from tuberculous one are as follows: the location of involved veterbrae, the number of and the pattern of destruction of trabecular and cortical layers, the extent of and the form of paravertebral tissue lesion.

[Differential diagnosis of tuberculous spondylitis under the conditions of a specialized sanatorium]

A total of 477 patients admitted to hospital for tuberculous spondylitis were examined. Further studies revealed that the process in the vertebral column was regarded as degenerative and dystrophic changes in 140 patients, nonspecific osteomyelitis in 94, and cancer in 22. The basis of diagnostic errors was the similarity of some clinical and X-ray manifestations and the pathomorphosis of tuberculous spondylitis, older patients, the wide use of antibiotics, which changes the clinical course of spinal tuberculosis. The causes of great difficulties in the differential diagnosis of tuberculous spondylitis lie in the insufficient diagnostic capacities of district tuberculosis dispensaries and in the clinical and X-ray manifestations of spinal tuberculosis which have changed today.

[Radiographic methods in the diagnosis of tuberculous spondylitis]

During one year period (from May 2000 to June 2001) 136 radiographic examinations were performed in Kulautuva tuberculosis hospital due to suspision of skeletal tuberculosis. Tuberculous spondilitis being most frequent presentation of skeletal tuberculosis, showed radiographic signs in 31 cases (22.8%). The role of conventional X-rays and computed tomography diagnosis of tuberculous spondilitis is reviewed. Early changes on plain films are non-specific making early diagnosis of spine tuberculosis a challenging task. In such cases spinal computed tomography may be helpful. Must frequently pathologic changes include high spectrum varying from osteoporosis to destruction of vertebrae and two or three vertebraes and intervertebrae disks are always involved.

[Use of carbon-carbonic implants in surgery of tuberculous spondylitis]

For surgical treatment of spinal tuberculosis, carbon-carbonic implants were used for anterior spondylosis in 29 patients; in 14 of them bone autografts were additionally applied. Carbon-carbonic implants reliably fixed the operated part of the vertebral column, prevented an increase in kyphotic deformity, and, in combined plastic repair, created favorable conditions for consolidation of bone autografts. A bone-carbon block formed in the late postoperative period.

[Vertebral manifestation of chronic recurrent multifocal osteomyelitis (CRMO)]

Chronic recurrent multifocal osteomyelitis (CRMO) is a systemic osteo-articular disease that is characterized by a sterile, primarily chronic osteomyelitis with various distribution patterns of the individual lesions. In this article, we describe the "axial type" with predominant involvement of the spine, which represents 13 of our 41 CRMO cases of different age groups. The important element of its diagnosis is the typical lympho-plasmacellular spondylitis that can be detected and staged by scintigraphy, MRI and conventional radiography. Potentially affected are all vertebrae from the mid-cervical spine to the sacrum. One or several segments can be involved, sometimes as transient inflammatory edema, sometimes as "migratory spondylitis" or "saltatory spondylitis", but also as chronic sclerosing type with early radiographically detectable manifestation. Vertebral deformity due to compression and total collapse (vertebra plana) are rare. A complicated course with patulous perivertebral edema can lead to concomitant symptomatic inflammatory changes in adjacent regions and organs. In the course of CRMO, spondylodiscitis only develops as secondary destruction following the spondylitis. This can help to differentiate spondyloarthropathies from CRMO that is initially detected as primary lesion in the spine. While CRMO generally has a good prognosis, its radiological differentiation from rheumatologic conditions plays an important role.

[Anterior cervical diskectomy and interbody arthrodesis using Cloward technique: retrospective study of complications and radiological results of 167 cases]

PATIENTS AND METHODS

We performed a retrospective analysis of complications and radiological results in 167 patients surgically treated, for discal or spondylotic disease of the cervical spine, with Cloward procedure. Using uni and multivariate analysis, we tried to identify risk factors that might be correlated with surgical complications or radiological results.

RESULTS

Surgical treatment was indicated for cervical radiculopathy in 68% of the patients and for myelopathy or radiculomyelopathy in the remaining 32%. The pathologic disease responsible of the symptomatology was soft disk herniation in 59% of the cases and spondylotic changes in 41%. The patients that underwent surgery because of myelopathy were one decade older, had a longer symptomatic period and presented multi-segmentary spondylotic disease with higher frequency than patients affected of radiculopathy. The most common segments operated were CS-C6 (44.3%) and C6-C7 (30.5%). Surgical mortality was 0.6% and morbidity 29.3%. Most of the complications were transient, although 4.8% of the patients developed permanent neurological deterioration.

CONCLUSIONS

Complications were most commonly seen in the group of the patients undergoing surgery because of long-lasting myelopathy with multi-segmentary spondylotic disease, in those with vascular risk factors and in those operated of more than one segment. Surgeon anatomic knowledge and experience are critical for diminishing such complications. Non-union rate was 9.6%, and another 9.6% of the patients developed post-surgical kyphosis. Both factors correlated with the need of re-operation.

Tuberculous spondylitis: epidemiologic and clinical study in non-HIV patients from northwest Spain

OBJECTIVES

To study the epidemiology, clinical features, and outcome of non-human immunodeficiency virus (HIV) patients diagnosed with tuberculous spondylitis (TS) in a well-defined region of northwestern Spain.

METHODS

Retrospective chart review of patients older than 14 years of age diagnosed with TS at two contiguous areas between 1986 and 1999.

RESULTS

Thirty-seven patients (19 men; mean age 60.3 years) were diagnosed with TS. The average annual incidence rate of TS was 0.55/100,000 population 15 years of age and older. The thoracic and lumbar regions were affected in most cases. The mean duration of symptoms before diagnosis was 28 weeks (range 3-129). Active or healed pulmonary tuberculosis was observed in only 30%. The tuberculin skin test was negative in 24%. The most common findings at the time of diagnosis were back pain and elevated ESR (either 89%). Of note, only 19% had fever. On admission plain radiographs disclosed the presence of spondylitis in 84% of the patients. Computed tomography scan and magnetic resonance imaging yielded conclusive diagnostic data in the cases with normal radiographs, and were very useful in the visualization of abscesses and intraspinal compression. Cultures of material from percutaneous needle aspiration and open bone biopsy were positive for Mycobacterium tuberculosis in 79% and 77% of the cases, respectively. Antituberculous therapy was given to all patients (mean duration of treatment 44 weeks). Surgical procedures were performed in 12 cases, in 7 of them to remove paraspinal and/or epidural abscesses, and in 5 because of neurological complications. Local pain and neurological deficits were the mostfrequent sequelae (16 and 8 cases, respectively). One patient died during the course of treatment due to a co-morbid disease. None of the patients had relapses of tuberculosis.

CONCLUSION

TS is a major cause of morbidity. There is a long delay to the diagnosis in most patients. Awareness of its clinical features and early therapy are required to reduce severe complications.

18F-FDG hybrid PET in patients with suspected spondylitis

This study investigated the value of fluorine-18 2'-deoxy-2-fluoro- D-glucose (FDG) imaging with a double-headed gamma camera operated in coincidence (hybrid PET) detection mode in patients with suspected spondylitis. Comparison was made with conventional nuclear medicine imaging modalities and magnetic resonance imaging (MRI). Sixteen patients with suspected spondylitis (nine male, seven female, mean age 59 years) prospectively underwent FDG hybrid PET (296 MBq) and MRI. For intra-individual comparison, the patients were also imaged with technetium-99m methylene diphosphonate (MDP) (555 MBq) ( n=13) and/or gallium-67 citrate (185 MBq) ( n=11). For FDG hybrid PET, two or three transverse scans were performed. Ratios of infected (target) to non-infected (background) (T/B) vertebral bodies were calculated. MR images were obtained of the region of interest. Patients found positive for spondylitis with MRI and/or FDG hybrid PET underwent surgical intervention and histological grading of the individual infected foci. Twelve out of 16 patients were found to be positive for spondylitis. Independent of the grade of infection and the location in the spine, all known infected vertebrae ( n=23, 9 thoracic, 12 lumbar, 2 sacral) were detected by FDG hybrid PET. T/B ratios higher than 1.45+/-0.05 (at 1 h p.i.) were indicative of infectious disease, whereas ratios below this value were found in cases of degenerative change. FDG hybrid PET was superior to MRI in patients who had a history of surgery and suffered from a high-grade infection in combination with paravertebral abscess formation ( n=2; further computed tomography was needed) and in those with low-grade spondylitis ( n=2, no oedema) or discitis ( n=2, mild oedema). False-positive 67Ga citrate images ( n=5: 2 spondylodiscitis, 1 aortitis, 1 pleuritis, 1 pulmonary tuberculosis) and 99mTc-MDP SPET ( n=4: 1 osteoporosis, 2 spondylodiscitis, 1 fracture) were equally well detected by FDG hybrid PET and MRI. No diagnostic problems were seen in the other patients ( n=5). In this study, FDG hybrid PET was superior to MRI, 67Ga citrate and (99m)Tc-MDP, especially in patients with low-grade spondylitis (as compared with MRI), adjacent soft tissue infections (as compared with 67Ga citrate) and advanced bone degeneration (as compared with 99mTc-MDP).

The cervical spine in juvenile chronic arthritis

BACKGROUND CONTEXT

In patients with juvenile chronic arthritis (JCA) the cervical spine is often affected, leading to pain and functional limitations.

PURPOSE

To describe the frequency of the radiographic abnormalities in the cervical spine of a large series of patients with JCA, examined after skeletal maturity.

STUDY DESIGN

Consecutive patients with JCA, who had cervical spine radiographs available taken at adult age (>18 years) were included in the study from one outpatient clinic and one rheumatology ward in the Rheumatism Foundation Hospital, Heinola, Finland.

PATIENT SAMPLE

The series consisted of 159 patients fulfilling the diagnostic criteria of the European League Against Rheumatism for JCA.

OUTCOME MEASURES

Evaluation of cervical spine radiographs for inflammatory changes.

METHODS

Inflammatory changes in the cervical spine radiographs were measured as well as the size of the fourth cervical vertebra. Patient records were studied. The statistical analysis was calculated by Student's t-test or Mann-Whitney U test.

RESULTS

In 98 cases (62%) some inflammatory changes were detected in the cervical spine. Apophyseal joint ankylosis was noted in 65 patients (41%), anterior atlantoaxial subluxation in 27 (17 %) and atlantoaxial impaction in 39 (25 %). The fourth cervical vertebra was abnormally small in 41 patients (26%).

CONCLUSIONS

Radiographically, the most frequent inflammatory change in the cervical spine of patients with JCA was apophyseal joint ankylosis at multiple levels. Atlantoaxial impaction and anterior atlantoaxial subluxation were typical of the upper cervical spine. Clinically, these changes tend to limit neck movements. A small C4 vertebral body was seen in patients with early disease onset and short body stature.

Clinically asymptomatic axial disease in psoriatic spondyloarthropathy. A retrospective study

The aim of this study was to analyse retrospectively the prevalence and the clinical features of clinically asymptomatic axial involvement in patients with psoriasis and axial radiological features of spondyloarthropathy (PsSpA). We performed a cross-sectional study based on the clinical records of 70 patients, 44 men and 26 women, with a mean age of 48.7+/-14.2 years. PsSpA was defined by the presence of radiographic sacroiliitis (SI) greater than or equal to grade 2, and/or any other typical radiological sign of spondylitis in patients with psoriasis. When the radiological signs were present in the absence of inflammatory back pain and/or buttock pain, patients were grouped as having asymptomatic axial disease. HLA-B27 was determined by serological methods in the 70 patients and in 82 healthy controls from our general population. Fourteen patients (20%), 11 with radiological SI, two with facet joint erosion-fusion and one with aseptic discitis, showed no evidence of symptomatic spinal disease. Twenty-nine patients (41%) showed cervical spine disease (CSD), but only 17 of them (58.6%) had pain and rigidity at this level, whereas 12 (41.4%) did not show clinical symptoms. CSD was associated with duration of arthritis (P = 0.043) and peripheral erosions (P = 0.037). HLA-B27 correlated well with bilateral SI (P = 0.002) and PsSpA (P<0.0004, RR 6.4), but showed no association with unilateral SI nor with syndesmophytes or asymptomatic disease. Univariate analysis demonstrated associations between symptomatic disease and longer duration of arthritis (P = 0.041) and higher IgM values (P = 0.05). There is a high prevalence of asymptomatic involvement in patients with PsSpA The significance of these asymptomatic changes is not known, but they probably represent a common characteristic of spondyloarthropathies rather than a specific feature associated with psoriasis.

[Diagnostic imaging of inflammatory rheumatic joint diseases. Part II: techniques and axial joints]

Imaging of inflammatory disorders of the spine and sacro-iliac joints is important for the diagnosis, prognosis, and evaluation of therapy. Conventional radiography still constitutes the basic imaging modality, but supplementary computed tomography (CT) and especially magnetic resonance imaging (MR-scanning) may provide additional important information. The radiation dose by CT must be taken into account. It is therefore expected that MR-scanning, which is without known risks, will increasingly become the method of choice when the information obtained by conventional radiography is inadequate.

[Vertebral hydatidosis: three case reports]

PURPOSE OF THE STUDY

Vertebral hydatidosis, the most frequent localization of skeletal hydatidosis, has an ominous prognosis with the risk of progressive but permanent neurological damage. There is no consensus on appropriate management. Treatment is often unsuccessful with frequent recurrence. The purpose of this study was to assess our experience with this rare disease to identify diagnostic, therapeutic and prognostic features.

MATERIAL AND METHODS

We reviewed the charts of three patients with vertebral hydatidosis treated at the department of orthopedics at the Casablanca children's hospital between January 1989 and January 1998. Diagnosis was made early in the first patients, allowing complete excision of the hydatid cyst. Follow-up was uneventful 10 years after surgery. The second patient presented after a long disease course and had definitive neurological complications despite treatment. The lesions were extensive in the third patient and cure could not be achieved although the patient remained asymptomatic.

DISCUSSION

Vertebral hydatidosis is a severe disease causing frequent neurological complications. Surgical treatment, though difficult, is the only efficient option. Complete recovery can be achieved after surgical excision of lesions diagnosed early. Prevention is the best therapeutic strategy in endemic areas.

Aspergillus spondylitis in immunocompetent patients

Four immunocompetent patients with neurological deficit underwent anterior decompression for Aspergillus osteomyelitis of the spine. All patients improved neurologically following anterior spinal decompression and antifungal therapy. This study emphasizes the importance of obtaining a tissue diagnosis as these unusual infections may mimic tuberculosis, which is more common.

[Results of decompression operations in patients with tuberculous spondylitis]

The paper summarizes the outcomes of decompression and decompression-reparative operations in patients with tuberculous spondylitis. Good surgical results with complete elimination or alleviation of neurological disorders have been achieved in 94.8% of cases.

Use of fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography in assessing the process of tuberculous spondylitis

Fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography can be used to quantify the pathologic increase in glucose metabolism of inflammatory processes. Preliminary studies indicate a high level of sensitivity and specificity in detecting and identifying chronic osteomyelitis. This case study shows that positron emission tomography can be used to assess the process of inflammatory activity in tuberculous spondylitis. This technology also has the advantage of higher spatial resolution compared with other nuclear medicine procedures. In addition, it can differentiate between bone and soft tissue infection and allows imaging in the presence of metal implants.