Vertebral osteomyelitis caused by Campylobacter jejuni in an immunocompetent patient

BACKGROUND

Campylobacter jejuni is the leading cause of human bacterial gastroenteritis worldwide. However, systemic infection with C. jejuni is uncommon, and osteomyelitis caused by C. jejuni is extremely rare. Cultivation from spinal bone biopsies has not previously been reported in the literature.

CASE PRESENTATION

A 79-year-old immunocompetent male was admitted to the emergency department at Aalborg University Hospital in Denmark with lower back pain, fever and diarrhoea. A FecalSwab obtained upon admission was PCR-positive for Campylobacter spp, while an aerobic blood culture bottle was positive for C. jejuni (Time to detection: 70.4 h). A MRI of columna totalis showed osteomyelitis at L1/L2 with an epidural abscess from L1 to L2 with compression of the dura sack. The patient underwent spinal surgery with spondylodesis and decompression of L1/L2. The surgery was uncomplicated and the discus material was also culture positive for C. jejuni. The patient was treated with meropenem for a total duration of four weeks, followed by four weeks of oral treatment with clindamycin in tapered dosage. The patient recovered quickly following surgery and targeted antibiotic treatment with decreasing lumbar pain and biochemical response and was fully recovered at follow-up three months after end of treatment.

CONCLUSIONS

While C. jejuni osteomyelitis is rare, it should still be suspected as a possible causative bacterial aetiology in patients with vertebral osteomyelitis, in particular when symptoms of diarrhoea is involved in the clinical presentation. Susceptibility testing is crucial due to emerging resistance, and targeted treatment strategies should rely upon such tests.

Understanding the management of pediatric spondylodiscitis based on existing literature; a systematic review

BACKGROUND

Spondylodiscitis (SD), a rare disease in children, poses diagnostic challenges due to non-specific presenting symptoms, scarcity in incidence, and difficulty expressing pain in non-verbal children.

METHOD

A comprehensive search was conducted on three databases, including PubMed/Medline, Web of Science, and Scopus until March 2023. The inclusion criteria were studies that investigated the clinical characteristics, treatment, and complications of children's spondylodiscitis. Full text of cross-sectional and cohort studies were added. The quality assessment of cohort studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. The search, screening, and data extraction were performed by two researchers independently.

RESULT

Clinical manifestations of discitis in children are nonspecific, such as back pain, fever, reduced ability or inability to walk or sit, limping, and reduced range of movements. The mean delay in the time of diagnosis was 4.8 weeks. The most affected site of all the studies was the lumbar spine. 94% of studies reported increased inflammatory markers such as white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Less than 30% of patients had positive blood cultures and biopsy findings. The most common microbiological results (64%) were Staphylococcus Aureus and Kingella kingae. In radiographic evaluation, intervertebral disk narrowing, lumbar lordosis reduction, loss of disk height, and destruction of the vertebral body have been reported. In all studies, antibiotic therapy was initiated; in 52% immobilization was employed, and 29% of studies reported surgery was performed, and the follow-up period differed from 1.5 months to 156 months. 94% of studies reported complications such as vertebral body destruction, back pain, kyphosis, reduced range of movement, scoliosis, and neurological complications.

CONCLUSION

Spondylodiscitis is an uncommon, heterogeneous, multifactorial disease with resulting difficult and delayed diagnosis. Due to its morbidity, it is essential to investigate children with refusal to walk, gait disturbances, or back pain, particularly when associated with elevated inflammatory markers.

Incidental finding of Pott's disease with abscesses of the psoas simulating an appendicular syndrome

Pott's disease or tuberculous spondylodiscitis is the disco-vertebral localization of Koch's bacillus. It causes progressive spinal lesions, with abscesses forming in the perivertebral soft tissues and epidural spaces. Medical imaging plays an indisputable role in the diagnosis and management of Pott's disease. Magnetic resonance imaging (MRI) enables early positive diagnosis and assessment of spinal damage. Computed tomography (CT) is currently the best interventional imaging method for the drainage of soft tissue abscesses and disco-vertebral biopsies for bacteriological and histological purposes. We report a case of accidental discovery of Pott's disease with abscesses of the psoas simulating an appendicular syndrome and describe its epidemiological, clinical, and radiological aspects through a review of the literature.

A rare anaerobic cause of vertebral osteomyelitis and psoas abscess: A case study

Parvimonas micra is an obligate anaerobe that forms part of the normal gastrointestinal flora. The advent of matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF) and 16s ribosomal RNA gene sequencing has led to increased detection of many rare anaerobic isolates, including Parvimonas micra. Typical risk factors for Parvimonas micra bacteremia include dental procedures or spinal instrumentation. Here, we report a case of Parvimonas micra spondylodiscitis and psoas abscess in a patient with no obvious antecedent risk factors and explore the challenges in isolation of the organism from tissue samples.

Incidence and outcome of patients suffering from meningitis due to spondylodiscitis

Introduction

Meningitis is a rare but severe complication in patients with spondylodiscitis. Data about the incidence and clinical management are rare.

Research question

Aim of this study was to assess the incidence, clinical course and outcome of patients suffering from meningitis due to spondylodiscitis.

Material and methods

We performed a retrospective analysis of our prospective clinical database that included all patients suffering from spondylodiscitis between January 2010 and December 2019 were included. We assessed clinical findings, laboratory tests, treatment and outcome comparing patients with and without meningitis.

Results

Out of 469 patients suffering from spondylodiscitis, 30 patients (14 female) were diagnosed with an associated meningitis (6.4%). The mean CSF cell count was 3375.85 ± 8486.78/μl (range 32-41500/μl). The mean age at presentation was 70.87 ± 8.84 yrs (range 48-88 yrs). Mean C-reactive protein (CRP) and white blood cell (WBC) counts at time of admission were statistically higher in patients with associated meningitis (CRP: 19.81 ± 12.56 mg/dl vs. 11.63 ± 11.08 mg/dl, p = 0.001; WBC: 14.67 ± 7.76 g/l vs. 10.88 ± 05.11 g/l, p = 0.005. Mortality was also higher, as 13.3% and 7.1% of patients with and without concomitant meningitis died, respectively.

Conclusion

Bacterial meningitis due to spondylodiscitis is a rare but severe condition and is associated with higher morbidity and mortality rates. In patients with spondylodiscitis presenting with an altered state of consciousness an associated meningitis should be ruled out.

A proposed management classification for spinal brucellosis from India

INTRODUCTION

The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopaedic and rheumatology specialists. Moreover, the lack of disease-specific symptomatology is the leading cause of the delay in diagnosing osteoarticular brucellosis. Given the increasing number of spinal brucellosis cases across the country, no literature is presented on the systematic management of spinal brucellosis. However, with our experience, we formulated a classification for managing spinal brucellosis.

METHODS

A single-centred prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analysed and graded clinically, serologically, and radiologically and were managed with antibiotics for 10-12 weeks, and if necessary, stabilisation and fusion were done based on the treatment classification devised. All patients were followed up to ensure disease clearance at serial follow-up with relevant investigations.

RESULTS

The mean age of the study participants was 52.16 ± 12.53 years. According to spondylodiscitis severity code (SSC) grading, four patients belong to grades 1, 12 to grade 2 and 9 to grade 3 at presentation. Erythrocyte sedimentation rate (p = 0.02), c-reactive protein (p < 0.001), Brucella agglutination titers (p < 0.001), and radiological outcomes improved statistically by six months. The treatment duration was individualised according to the patient's response to the treatment, with a mean time of 11.42 ± 2.66 weeks. The mean follow-up period was 14.42 ± 8 months.

CONCLUSION

High index of suspicion of patients from endemic regions, proper clinical assessment, serological evaluation, radiological assessment, appropriate decision-making (medical/surgical) in treatment, and regular follow-up were the key to successful comprehensive management of spinal brucellosis.

The use of MRI, PET/CT, and nuclear scintigraphy in the imaging of pyogenic native vertebral osteomyelitis: a systematic review and meta-analysis

BACKGROUND CONTEXT

Native vertebral osteomyelitis (NVO) is a severe infection with an increasing incidence globally. Although there is no widely agreed upon reference standard for diagnosis of the disease, imaging plays a crucial role. Magnetic resonance imaging (MRI) is currently the imaging modality of choice. In recent years, advances in imaging have allowed for a larger role for alternative imaging techniques in the setting of NVO.

PURPOSE

Our aim was to evaluate the diagnostic accuracy of MRI, PET/CT, and nuclear imaging, namely 67Gallium and 99mTechnetium scintigraphy, in the diagnosis of pyogenic NVO.

STUDY DESIGN/SETTING

We conducted a systematic review of five medical databases and included all studies from 1970 to September 2021 that compared imaging techniques and provided sufficient data for diagnostic test accuracy meta-analysis.

METHODS

Abstract screening, full text review, and data extraction were done by a pair of independent reviewers. Nonnative and nonpyogenic patients were excluded. A bivariate random effect model was used for meta-analysis.

RESULTS

Twenty studies were included in the meta-analysis, encompassing a total of 1,123 imaging studies. The meta-analysis sensitivity and specificity of MRI were 90% and 72% respectively; those of PET/CT were 93% and 80%; those of 67Ga were 95% and 88%; those of 99mTc were 86% and 39%; and the sensitivity and specificity of combined Ga and Tc were 91% and 92% respectively in the setting of suspected NVO.

CONCLUSIONS

67Ga has the highest sensitivity for NVO, and its specificity is augmented when combined with 99mTc. MRI and PET/CT are both highly sensitive modalities, although the specificity of PET/CT is slightly better. MRI remains an appropriate initial test depending on the availability of other modalities.

Increasing incidence of spondylodiscitis in England: An analysis of the national health service (NHS) hospital episode statistics from 2012 to 2021

Background

Spondylodiscitis is a potentially life-threatening infection of the intervertebral disk and adjacent vertebral bodies, with a mortality rate of 2-20%. Given the aging population, the increase in immunosuppression, and intravenous drug use in England, the incidence of spondylodiscitis is postulated to be increasing; however, the exact epidemiological trend in England remains unknown.

Objective

The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise the annual activity and longitudinal change of spondylodiscitis in England.

Methods

The HES database was interrogated for all cases of spondylodiscitis between 2012 and 2019. Data for the length of stay, waiting time, age-stratified admissions, and 'Finished Consultant Episodes' (FCEs), which correspond to a patient's hospital care under a lead clinician, were analysed.

Results

In total, 43135 FCEs for spondylodiscitis were identified between 2012 and 2022, of which 97.1% were adults. Overall admissions for spondylodiscitis have risen from 3 per 100,000 population in 2012/13 to 4.4 per 100,000 population in 2020/21. Similarly, FCEs have increased from 5.8 to 10.3 per 100,000 population, in 2012-2013 and 2020/21 respectively. The highest increase in admissions from 2012 to 2021 was recorded for those aged 70-74 (117% increase) and aged 75-59 (133% increase), among those of working age for those aged 60-64 years (91% increase).

Conclusion

Population-adjusted admissions for spondylodiscitis in England have risen by 44% between 2012 and 2021. Healthcare policymakers and providers must acknowledge the increasing burden of spondylodiscitis and make spondylodiscitis a research priority.

[Recurrent Serratia marcescens bacteremia: seek and you shall find]

A 79-year-old patient was hospitalized due to recurrent Serratia marcescens bacteremia. An implantable cardioverter-defibrillator (ICD) electrode infection with septic pulmonary emboli and vertebral osteomyelitis were diagnosed. In addition to antibiotic therapy, the ICD system was completely extracted. In patients with cardiac implantable electronic devices (CIED) and bacteremia that cannot be adequately explained or recurs, regardless of the pathogen involved, a CIED-associated infection always needs to be ruled out.

Spinal infections in the north-east of Scotland: a retrospective analysis

INTRODUCTION

Spinal infection (SI) is uncommon and patients present with varied clinical features. In this review, the presentation, investigation, treatment and outcome of patients with SI in the north-east of Scotland were assessed.

METHODS

Electronic medical records of adult patients with SI hospitalised at a health board in the north-east of Scotland between 2014 and 2018 were analysed retrospectively. Collected variables included demographics, presenting clinical features, risk factors, comorbidities, admission blood results, microbiological investigations, imaging, treatment and outcomes.

RESULTS

Seventy-two patients were included. Mean age (±sd) was 63.3 years (±14.5). The lumbar spine was the most commonly involved region (51.4%). Back pain (84.7%), altered mobility (33.3%) and fever (29.2%) were the most frequent presenting features. Thoracic spine involvement (p = 0.041), urinary symptoms (p = 0.033), cauda equina syndrome (CES) (p = 0.027) and limb weakness (p = 0.026) were associated with poorer outcome. A better outcome was associated with back pain at presentation (p = 0.03) and underlying malignancy (p = 0.045). Diabetes (15.3%), recent falls (15.3%) and immunosuppression (12.5%) were common. A likely causative organism was found in 54 patients (75.0%) and Staphylococcus aureus was isolated in 41.7% of patients. Penicillins were used in 56.3% of patients and 20.8% underwent surgery. Outcomes were full recovery (38.2%), residual symptoms or neurological deficits (50.0%), paraplegia (4.4%) and death (7.4%).

CONCLUSIONS

Poorer outcomes occurred in patients with thoracic disease, limb weakness, urinary symptoms or CES, whereas better outcomes were associated with the presence of back pain on presentation and malignancy. This analysis highlights the diagnostic and therapeutic challenges of SI, alerting clinicians to key factors associated with prognosis.

The epidemiology of concurrent infection in patients with pyogenic spine infection and its association with early mortality: A nationwide cohort study based on 10,695 patients

BACKGROUND

Generally, a sufficient duration of relevant antibiotics based on an appropriate culture combined with proper surgical treatment guarantees a favorable clinical outcome in patients with pyogenic spine infections. However, a patient's condition often deteriorates as concurrent infections occur in other organs, leading to mortality. Therefore, this study aimed to investigate the epidemiology of concurrent infections in patients with a pyogenic spine infection and estimate the rates and risks of early mortality.

METHODS

Patients with a pyogenic spine infection were identified using a national claims database that includes the entire population. The epidemiology of the six types of concurrent infections was investigated, and the corresponding early mortality rates and risks were estimated. The results were validated internally by bootstrapping and externally by defining two additional cohorts for sensitivity analysis.

RESULTS

Among 10,695 patients with a pyogenic spine infection, the prevalence of the six types of concurrent infections was 11.3 % for urinary tract infections, 9.4 % for intra-abdominal infections, 8.5 % for pneumonia, 4.6 % for septic arthritis or osteomyelitis of the extremities, 0.7 % for central nervous system infections, and 0.5 % for cardiac infections. Patients with a concurrent infection had approximately 4-fold greater mortality than those without (3.3 % vs. 0.8 %). The early mortality rates were particularly higher in patients with multiple or specific types of concurrent infections, including central nervous system infections, cardiac infections, and pneumonia. In addition, the mortality trends differed significantly according to the number and type of concurrent infections.

CONCLUSIONS

These data on six types of concurrent infection among patients with pyogenic spinal infection can be used as a source of reference by clinicians.

Spondylodiscitis following ingestion of button battery in an infant-a case-based update

Button battery ingestion in infants is an increasingly common surgical emergency which can lead to oesophageal perforation, mediastinitis, trachea-oesophageal fistulation, airway compromise and death. One exceedingly rare complication of battery ingestion is discitis and osteomyelitis in the cervical and upper thoracic spine. Diagnosis is normally delayed due to the non-specific presentation, delayed imaging findings and the initial clinical focus on dealing with the immediate, and potentially life-threatening, complications. We describe a case of a 1-year-old girl who presented with haematemesis and an oesophageal injury, secondary to button battery ingestion. Sagittal reconstruction of the CT chest demonstrated a suspicious area of vertebral erosion in the cervicothoracic spine which prompted a further evaluation with MRI demonstrating spondylodiscitis of C7-T2 with vertebral erosion and collapse. The child was successfully treated with long course of antibiotics. We wish to highlight the importance of clinical and radiological spinal assessment in children with button battery ingestion to avoid delayed diagnosis and complications of spinal osteomyelitis.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Site matters: Image-guided percutaneous sampling of intervertebral disc results in increased positive diagnostic yield in spondylodiscitis

Spondylodiscitis is a common referral to spinal on call services. Identification of the causative organism is vital in order to dictate the appropriate antibiotic treatment. In this context, the surgical and interventional radiology team is often asked to perform a diagnostic biopsy. The aim of the present study was to assess whether the sampling location affects the diagnostic yield. Our results suggest that the overall positive diagnostic yield was 35%. When disc material was included in the sample the diagnostic yield significantly improved to 47%. Bone sampling alone had a positive yield of 15%. Age, pre-biopsy CRP, pre-biopsy use of antibiotics did not seem to affect the likelihood of obtaining a positive yield. These results suggests that when performing image guided biopsies for suspected cases of spondylodiscitis the inclusion of disc material is important.

Management of lumbar pyogenic spondylodiscitis in Germany: a cross-sectional analysis of spine specialists

OBJECTIVE

The incidence of pyogenic spondylodiscitis (PS) is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilisation and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar PS (LPS).

METHODS

An electronic survey covering provider information, diagnostic approaches, treatment algorithms and follow-up care of patients with lumbar PS was distributed to members of the German Spine Society.

RESULTS

79 survey responses were included in the analysis. MRI is the diagnostic imaging modality of choice for 87% of respondents. 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation. 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective. 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is two weeks. The median total duration of the antibiotic therapy (intravenous and oral) is eight weeks. MRI is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS.

CONCLUSION

There exists considerable variation of care in the diagnosis, management and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS.

Spondylodiscitis-a cohort analysis of its identification and management

PURPOSE

Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre.

METHODS

A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study.

RESULTS

A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks.

CONCLUSION

Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis.

Comparative Clinical Efficacy and Safety of Sacral-2-Alar Iliac Screw Versus Iliac Screw in the Lumbosacral Reconstruction of Spondylodiscitis

OBJECTIVE

This study aimed to evaluate the clinical efficacy and safety of S2-alar-iliac (S2AI) and iliac screw (IS) techniques in treating lumbosacral spondylodiscitis.

METHODS

Between January 2020 and January 2022, 28 patients suffering from lumbosacral spondylodiscitis underwent lumbosacral fixation and were divided into the IS group (14 patients) and the S2AI group (14 patients). Surgical details, demographic characteristics, preoperative and postoperative Oswestry Disability Index, visual analog scale, and complications were analyzed.

RESULTS

Twenty-eight patients were included in this study, including 14 patients treated with IS and 14 patients treated with S2AI. The 2 groups were similar in sex, age, follow-up period, total drainage volume, hospitalization stay, and fusion time. (P > 0.05) The estimated blood loss and surgical time of S2AI during surgery were significantly lower than those of IS. (P < 0.05) The visual analog scale and Oswestry Disability Index scores significantly improved in both groups from preoperative to the last follow-up. Sacroiliac joint pain was found in both groups in the follow-up period, but the incidence was not significantly different (P = 0.663). Compared with the IS approach, the incidence of symptomatic screw prominence was lower in the S2AI group, but the difference was not significant. (P = 0.088).

CONCLUSIONS

S2AI, as well as IS techniques, can achieve promising results for reconstructing lumbosacral stability in spondylodiscitis. In addition, the S2AI technique can also reduce surgical trauma and operation time.

The added value of a commercial 16S/18S-PCR assay (UMD-SelectNA, Molzym) for microbiological diagnosis of spondylodiscitis: an observational study

In spondylodiscitis, pathogen identification is important to guide therapy strategies. Here the use of an rDNA PCR assay (Molzym UMDSelectNA) for pathogen detection in spondylodiscitis was evaluated in 182 specimens from 124 spondylodiscitis patients. In 81% of specimens rDNA PCR and conventional culture produced concordant results. Compared to conventional culture, sensitivity and specificity of rDNA PCR were 75% and 83.9%, respectively. The rDNA PCR performed better than conventional culture in identification of Streptococcus spp.. However, overall sensitivity was suboptimal, e.g., in cases with low bacterial burden, and only 5 of 124 patients (4%) received a microbiological diagnosis by employing rDNA PCR. Thus, the added value of routine use of rDNA PCR on spondylodiscitis specimens is limited. Targeted use of the assay in culture-negative cases may be efficient and moderately increase diagnostic yield. The need for susceptibility information implies that 16S rDNA PCR may only be used as an add-on tool to culture.

Meningitis and spondylodiscitis due to Nocardia nova in an immunocompetent patient

BACKGROUND

Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova.

CASE PRESENTATION

We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years.

CONCLUSIONS

Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR.

[Infections of the spinal cord and adjacent structures]

Inflammation of the spinal cord and the adjacent structures can be caused by viruses, bacteria, fungi and parasites. Viruses predominantly infect the spinal cord and the nerve roots directly or trigger a secondary immune response, whereas bacteria, fungi and parasites tend to form abscesses, granulomas and cysts and can lead to a secondary compression of the spinal cord, similar to a destructive osteomyelitis. The etiological clarification of an acute or subacute spinal process is carried out based on the clinical presentation, the time course of the development of symptoms, the immune status, neuroimaging and microbial and/or molecular biological examinations of cerebrospinal fluid and serum. The tropism of individual pathogens to certain fiber structures and cellular clusters in the spinal cord in synopsis with the clinical presentation, neuroimaging and a history of exposure, can often quickly lead to a focused clarification and diagnosis. This article deals with important pathogens of spinal and paraspinal infections, the geographical distribution, the clinical and neuroimaging presentation with special consideration of the anatomical and topographical localization and recent epidemiological developments. Particular attention is paid to the outbreak of poliomyelitis due to circulating vaccine-derived poliovirus (cVDPV).

Outcomes of C-arm cone-beam CT-guided percutaneous procedures for thoracolumbar spondylodiscitis: a comparison between with and without intradiscal drainage

INTRODUCTION

Percutaneous intradiscal drainage had little established evidence to date. We assessed the outcomes of C-arm cone-beam CT-guided (CBCT-guided) procedures for spondylodiscitis and compare procedures with and without intradiscal drainage.

MATERIAL AND METHODS

A retrospective review was conducted on patients who underwent CBCT-guided procedures for spondylodiscitis with fluid collection in the intradiscal space between January 2010 and September 2021. Included patients were divided into two groups: with and without 'intradiscal drainage' (ID and non-ID, respectively).

RESULTS

A total of 87 patients with thoracolumbar discitis (mean age 73.4 ± 12.3 years, 35 females) were included. There was no significant difference in clinical outcomes between groups. Although insignificant, a subgroup analysis of patients with discitis and psoas abscess showed a higher infection control success rate (81% (17/21) vs 58% (7/12), p = .23) and faster median C-reactive protein improvement (CRP <3 mg/dL: 12 vs 42 days, p = .11, CRP <1 mg/dL: 27 vs 45 days, p = .097) of ID than of non-ID.

CONCLUSIONS

Findings did not clarify the role of intradiscal drainage when it was indicated in all cases of spondylodiscitis with fluid collection. Future studies with larger sample sizes of selected discitis cases are expected to demonstrate the superiority of intradiscal drainage.

Extreme Lateral Interbody Fusion as a Feasible Treatment for Thoracolumbar Spondylodiscitis: A Multicenter Belgian Case-Series

BACKGROUND

Spondylodiscitis is, after tissue sampling, initially managed with intravenous antibiotics. In patients with treatment failure, surgical debridement and stabilization is considered. An anterior or posterior approach has already been reported as a successful surgical access, but is associated with a large exposure and a significant morbidity.

METHODS

We present a multicenter Belgian case-series on the use of a minimally invasive extreme lateral interbody fusion procedure with add-on percutaneous pedicle screw fixation for patients with a need for surgical debridement and tissue samples or intractable back pain due to spondylodiscitis. Patient characteristics, microbiology results, antibiotic treatment, pre- and postoperative Visual Analogue Pain Score (VAS) scores, time to bony consolidation, complications and duration of the hospital stay were collected.

RESULTS

Seven patients with one level spondylodiscitis were included. The mean age 64 years with a mean preoperative VAS score of 8.86 ( ± 0.90). Postoperative VAS score significantly decreased to 2.57 (-70.3%, P < 0.001). Mean antibiotic treatment duration was 8 weeks. Median duration of the hospital stay was 14 days. Patients were followed for 1 year. Complete bony consolidation was observed in 6 out of 7 patients after 1 year. One patient had a stable pseudarthrosis.

CONCLUSIONS

These results indicate that extreme lateral interbody fusion topped off with a percutaneous pedicle screw fixation might be a feasible, safe and valuable choice to surgically treat patients with spondylodiscitis with fast and important improvement in VAS. Further prospective research might strengthen the sparsely existing literature of minimally invasive surgery for spondylodiscitis to provide the best possible care.

Management of vertebral osteomyelitis in adults

Vertebral osteomyelitis is a condition that predominantly affects older men with chronic comorbidities, such as diabetes, renal and hepatic failure, or immunosuppression. Symptoms develop insidiously and a high index of suspicion is required to diagnose the condition; this is achieved through serological testing and imaging. The mainstay of treatment is long-term antibiotic therapy, lasting a minimum of 6 weeks; however, surgical debridement with stabilisation is required when conservative treatment is proving ineffective and infection progresses. It is critically important that sufficient treatment is provided for those experiencing vertebral osteomyelitis, as not doing so could lead to severe neurological compromise and death.

Modified percutaneous biopsy of the spine: improvement of the technique

PURPOSE

Biopsy of the spine can be performed by open surgery or percutaneous needle sampling. The first has the highest diagnostic yield while the second is a less invasive procedure with lower rate of complications and shorter hospitalization time. We described a modified technique of percutaneous biopsy using semi-rigid grasping forceps that may offer the advantages of both, open and minimally invasive surgery.

METHODS

Thirty consecutive patients with spinal lesions requiring biopsy were admitted to Neurosurgical Unit of Belcolle Hospital (Viterbo, Italy) from January 2017 to September 2021. There was a suspicion of spondylodiscitis in 25 cases and of tumor in 5 cases. Percutanous trans-pedicular spine biopsy has been performed using this new semi-rigid grasping forceps. Combining the opening width, jaw length and full 360° rotation, the device allows a wide and precise sampling.

RESULTS

Sampling was sufficient in all cases (100%); tumors was observed in 5 cases (16.7%%) with a percentage of definitive histopathologic diagnosis of 100% (n = 5); among the remaining patients histological examination yielded a diagnosis of spinal infection in 25 cases (100%), and microbiologic culture provided an aetiologic diagnosis in 23 cases (92%). All procedures were well tolerated, and no postoperative complications were observed. Levels involved included: thoracic (T5-T9) in 8 cases, thoracolumbar junction (T10-L2) in 12 cases and lumbar (L3-L5) in 10 cases.

CONCLUSIONS

Percutaneous biopsy with the semi-rigid grasping forceps is a safe and effective procedure that can be used for diagnosis of both infectious and tumor lesions of the spine. It allows to obtain a larger specimen volume and to use a multidirectional trajectory for sampling, resulting in a minimally invasive technique with strong ability to yield etiologic diagnosis.