Comparison of brucellar and tuberculous spondylodiscitis patients: results of the multicenter "Backbone-1 Study"

Investigation of new inflammatory biomarkers in patients with brucella

BACKGROUND

Delayed diagnosis and inadequate treatment of infectious and inflammatory diseases, such as Brucella, lead to high rates of mortality and morbidity. The aim of our study was to investigate the association between serum levels of apelin, presepsin, and irisin with inflammation, laboratory parameters, and blood culture in patients with brucella.

PATIENTS AND METHODS

This prospective case-control study involves 30 patients with brucellosis and 30 healthy, matched control subjects. Thirty patients who were diagnosed with brucellosis were aged ≥ 18 years. Blood samples were taken from the patients on the first day they were diagnosed with brucellosis. The values of irisin, presepsin, and apelin were studied. In addition, blood samples were also taken from 30 healthy individuals for the control group. Irisin, presepsin, and apelin values that were measured in the patients on the first day were compared with those values measured in the control group.

RESULTS

The sex and age statuses of the subjects are matched among the groups. The levels of irisin were significantly higher in patients with brucellosis compared to the control group (p<0.045). There was no significant difference between the two groups in terms of apelin and presepsin levels (p values 0.087 and 0.162, respectively). There was a positive correlation between irisin levels and elevated ALT levels, as well as positive blood cultures.

CONCLUSIONS

It appears that the measurement of irisin levels may be beneficial in patients with brucellosis. Irisin can be used as a diagnostic marker for brucella infection and may greatly clinicians to predict the severity disease and treatment response.

Brucella Spondylitis: Current Knowledge and Recent Advances

The most prevalent zoonotic disease is brucellosis, which poses a significant threat for worldwide public health. Particularly in endemic areas, spinal involvement is a major source of morbidity and mortality and can complicate the course of the disease. The diagnosis of Brucella spondylitis is challenging and should be suspected in the appropriate epidemiological and clinical context, in correlation with microbiological and radiological findings. Treatment depends largely on the affected parts of the body. Available treatment options include antibiotic administration for an adequate period of time and, when appropriate, surgical intervention. In this article, we examined the most recent data on the pathophysiology, clinical manifestation, diagnosis, and management of spinal brucellosis in adults.

Comparison of two surgical interventions for lumbar brucella spondylitis in adults: a retrospective analysis

This retrospective study aimed to compare the clinical efficacy of the posterior procedure with the combined anterior and posterior procedure in the surgical management of lumbar Brucella spondylitis. From January 2015 to June 2020, a total of 62 patients presenting with lumbar Brucella spondylitis underwent either one-stage posterior pedicle fixation, debridement, and interbody fusion (Group A, n = 33) or anterior debridement, bone grafting, and posterior instrumentation (Group B, n = 29). All patients were followed up for an average of 25.4 ± 1.5 months and achieved complete resolution of lumbar Brucella spondylitis. No significant differences between the groups were observed in terms of age or pre-operative, three-month postoperative and final follow-up indices of the VAS, ESR, CRP, lordosis angle, ODI scores, fusion time, and time of serum agglutination test conversion to negative (P > 0.05). Each patient exhibited notable improvements in neurological function, as assessed by the JOA score rating system. Group A demonstrated significantly shorter operative duration, intraoperative blood loss, and hospital stay compared to Group B (P < 0.05). Superficial wound infection was observed in one case in Group A, whereas Group B experienced one case each of intraoperative peritoneal rupture, postoperative ileus, iliac vein injury, and superficial wound infection. This study supports the efficacy of both surgical interventions in the treatment of lumbar Brucella spondylitis, with satisfactory outcomes. However, the posterior approach demonstrated advantages, including reduced surgical time, diminished blood loss, shorter hospital stays, and fewer perioperative complications. Consequently, the one-stage posterior pedicle fixation, debridement, and interbody fusion represent a superior treatment option.

Development and validation of a diagnostic model for differentiating tuberculous spondylitis from brucellar spondylitis using machine learning: A retrospective cohort study

Background

Tuberculous spondylitis (TS) and brucellar spondylitis (BS) are commonly observed in spinal infectious diseases, which are initially caused by bacteremia. BS is easily misdiagnosed as TS, especially in underdeveloped regions of northwestern China with less sensitive medical equipment. Nevertheless, a rapid and reliable diagnostic tool remains to be developed and a clinical diagnostic model to differentiate TS and BS using machine learning algorithms is of great significance.

Methods

A total of 410 patients were included in this study. Independent factors to predict TS were selected by using the least absolute shrinkage and selection operator (LASSO) regression model, permutation feature importance, and multivariate logistic regression analysis. A TS risk prediction model was developed with six different machine learning algorithms. We used several metrics to evaluate the accuracy, calibration capability, and predictability of these models. The performance of the model with the best predictability was further verified with the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and the calibration curve. The clinical performance of the final model was evaluated by decision curve analysis.

Results

Six variables were incorporated in the final model, namely, pain severity, CRP, x-ray intervertebral disc height loss, x-ray endplate sclerosis, CT vertebral destruction, and MRI paravertebral abscess. The analysis of appraising six models revealed that the logistic regression model developed in the current study outperformed other methods in terms of sensitivity (0.88 ± 0.07) and accuracy (0.79 ± 0.07). The AUC of the logistic regression model predicting TS was 0.86 (95% CI, 0.81-0.90) in the training set and 0.86 (95% CI, 0.78-0.92) in the validation set. The decision curve analysis indicated that the logistic regression model displayed a higher clinical efficiency in the differential diagnosis.

Conclusions

The logistic regression model developed in this study outperformed other methods. The logistic regression model demonstrated by a calculator exerts good discrimination and calibration capability and could be applicable in differentiating TS from BS in primary health care diagnosis.

Discussion on treatment courses of brucellosis with spondylitis - a report of two cases

Human Brucellosis is a zoonotic contagious disease caused by Brucella infection and is common throughout the world, which can travel through the bloodstream to various organs. Brucellar spondylitis(BS) is the foremost cause of brucellosis's debilitating and disabling complications. We report two sisters with brucellosis complicated by lumbar spondylodiscitis accompanied by cold abscess formation. The diagnosis was based on their symptoms, epidemiological characteristics, laboratory and magnetic resonance imaging(MRI) results. Our therapeutic strategy in these two cases indicate that drug combination and prolongation of the use of antibiotics is a therapeutic strategy worthy of popularizing to reach a greater clearance rate of the infection.

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess: a case report

Background

Human brucellosis is the most frequently contracted zoonotic infection worldwide. Although being an old disease that carries minimal risks of mortality, it remains a source of considerable sequelae and disability. However, noncontiguous multifocal spinal involvement is an exceptional presentation of brucellosis; additionally, an associated paravertebral abscess is extremely rare.

Case presentation

This paper focuses on a 67-year-old Lebanese woman with noncontiguous multifocal Brucella spondylodiscitis, involving the T12–L1 and L3–L4 segments, with paravertebral abscess formation. She presented with a 3-week history of acute severe lumbar back pain, radiating to the lower extremities and associated with impaired mobility and lower extremity weakness. The patient complained of night sweating but had no fever. No lymphadenopathy, hepatomegaly, or splenomegaly could be observed. She had painful percussion of the lumbar spine, painful passive mobilization, and paravertebral tenderness, yet her neurological examination was completely normal. BrucellaCapt test was positive at a titer of 1/5120 (reference range 1/180). The patient was treated with an inpatient regimen for 2 weeks, which was followed by an outpatient oral antibiotic regimen with doxycycline, rifampin, and ciprofloxacin to complete a total treatment duration of 3 months. Magnetic resonance imaging was performed at the end of the treatment and showed a complete resolution of the paravertebral abscess.

Conclusion

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess is an extremely rare presentation. It may be effectively managed by antibiotic therapy, without surgery or drainage, in the absence of neurological complications. Nonetheless, the principal challenge to an efficient management is establishing the diagnosis of Brucella in the first place. In endemic countries, a strong suspicion of spinal involvement of brucellosis should be elicited in front of back pain presentations—even in the absence of fever and other related symptoms.

Critical infections in the head and neck: A pictorial review of acute presentations and complications

Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.

A case report of endocarditis and spondylitis caused by Brucella melitensis biovar 3

Background

This case report describes the clinical process of a shepherd who suffered brucellosis-related endocarditis (BE) and spondylitis (BS) and was infected with Brucella melitensis biovar 3 (B. melitensis biovar 3).

Case presentation

A 55-year-old male patient was admitted to The First Affiliated Hospital of Shihezi University on October 11, 2018, due to over 3 months of intermittent fever, back pain, and heart trouble. The Rose Bengal Plate test was positive, the standard agglutination test titer for brucellosis was 1/800, and the blood culture was positive for B. melitensis biovar 3. Three instances of transthoracic echocardiography examination at days 1, 25, and 376 after admission to the hospital and magnetic resonance imaging (MRI) and computed tomography (CT) checks at days 5 and 38 revealed that the size of the vegetation on the posterior leaflet of the mitral valve increased from 0.71.4cm to 1.21.5cm and that the left atrium and ventricle were enlarged. The MRI and CT results showed hyperplasia of the second and third vertebra, a cold abscess formed on both sides of the psoas major muscles, and the vertebra hyperplasia became aggravated at a later time point. The patients situation deteriorated, and heart failure was discovered on October 22, 2019. At the moment of submission of this manuscript, the patient remains in bed at home because of severe debility caused by brucellosis.

Conclusions

This is the first reported case of endocarditis combined with spondylitis caused by B. melitensis biovar 3 in a shepherd. Brucellosis infection can cause work-power losses because of misdiagnosis or a lack of proper treatment. Early diagnosis and treatment are essential for a successful outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06142-3.

Granulomatous spondylodiscitis: A case series with focus on histopathological features

Objective: To report a series of Granulomatous Spondylodiscitis (GS) with focus on the histopathological features of the different forms of GS.Design: Case series.Setting: Pathology department of Charles Nicolle's Hospital of TunisiaParticipants: This study included 57 patients diagnosed with GS. There were 44 (77.2%) female patients and 13 (22.8%) male patients (sex ratio = 0.28).Intervention: Not applicable.Outcome measures: Clinical, microbiological and histopathological features were assessed in this study.Results: Fifty-seven patients with GS were enrolled: 51 tuberculous spondylodiscitis (TS), 2 fungal spondylodiscitis (FS), 3 brucellar spondylodiscitis (BS) and 1 case of sarcoidosis. Granulomas with necrosis were seen in 38 (66.6%) cases: 36 TS and 2 FS, while granulomas without necrosis were observed in the remaining 19 cases: 15 TS, 3 BS and 1 sarcoidosis. In all cases of TS, granulomas were epithelioid type, associated with histiocytic type granulomas in 7 cases. Caseous necrosis was seen in 35 cases of TS and suppurative granuloma in one case. The 3 cases of BS exhibited non-necrotizing and histiocytic type granulomas. The 2 cases of FS showed histiocytic, epithelioid and necrotizing granulomas. Necrosis was mixed: suppurative and caseous in both cases of FS. Sarcoidosis was characterized with epithelioid type granulomas without necrosis.Conclusion: Granuloma with caseous necrosis is highly suggestive of TS but does not rule out FS. Certain fungi can exhibit this type of necrosis as do tuberculosis species. Suppurative inflammation, although rare in TS, does exist. Histiocytic type granuloma without necrosis is suggestive of brucellosis.

Evaluation of clinical, diagnostic features and therapeutic outcome of neurobrucellosis: a case series and review of literature

AIM

In this study, we aimed to discuss the clinical features, laboratory findings, treatment and outcome of seven cases of neurobrucellosis from a tertiary care center and review the available global literature.

MATERIALS AND METHODS

The diagnosis of neurobrucellosis was established using the following criteria in our setting: (1) signs and symptoms of neurological infection with examination of cerebrospinal fluid (CSF) revealing signs of meningitis, (2) isolation of Brucella spp. from blood and/or CSF and/or antibody titer ≥1:160 in serum using standard agglutination test (SAT) and/or the presence of anti-Brucella antibodies in CSF and/or detection of Brucella spp.-specific DNA from CSF using PCR. A literature search was performed to review previous cases of neurobrucellosis published worldwide during the last 30 years.

RESULTS

The proportion of neurobrucellosis was 2.8% in our setting. Fever with headache and altered sensorium were the major presenting complaints. Brucella melitensis was isolated from blood culture in 6 patients. From the literature search, a total of 221 cases of neurobrucellosis were reviewed and analyzed. Meningitis (32.6%), loss of hearing (25.8%) and encephalitis (14.9%) were the most common clinical features. Involvement of cranial nerves, polyradiculopathy and paraplegia were the major complications found in patients with neurobrucellosis.

CONCLUSIONS

Neurobrucellosis should always be considered in the differential diagnosis of befitting neurological, rheumatological, and neuropsychiatric presentations in endemic regions for brucellosis. To prevent morbidity and mortality associated with neurobrucellosis, a multimodal diagnostic approach is essential for early and accurate diagnosis and effective treatment.

Tuberculous and Brucellar Spondylodiscitis: Comparative Analysis of Clinical, Laboratory, and Radiological Features

Study Design

This was a retrospective study.

Purpose

The aim was to compare the clinical, laboratory, radiological, and evolutionary features of tuberculous spondylodiscitis (TS) and brucellar spondylodiscitis (BS).

Overview of Literature

Clinical presentation of spondylodiscitis varies according to the underlying etiology, among which brucellosis and tuberculosis represent the primary cause, in endemic countries. Only a few studies have compared the characteristics between TS and BS.

Methods

A retrospective study was conducted using the data of all patients hospitalized for TS and BS in the infectious diseases department between 1991 and 2018.

Results

Among a total of 117 patients, 73 had TS (62.4%) and 44 had BS (37.6%). Females were significantly more affected with TS than males (56.2% vs. 22.7%, p<0.001). Fever (72.7% vs. 45.2%, p=0.004) and sweating (72.7% vs. 47.9%, p=0.009) were significantly more frequent among patients with BS. The median erythrocyte sedimentation rate was significantly higher in the TS group (median, 70 mm/hr; interquartile range [IQR], 45–103 mm/hr) than in the BS group (median, 50 mm/hr; IQR, 16–75 mm/hr) (p=0.003). Thoracic involvement was significantly more frequent in the TS group (53.4% vs. 34.1%, p=0.04), whereas lumbar involvement was significantly more frequent in the BS group (72.7% vs. 49.3%, p=0.01). Initial imaging findings revealed significantly higher frequencies of posterior vertebral arch involvement, vertebral compaction, and spinal cord compression in the TS group. Percutaneous abscess drainage (20.5% vs. 2.3%, p=0.005) and surgical treatment (17.8% vs. 2.3%, p=0.01) were more frequently indicated in the TS group, with a significant difference.

Conclusions

A combination of clinical, laboratory, and radiological features can be used to distinguish between TS and BS while these patients await diagnosis confirmation.

Current therapeutic strategy in osteoarticular brucellosis

Brucellosis is a common zoonotic disease with high morbidity. In the majority of human cases, the causative agent is B. melitensis. Infection is transmitted to humans by direct/indirect contact with the contaminated animal products (e.g., consumption of unpasteurized milk), infectious aerosols and aborted fetus. Brucellosis often affects middle-aged adults and young people. Patients with brucellosis tend to have non-specific symptoms, including fever, chills, night sweats, joint pain and myalgia. Brucellosis affects various organs and tissues. The osteoarticular system is one of the most commonly described affected systems in humans. In several clinical studies, the prevalence of Osteoarticular Brucellosis (OB) is reported as 2-77%. Most important osteoarticular clinical forms osteomyelitis, spondylitis, sacroiliitis, arthritis and bursitis. Spondylitis and spondylodiscitis are the most frequent complications. Spondylodiscitis often affects the lumbar (especially at the L4- L5 levels) and low thoracic vertebrae than the cervical spine. Back pain and sciatica radiculopathy are the most common complaints about patients. Sacroiliitis is associated with severe pain, especially back pain in affected individuals. Spinal destructive brucellar lesions are also reported in adults in previous studies. Brucellosis is diagnosed with clinical inflammatory signs (eg. tenderness, pain) of the affected joints together with positive serological tests and positive blood/synovial fluids cultures. Serological test measures the total amount of IgM/IgG antibodies. Standard agglutination test (SAT) titer ≥1:160 is in favor of brucellosis diagnosis. Enzyme-Linked Immunosorbent Assay (ELISA) and Polymerase chain reaction (PCR) are other types of diagnostic tests. Radiological assessments, such as joint sonography, computed tomography, magnetic resonance imaging, are the most helpful radiological methods to diagnose spinal brucellosis.

The agents commonly used in the treatment of brucella spondylitis are doxycycline, streptomycin, gentamicin, ciprofloxacin, trimethoprim/sulfamethoxazole and rifampicin. The recommended regimens for treatment of brucella involve two or three antibiotics combinations. No standard treatment, physicians prescribe drugs based on conditions of the disease. Patients need a long-term (usually at three months) antibiotic therapy for mainly aiming to prevent relapses. Surgery may be required for patients with spinal abscess. This review focused on physicians’ awareness for osteoarticular involvement, clinical presentation, diagnosis and current treatment of OB.

Spinal brucellosis in Hulunbuir, China, 2011-2016

Purpose: To investigate the demographic, epidemiological, clinical, and laboratory characteristics; treatment options; and outcome of human brucellosis with spine involvement at a major hospital in Hulunbuir, a brucellosis epidemic region of China. Patients and methods: A total of 842 patients with human brucellosis treated in the Department of Brucellosis, Hulunbuir People's Hospital from January 2011 to December 2016 were included and analyzed in this study. The results of 67 brucellar spondylodiscitis (BS) cases were compared with those that were negative for spine involvements. Results: The mean age of spinal brucellosis patients was 50.5±10.2 years (43 males and 24 females; age range 29-70). The risk factors for transmission are direct contact with animals, such as working in the farm, and consumption of unpasteurized milk or daily products. Back pain (92.5%), fever (85.1%), sweating (62.7%), and fatigue (52.8%) were the most common symptoms. Magnetic resonance imaging (MRI) was performed in all the patients with spondylodiscitis. The sites of involvement were lumbar (81.2%), thoracic (8.7%), cervical (4.3%), thoracolumbar (2.9%), and lumbosacral (2.9%). All isolates from blood culture were identified as Brucella melitensis, with 61% biovar 3 and 39% biovar 1 isolates. The antimicrobial therapy for BS lasted for at least 3 months. In the presence of paravertebral or epidural abscess, longer treatment was conducted to avoid possible sequelae. Conclusion: In endemic areas such as Hulunbuir, BS should be considered in patients with back pain and fever. MRI is a highly sensitive imaging modality that can be used to differentiate BS from other spinal infections. This study will be helpful to establish strategies for prevention, surveillance, and management of spinal brucellosis in China.

The use of CaSO4 drug delivery system in transforaminal lumbar interbody fusion for spinal brucellosis

OBJECTIVES

The incidence of human brucellosis has risen dramatically in China with few reports regarding the operation on spinal brucellosis. In this retrospective study we introduced CaSO₄drug delivery system into the TLIF surgical procedure and evaluated its clinical effectiveness and feasibility.

PATIENTS AND METHODS

36 patients with lumbar brucellosis were enrolled and treated by posterior transforaminal decompression, instrumentation and fusion. Prepared CaSO₄ beads carrying doxycycline were placed into the disc space and around pedicle screws. The activity of infection and pain-related function scales were recorded. Neurologic and functional recovery was evaluated using ASIA and Kirkaldy-Willis scale. Segmental and overall lordotic angles were measured and fusion status was assessed at final follow up.

RESULTS

The average follow-up period was 15.6 ± 3.73 months. The level of ESR and CRP returned to normal at 3 months post-op. 14 patients with ASIA grade D pre-op returned ASIA grade E with 3 months. The improvement of VAS and ODI was 82% and 85.8% at 3 months post-op. The corrections of segmental and overall lordotic angle were 5.98 ± 3.54° and 6.24 ± 7.93°. 69% of patients reached definitive union at 12 months after surgery. The satisfactory rate on Kirkaldy-Willis functional outcome criteria was 88.9%.

CONCLUSION

The use of CaSO₄ drug delivery system during single-stage TLIF for spinal brucellosis was safe and showed no negative impacts on fusion status and neurological function recovery. Our results are promising and the drug delivery system may be considered as a choice for future treatment in spinal brucellosis or other spondylodiscitis.

Osteoarticular manifestations of human brucellosis: A review

Brucellosis is a common global zoonotic disease, which is responsible for a range of clinical manifestations. Fever, sweating and musculoskeletal pains are observed in most patients. The most frequent complication of brucellosis is osteoarticular involvement, with 10% to 85% of patients affected. The sacroiliac (up to 80%) and spinal joints (up to 54%) are the most common affected sites. Spondylitis and spondylodiscitis are the most frequent complications of brucellar spinal involvement. Peripheral arthritis, osteomyelitis, discitis, bursitis and tenosynovitis are other osteoarticular manifestations, but with a lower prevalence. Spinal brucellosis has two forms: focal and diffuse. Epidural abscess is a rare complication of spinal brucellosis but can lead to permanent neurological deficits or even death if not treated promptly. Spondylodiscitis is the most severe form of osteoarticular involvement by brucellosis, and can have single- or multi-focal involvement. Early and appropriate diagnosis and treatment of the disease is important in order to have a successful management of the patients with osteoarticular brucellosis. Brucellosis should be considered as a differential diagnosis for sciatic and back pain, especially in endemic regions. Patients with septic arthritis living in endemic areas also need to be evaluated in terms of brucellosis. Physical examination, laboratory tests and imaging techniques are needed to diagnose the disease. Radiography, computed tomography, magnetic resonance imaging (MRI) and bone scintigraphy are imaging techniques for the diagnosis of osteoarticular brucellosis. MRI is helpful to differentiate between pyogenic spondylitis and brucellar spondylitis. Drug medications (antibiotics) and surgery are the only two options for the treatment and cure of osteoarticular brucellosis.

Analysis of infectious spondylodiscitis: 7-years data

Objective:

Infectious spondylodiscitis (SD) is an infectious disease that is rare and difficult to diagnose due to its non-specific clinical features. In this study, we aimed to describe the clinical and diagnostic features of infectious spondylodiscitis.

Methods:

All patients who were diagnosed with SD at our hospital during a 7-year period from January 1, 2011 through December 31, 2017 were included in the study. Spondylodiscitis is divided into the following three types: pyogenic, tuberculous, and brucellar. Clinical and laboratory data were collected retrospectively from the medical records of the patients.

Results:

Of the 118 patients, 66 (55.9%) were female, 81 (68.6%) had pyogenic SD (PSD), 21 (17.8%) had tuberculous SD (TSD), and 16 (13.6%) had brucellar SD (BSD). The mean age was 59.3 ± 14.6 years. Leucocytosis was significantly higher in patients with PSD (p=0.01) than in patients with other types of SD. Thoracic involvement (47.6%) was significantly higher in patients with TSD (p=0.005) than in other patients. Sacral involvement (12.5%) was significantly higher in patients with BSD (p=0.01) than in other patients. Paravertebral abscess formation (42.8%) occurred most frequently in patients with TSD. Microbiologic agents were defined in 50% (18/36) of the surgical specimens and in 12.5% of the fine needle aspiration biopsy (FNAB) specimens. Staphylococcus aureus was the most common microbiological agent in patients with PSD. Spinal surgery was defined as a risk factor for PSD (p = 0.0001). Binary logistic regression analysis revealed that female gender, thoracic involvement and night sweats were the predictive markers for TSD (OR 4.5 [95% CI 1.3-15.3] and OR 5 [95% CI 1.7-14.6]).

Conclusion:

PSD is the most frequent form of SD. Leucocytosis is most common in patients with PSD. Thoracic involvement and paraspinal abscess were prominent in patients with TSD. Sacral involvement was most common in patients with BSD. Thoracic involvement, female gender and night sweats were the predictive markers for TSD. The microbiological culture positivity rate was higher in surgical specimens compared to FNAB specimens. The need for surgical treatment was most common in patients with TSD.

Differentiation Between Brucellar and Tuberculous Spondylodiscitis in the Acute and Subacute Stages by MRI: A Retrospective Observational Study

RATIONALE AND OBJECTIVES

The aim of this study was to reveal the distinctive features of magnetic resonance imaging (MRI) for distinguishing brucellar spondylodiscitis (BSD) from tuberculous spondylodiscitis (TSD) in the acute and subacute stages.

METHODS

This study involved 14 patients with BSD and 18 patients with TSD from May 2011 to January 2015. BSD was diagnosed based on ≥1/160 titers of a Brucella agglutination test or isolation of Brucella spp. TSD was diagnosed based on the isolation of tuberculosis bacteria. All patients underwent T1- and T2-weight imaging (T1WI and T2WI) and fat suppression T2WI (FS T2WI). The height and the signal intensity (SI) of the vertebra and intervertebral disc were assessed. The distinctive MRI features were compared using the chi-square test. The SI of the vertebra between BSD and TSD was observed in terms of histogram characteristics of kurtosis, skewness, and percentile (75%-25%) on FS T2WI.

RESULTS

Twenty-nine (76.3%) vertebrae of BSD were infected throughout the whole vertebra, and 49 (90.7%) vertebrae of TSD were infected near the osseous end plate (P <.001). Compared to TSD, the vertebral height of BSD was nearly intact (P <.001), owing to the new bone formation in the end plate without vertebral collapse. Furthermore, significant differences in the SI of the vertebra were observed between patients with BSD and TSD in terms of homogeneous characteristics on FS T2WI, that is, kurtosis (BSD vs TSD, 0.107 vs -0.250, P = .023), skewness (BSD vs TSD, -0.021 vs 0.266, P = .017), and percentile (75%-25%) (BSD vs TSD, 54.498 vs 79.399, P = .00049).

CONCLUSIONS

The nearly intact vertebra with homogeneous high signal on FS T2WI was an important MRI feature for distinguishing BSD from TSD in the acute and subacute stages.

Imaging-Assisted Diagnosis and Characteristics of Suspected Spinal Brucellosis: A Retrospective Study of 72 Cases

Background

We clarified the imaging features of Brucella spondylitis to enhance our understanding of the disease and to minimize misdiagnosis.

Material/Methods

Imaging data (X-ray, computed tomography [CT], and magnetic resonance imaging [MRI] data) of 72 Brucella spondylitis patients treated from 2010 to 2017 were retrospectively analyzed; diagnoses was made by evaluating laboratory and pathological data.

Results

X-ray films revealed changes in intervertebral space heights, the number of lateral osteophytes, and bone destruction, which were more severe in the following order: lumbosacral vertebrae (56 cases, 77.8%), cervical spine (6 cases, 8.3%), thoracic spine (5 cases, 6.9%), and multi-segmental mixed vertebrae (5 cases, 6.9%). CT revealed osteolytic destruction attributable to early-stage Brucella spondylitis (endplate and vertebral lamellar osteolysis), usually associated with multiple vertebral involvement, with the middle and late disease stages being characterized by osteophytes in the vertebral margins and bony bridges, endplate sclerosis, and vertebral osteosynthesis. We encountered 54 cases (75%) with endplate lamellar osteolysis, 37 (51.4%) with vertebral lamellar osteolysis, 59 (81.9%) with marginal osteophytes, 10 (13.9%) with bony bridges, 25 (34.7%) with vertebral laminar sclerosis, and 17 (23.6%) with vertebral osteosynthesis. MRI revealed early, low-intensity, differential T1WI vertebral and intervertebral signals, with occasional iso-signals, T2WI iso-signals or high-intensity signals; and T2WI-FS vertebral and intervertebral high-intensity signals, commonly from vertebral soft tissues and rarely from paravertebral abscesses.

Conclusions

A better understanding of the X-ray, CT, and MRI features of Brucella spondylitis could aid in diagnosis when combined with epidemiological and laboratory data, thus minimizing misdiagnosis.

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral brucellosis

Background

Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis.

Methods

From February 2012 to April 2015, 32 consecutive patients (19 males and 13 females, mean age 53.7 ± 8.7) with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria.

Results

The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months’ follow-up. VAS and ODI scores were significantly improved (P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up.

Conclusions

Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis.

An Imaging-Based Approach to Spinal Cord Infection

Infections of the spinal cord, nerve roots, and surrounding meninges are uncommon, but highly significant given their potential for severe morbidity and even mortality. Prompt diagnosis can be lifesaving, as many spinal infections are treatable. Advances in imaging technology have now firmly established magnetic resonance imaging (MRI) as the gold standard for spinal cord imaging evaluation, enabling the depiction of infectious myelopathies with exquisite detail and contrast. In this article, we aim to provide an overview of MRI findings for spinal cord infections with special focus on imaging patterns of infection that are primarily confined to the spinal cord, spinal meninges, and spinal nerve roots. In this context, we describe and organize this review around 5 distinct patterns of transverse spinal abnormality that may be detected with MRI as follows: (1) extramedullary, (2) centromedullary, (3) eccentric, (4) frontal horn, and (5) irregular. We seek to classify the most common presentations for a wide variety of infectious agents within this image-based framework while realizing that significant overlap and variation exists, including some infections that remain occult with conventional imaging techniques.