A Novel Report of mycetoma with Spinal Spread due to Madurella fahalli from India

Eumycetoma caused by Madurella fahalii, a drug-resistant fungus, has never been reported in India. Here, we describe a fatal case of eumycetoma with spinal involvement due to M. fahalii for the first time in India.

Vertebral Candidiasis, the State of the Art: A Systematic Literature Review

OBJECTIVE

In recent years, Candida spondylodiscitis has represented an increasingly emerging disease in clinical practice. This condition requires long-term antibiotic therapy and sometimes surgical treatments. The main purpose of this study is to investigate the epidemiology, clinical and radiological aspects, treatment protocols, and outcomes of Candida-mediated vertebral osteomyelitis.

METHODS

A systematic review of the English literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The research was conducted on Medline, Cochrane library, PubMed, and Scopus using as search terms "vertebral"; "spinal"; "infection"; "spondylodiscitis"; "discitis"; "osteomyelitis"; "Candida"; and "Candidosis." A case of vertebral candidiasis that was surgically managed was also reported.

RESULTS

In total, 88 articles were included in our systematic review. Including the reported case, our analysis covered 113 cases of vertebral candidiasis. Candida albicans was isolated in 64 cases (56.1%), Candida tropicalis in 21 (18.4%), Candida glabrata in 14 (12.3%), and Candida parapsilosis in five (4.4%). The mean duration of the follow-up was 395 days. Finally, 87 (82%) patients completely recovered, ten (9.4%) died, and nine (8.5%) reported sequelae.

CONCLUSION

This systematic review summarized the state of the art on vertebral candidiasis, describing data on its clinical features, diagnostic criteria and current limitations, and treatment alternatives and their outcomes.

Influence of microbiological diagnosis on the clinical course of spondylodiscitis

Purpose

This study sought to recognize differences in clinical disease manifestations of spondylodiscitis depending on the causative bacterial species.

Methods

We performed an evaluation of all spondylodiscitis cases in our clinic from 2013–2018. 211 patients were included, in whom a causative bacterial pathogen was identified in 80.6% (170/211). We collected the following data; disease complications, comorbidities, laboratory parameters, abscess occurrence, localization of the infection (cervical, thoracic, lumbar, disseminated), length of hospital stay and 30-day mortality rates depending on the causative bacterial species. Differences between bacterial detection in blood culture and intraoperative samples were also recorded.

Results

The detection rate of bacterial pathogens through intraoperative sampling was 66.3% and could be increased by the results of the blood cultures to a total of 80.6% (n = 170/211). S. aureus was the most frequently detected pathogen in blood culture and intraoperative specimens and and was isolated in a higher percentage cervically than in other locations of the spine. Bacteremic S. aureus infections were associated with an increased mortality (31.4% vs. overall mortality of 13.7%, p = 0.001), more frequently developing complications, such as shock, pneumonia, and myocardial infarction. Comorbidities, abscesses, length of stay, sex, and laboratory parameters all showed no differences depending on the bacterial species.

Conclusion

Blood culture significantly improved the diagnostic yield, thus underscoring the need for a structured diagnostic approach. MSSA spondylodiscitis was associated with increased mortality and a higher incidence of complications.

2021 Young Investigator Award Winner: Anatomic Gradients in the Microbiology of Spinal Fusion Surgical Site Infection and Resistance to Surgical Antimicrobial Prophylaxis

STUDY DESIGN

Retrospective hospital-registry study.

OBJECTIVE

To characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis.

SUMMARY OF BACKGROUND DATA

SSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice.

METHODS

Spinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled.

RESULTS

Among 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P < 0.001). The majority (57.5%) of infections were resistant to the prophylaxis administered during the procedure. Cephalosporin-resistant gram-negative infection was common at lumbosacral levels and undetected methicillin-resistance was common at cervical levels.

CONCLUSION

Individualized infection prevention strategies tailored to operative level are needed in spine surgery. Endogenous wound contamination with enteric flora may be a common mechanism of infection in lumbosacral fusion. Novel approaches to prophylaxis and prevention should be prioritized in this population.Level of Evidence: 3.

Potential novel proteomic biomarkers for diagnosis of vertebral osteomyelitis identified using an immunomics protein array technique: Two cases reports

RATIONALE

Although vertebral osteomyelitis (VO) is commonly associated with high morbidity and high recurrence rate, effective diagnostic and prognostic biomarkers of VO are still lacking.

PATIENTS CONCERNS

Case 1: a 60-year-old male had had upper back pain for 3 days. Case 2: a 71-year-old female presented upper back pain for 2 days.

DIAGNOSES

Based on physical examination and findings of magnetic resonance imaging and findings by matrix-assisted laser desorption ionization-time of flight mass spectrometry, they were diagnosed with Staphylococcus aureus VO.

INTERVENTIONS

Using Sengenics Immunome Protein Array by analyzing autoantibodies in both VO patients, potential biomarkers of VO were explored.

OUTCOMES

Four subjects with more than 1600 antigens screened while the results showed that 14-3-3 protein gamma, pterin-4-alpha-carbinolamine dehydratase, fructose-bisphosphate aldolase A, and keratin type II cytoskeletal 8 were highly differentially expressed among VO and controls. Relevant auto-antibody profiles were discovered after intra-group and inter-group comparison, and based on functional rationality, an adapter protein 14-3-3 protein gamma, and pterin-4-alpha-carbinolamine dehydratase that involved in tetrahydrobiopterin biosynthesis, might serve as valuable diagnostic biomarkers.

LESSONS

This pilot study on 4 subjects with more than 1600 antigens screened on the Sengenics Immunome protein array provided a general outlook on autoantibody biomarker profiles of VO subjects. Future large-scale trials with longer follow-up times are warranted.

Diagnostic performance of suction drainage fluid culture for acute surgical site infection after aseptic instrumented spine surgery: a retrospective analysis of 363 cases

PURPOSE

Analyze the diagnostic performance of suction drainage fluid culture for acute surgical site infection, which has not been specifically reported in spine surgery patients.

METHOD

This was a retrospective single-center observational study including data from 363 patients who underwent aseptic instrumented spine surgery between 2015 and 2017. A suction drain was inserted in all cases. Data analyzed were patient age, gender, ASA score, indication for surgery (degenerative disease, tumor, trauma), spine level (cervical, thoracic, lumbar), procedure performed and spine level, operative time, body temperature, postoperative C-reactive protein time-curve, clinical aspect of surgical scar, bacteriology results of suction drainage fluid, and in case of revision surgery, lavage fluid. Major criteria for periprosthetic infection proposed by the Musculoskeletal Infection Society (MSIS) were accepted as the gold standard for the diagnosis of acute surgical site infection.

RESULTS

The overall rate of surgical site infection was 6.9% (5.76% for 1- or 2-level fusion, 5.81% for 3- or 4-level fusion, and 15.6% for 5-level fusion and above). The suction drain was withdrawn on the second postoperative day in 44.1% of cases and the third day in 39.1%. The sensitivity of suction drainage fluid culture for the diagnosis of surgical site infection was 20% [95%CI 6.8-40.7%] with a 96.2% [95%CI 93.2-97.9] specificity.

CONCLUSION

The diagnostic performance of suction drainage fluid culture after aseptic instrumented spine surgery for acute surgical site infection is insufficient to warrant its use in routine practice.

Comparison of pyogenic postoperative and native vertebral osteomyelitis

BACKGROUND CONTEXT

Postoperative vertebral osteomyelitis (PVO) after spinal surgery is a clinical challenge. However, there is a paucity of evidence regarding the most likely etiologic organisms to guide the choice of empirical antibiotic therapy, and previous reports of treatment outcomes for PVO are scarce.

PURPOSE

To compare the microbiology, clinical characteristics, and outcomes of pyogenic PVO with native vertebral osteomyelitis (NVO).

STUDY DESIGN

Retrospective comparative study.

PATIENT SAMPLE

Patients with microbiologically proven vertebral osteomyelitis from three university-affiliated hospitals in South Korea between January 2005 and December 2015 with follow-up of at least 12 months after completion of antibiotics or until the patient was transferred. Patients who had a spine operation in the same location within 1 year of diagnosis, and all patients with remnant implants at the time of the vertebral osteomyelitis diagnosis, were defined as having PVO. The remainder of the patients was considered to have NVO. Spinal operations included discectomy, laminectomy, arthrodesis, and instrumentation for stabilization of the spine.

OUTCOME MEASURES

Overall mortality, neurologic outcomes, treatment failure, and relapse of infection.

METHODS

Demographic data, comorbidities, presenting symptoms, microbiological data, radiographic characteristics, laboratory data (including white blood cell counts, erythrocyte sedimentation rate, and C-reactive protein), surgical treatment, and neurologic outcomes for each patient were reviewed from electronic medical records and analyzed. Mortality rate, treatment failure, and relapse of infection were calculated for the two groups. Factors associated with treatment outcome were evaluated using univariate and multivariate logistic regression analyses.

RESULTS

The study evaluated 104 patients with PVO and 441 patients with NVO. In PVO, the most common isolate was Staphylococcus aureus (34%, n=35), followed by coagulase-negative staphylococci (31%, n=32). In NVO, the most common isolates were S. aureus (47%, n=206) and streptococci (21%, n=94). Of the staphylococci, the proportion of methicillin-resistant strains was significantly higher in PVO than that in NVO (75% vs. 39%, p<.001). The proportion of patients with gram-negative bacilli was 14% in PVO and 20% in NVO. Pre-existing or synchronous nonspinal infection was observed more frequently in NVO than in PVO (33% vs. 13%, p<.001). Although the duration of antibiotic use was similar in both groups, surgery for infection control was performed more frequently in PVO. The mortality rate was similar in both groups. However, the treatment failure and relapse rates at 12 months were higher in the PVO group (23% vs. 13%, p=.009; 14% vs. 7%, p=.028, respectively). Methicillin-resistant S.aureus was significantly associated with treatment failure or relapse via logistic regression (odds ratio 3.01, 95% confidence interval [1.71-5.32], p<.001; odds ratio 2.78, 95% confidence interval [1.40-5.49], p=.003).

CONCLUSIONS

Coverage of methicillin-resistant staphylococci should be considered when prescribing empirical antibiotics for PVO. Although surgery was performed more often in PVO than NVO, the treatment failure and relapse rates at 12 months were higher in PVO.

Selection of an appropriate empiric antibiotic regimen in hematogenous vertebral osteomyelitis

Background

Empiric antibiotic therapy for suspected hematogenous vertebral osteomyelitis (HVO) should be initiated immediately in seriously ill patients and may be required in those with negative microbiological results. The aim of this study was to inform the appropriate selection of empiric antibiotic regimens for the treatment of suspected HVO by analyzing antimicrobial susceptibility of isolated bacteria from microbiologically proven HVO.

Method

We conducted a retrospective chart review of adult patients with microbiologically proven HVO in five tertiary-care hospitals over a 7-year period. The appropriateness of empiric antibiotic regimens was assessed based on the antibiotic susceptibility profiles of isolated bacteria.

Results

In total, 358 cases of microbiologically proven HVO were identified. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (33.5%), followed by methicillin-resistant S. aureus (MRSA) (24.9%), Enterobacteriaceae (19.3%), and Streptococcus species (11.7%). Extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and anaerobes accounted for only 1.7% and 1.4%, respectively, of the causative pathogens. Overall, 73.5% of isolated pathogens were susceptible to levofloxacin plus rifampicin, 71.2% to levofloxacin plus clindamycin, and 64.5% to amoxicillin-clavulanate plus ciprofloxacin. The susceptibility to these oral combinations was lower in cases of healthcare-associated HVO (52.6%, 49.6%, and 37.6%, respectively) than in cases of community-acquired HVO (85.8%, 84.0%, and 80.4%, respectively). Vancomycin combined with ciprofloxacin, ceftriaxone, ceftazidime, or cefepime was similarly appropriate (susceptibility rates of 93.0%, 94.1%, 95.8%, and 95.8%, respectively).

Conclusions

Based on our susceptibility data, vancomycin combined with a broad-spectrum cephalosporin or fluoroquinolone may be appropriate for empiric treatment of HVO. Fluoroquinolone-based oral combinations may be not appropriate due to frequent resistance to these agents, especially in cases of healthcare-associated HVO.

Vertebral column decortication for the management of sharp angular spinal deformity in Pott disease: Case report

RATIONALE

Extremely sharp angular spinal deformity of healed tuberculosis can be corrected by vertebral column resection (VCR). However, the VCR techniques have many limitations including spinal column instability, greater blood loss, and greater risk of neurologic deficit.

PATIENT CONCERNS

We described a new spinal osteotomy technique to collect sharp angular spinal deformity in Pott disease. A 52-year-old woman presented with back pain and gait imbalance.

DIAGNOSIS

The kyphosis of healed tuberculosis was diagnosed based on history and imaging examinations.

INTERVENTION

A new posterior VCR was designed to treat this disease.

OUTCOMES

The neurological function improved from Japanese Orthopedic Association scale 3 to 7. The back pain and neurological function were significantly improved. The Oswestry Disability Index decreased from 92 to 34. There was also a significant decrease in back pain visual analog scale from 9 to 2.

LESSONS

For cases with extremely severe Pott kyphotic deformity, the technology of modified VCR offers excellent clinical and radiographic results.

Clinical characteristics, treatments, and outcomes of hematogenous pyogenic vertebral osteomyelitis, 12-year experience from a tertiary hospital in central Taiwan

BACKGROUND

In Taiwan, studies about hematogenous pyogenic vertebral osteomyelitis (HPVO) are limited. We conducted a retrospective study to evaluate the clinical presentations, treatment, and outcomes of patients with the diagnosis of HPVO.

METHOD

This 12.5-year retrospective study included patients with a diagnosis of HPVO. Medical records of all HPVO patients were thoroughly reviewed and their clinical data were analyzed by the SPSS software.

RESULT

414 HPVO cases were included and the mean age was 61.6 ± 13.4 years. The mean duration of symptoms was 29 ± 35.3 days and pain over the affected site was reported by most patients (86.0%). Gram-positive bacteria, especially Staphylococcus aureus (162/399 = 40.6%), were the main HPVO pathogens. Escherichia coli (42/399 = 10.5%) was the most common gram-negative isolate. Surgery was performed in 68.8% of cases and the mean duration of total antibiotic treatment was 104.7 ± 77.7 days. All-cause mortality and recurrence rates were 6.3% and 18.8%, respectively. In multivariate analysis, polymicrobial infection (OR: 4.154, 95% CI: 1.039-16.604, p = 0.044), multiple vertebral body involvement (OR: 2.202, 95% CI: 1.088-4.457, p = 0.028), abscess formation treated with antibiotics alone (OR: 2.912, 95% CI: 1.064-7.966, p = 0.037), and the duration of antimicrobial treatment less than 4 weeks (OR: 3.737, 95% CI: 1.195-11.683, p = 0.023) were associated with HPVO recurrence.

CONCLUSION

In Taiwan, HPVO mainly affected the elderly and S. aureus remained the most common HPVO pathogen. In patients with risk factors associated with HPVO recurrence, a longer duration (≥6 weeks) of antimicrobial therapy is suggested.

The Effect of Negative Pressure Wound Therapy With Antiseptic Instillation on Biofilm Formation in a Porcine Model of Infected Spinal Instrumentation

OBJECTIVE

This study evaluates the effect of negative pressure wound therapy with antiseptic instillation (NPWTi) in the clearance of infection and biofilm formation in an in vivo model of infected spinal implants compared to traditional treatment modalities.

MATERIALS AND METHODS

Five pigs underwent titanium rod implantation of their spinous processes followed by injection of 1 x 106 CFUs/100μL of methicillin-resistant Staphylococcus aureus through the fascia at each site. At 1 week postoperatively, an experimental arm of 3 pigs received NPWTi, and a control arm of 2 pigs received wet-to-dry dressings. The persistence of local infection in the experimental group was compared to the control group using tissue cultures. Biofilm development on spinal implants was evaluated using scanning electron microscopy.

RESULTS

Mean bacterial count showed a statistical difference between the experimental and the control groups (P < .05). Scanning electron microscopy revealed the presence of uniform biofilm formation across the surface of control group instrumentation, whereas the experimental group showed interrupted areas between biofilm formations.

CONCLUSION

The authors concluded that NPWTi is associated with decreased bacterial load and biofilm formation compared to wet-to-dry dressings in an in vivo porcine model of infected spinal instrumentation.

Clinical Differences Between Monomicrobial and Polymicrobial Vertebral Osteomyelitis

Little literature exists examining differences in presentation and outcomes between monomicrobial and polymicrobial vertebral infections. Seventy-nine patients treated for vertebral osteomyelitis between 2001 and 2011 were reviewed. Patients were divided into monomicrobial and polymicrobial cohorts based on type of infection. Various characteristics were compared between the 2 groups. The 26 patients with a polymicrobial infection were older and had a higher mortality rate, lower clearance of infection, larger infection, more vertebral instability, higher erythrocyte sedimentation rate at presentation, and longer mean length of stay. There were no significant differences in Oswestry Disability Index scores at final follow-up, but there were differences in presentation and clinical outcomes between monomicrobial and polymicrobial vertebral osteomyelitis. Patients may benefit from counseling regarding their disease type and potential prognosis. [Orthopedics. 2017; 40(2):e370-e373.].

Diagnostic yield of computed tomography-guided bone biopsy and clinical outcomes of tuberculous and pyogenic spondylitis

BACKGROUND/AIMS

This study aimed to evaluate the efficacy of computed tomography (CT)-guided bone biopsy for the diagnosis of spinal infection and compared the clinical outcomes between tuberculous and pyogenic spinal infections.

METHODS

The retrospective cohort study included patients who received CT-guided bone biopsy at a tertiary hospital over the 13 years.

RESULTS

Among 100 patients, 67 had pyogenic spondylitis and 33 had tuberculous spondylitis. Pathogens were isolated from bone specimens obtained by CT-guided biopsy in 42 cases, with diagnostic yields of 61% (20/33) for tuberculous spondylitis and 33% (22/67) for pyogenic spondylitis. For 36 culture-proven pyogenic cases, Staphylococcus aureus was the most commonly isolated organism. Patients with pyogenic spondylitis more frequently presented with fever accompanied by an increase in inflammatory markers than did those with tuberculosis. Among all patients who underwent surgery, the incidence of late surgery performed one month after diagnosis was higher in patients with tuberculous infection (56.3%) than in those with pyogenic disease (23.3%, p = 0.026).

CONCLUSIONS

Results obtained by CT-guided bone biopsy contributed to prompt diagnoses of spinal infections, especially those caused by tuberculosis. Despite administration of anti-tuberculous agents, patients with tuberculous spondylitis showed an increased tendency to undergo late surgery.

Spondylodiscitis Due to Aspergillus terreus in an Immunocompetent Host: Case Report and Literature Review

Aspergillus terreus, a saprophytic fungus, is recognized as an emerging pathogen responsible for various infections in human beings. However, bone and joint involvement is uncommon. We report a rare case of A. terreus spondylodiscitis in a 20-year-old male with a past history of recurrent, incompletely treated pulmonary tuberculosis. Clinical signs at the time of admission included cough, low-grade fever, general weakness and left-sided back pain. Histological examination of spinal biopsy samples revealed lesions of necrosis, granulomatous inflammation and septate hyphae with acute-angle branching. A. terreus was recovered from culture. The patient received antifungal therapy with voriconazole plus caspofungin and underwent surgical debridement. Further investigations revealed no cause of primary immunodeficiency such as chronic granulomatous disease, severe combined immunodeficiency syndrome or disorders of the IL-12/IFNγ signaling pathway. Moreover, HIV serological tests resulted negative and the patient was not under immunosuppressive therapy. Unfortunately, owing to precarity and medication non-adherence, vertebral sequelae occurred. This new report emphasizes the need to consider a fungal infection in patients with spondylodiscitis, regardless of the immune status.

Image guided interventions in spinal infections

Spinal infections are challenging to diagnose and represent a life-threatening medical condition. Diagnosis is often delayed because of nonspecific accompanying symptoms. The role of interventional neuroradiology in spinal infection is double: diagnostic and therapeutic, consisting substantially of 2 main procedures, represented by spine biopsies and positioning of percutaneous drainage, which represent a minimally invasive, faster and more cost-effective alternative to open surgery procedures. This article will focus on the available state-of-the-art techniques to perform discovertebral image-guided biopsies in case of suspected infections and on image-guided placement of percutaneous drainage to treat infectious collections of the spine and paravertebral structures.

CT-Guided Biopsy in Suspected Spondylodiscitis--The Association of Paravertebral Inflammation with Microbial Pathogen Detection

Objectives

To search for imaging characteristics distinguishing patients with successful from those with futile microbiological pathogen detection by CT-guided biopsy in suspected spondylodiscitis.

Methods

34 consecutive patients with suspected spondylodiscitis underwent CT-guided biopsy for pathogen detection. MR-images were assessed for inflammatory infiltration of disks, adjacent vertebrae, epidural and paravertebral space. CT-images were reviewed for arrosion of adjacent end plates and reduced disk height. Biopsy samples were sent for microbiological examination in 34/34 patients, and for additional histological analysis in 28/34 patients.

Results

Paravertebral infiltration was present in all 10/10 patients with positive microbiology and occurred in only 12/24 patients with negative microbiology, resulting in a sensitivity of 100% and a specificity of 50% for pathogen detection. Despite its limited sensitivities, epidural infiltration and paravertebral abscesses showed considerably higher specificities of 83.3% and 90.9%, respectively. Paravertebral infiltration was more extensive in patients with positive as compared to negative microbiology (p = 0.002). Even though sensitivities for pathogen detection were also high in case of vertebral and disk infiltration, or end plate arrosion, specificities remained below 10%.

Conclusions

Inflammatory infiltration of the paravertebral space indicated successful pathogen detection by CT-guided biopsy. Specificity was increased by the additional occurrence of epidural infiltration or paravertebral abscesses.

Osteological and biomolecular evidence of a 7000-year-old case of hypertrophic pulmonary osteopathy secondary to tuberculosis from neolithic hungary

Seventy-one individuals from the late Neolithic population of the 7000-year-old site of Hódmezővásárhely-Gorzsa were examined for their skeletal palaeopathology. This revealed numerous cases of infections and non-specific stress indicators in juveniles and adults, metabolic diseases in juveniles, and evidence of trauma and mechanical changes in adults. Several cases showed potential signs of tuberculosis, particularly the remains of the individual HGO-53. This is an important finding that has significant implications for our understanding of this community. The aim of the present study was to seek biomolecular evidence to confirm this diagnosis. HGO-53 was a young male with a striking case of hypertrophic pulmonary osteopathy (HPO), revealing rib changes and cavitations in the vertebral bodies. The initial macroscopic diagnosis of HPO secondary to tuberculosis was confirmed by analysis of Mycobacterium tuberculosis complex specific cell wall lipid biomarkers and corroborated by ancient DNA (aDNA) analysis. This case is the earliest known classical case of HPO on an adult human skeleton and is one of the oldest palaeopathological and palaeomicrobiological tuberculosis cases to date.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

Bioactive glass S53P4 as bone graft substitute in treatment of osteomyelitis

Bioactive glass (BAG)-S53P4 is an osteoconductive bone substitute with proven antibacterial and bone bonding properties. In a multicentre study 11 patients with verified chronic osteomyelitis in the lower extremity and the spine were treated with BAG-S53P4 as a bone substitute. The cavitary bone defect and the surrounding of a spinal implant were filled with BAG-S53P4. The most common pathogen causing the infection was Staphylococcus aureus. The mean follow-up was 24 months (range 10-38). BAG-S53P4 was well tolerated. Nine patients healed without complications. One patient who achieved good bone formation sustained a superficial wound infection due to vascular problems in the muscle flap, and one patient had an infection due to a deep haematoma. This study shows that BAG-S53P4 is a good and well-tolerated bone substitute, and can be used in treatment of osteomyelitis with good primary results.

Klebsiella pneumoniae-associated vertebral osteomyelitis after laparoscopic cholecystectomy

We report a case of a patient who underwent elective laparoscopic cholecystectomy and subsequently developed Klebsiella pneumoniae-associated vertebral osteomyelitis after 2 months. Development of vertebral osteomyelitis after laparoscopic cholecystectomy has never been reported previously. Diagnosis was made via magnetic resonance imaging. The patient was successfully treated with intravenous antibiotics and had a complete recovery with no neurologic sequelae.

Noncontiguous multifocal spondylitis: an exceptional presentation of spinal brucellosis

AIM

The aim of this study was to describe the imaging features of multilevel brucellar spondylitis and discuss the diagnostic challenges

CASE

The authors report describes one case of noncontiguous synchronous multifocal involvement of thoracic and lumbar spine.

RESULTS

Brucellosis is a zoonosis of worldwide distribution, relatively frequent in Mediterranean countries and in the Middle East that can involve many organs and tissues. The spine is the most common site of musculoskeletal involvement, but multilevel involvement is uncommon and only ten cases were reported in literature.

CONCLUSION

Although it is an exceptional form, multifocal brucellar spondylitis is worth to be known to avoid diagnostic mistakes.

Non-contiguous multifocal Staphylococcus aureus discitis: involvement of the cervical, thoracic and lumbar spine

INTRODUCTION

Multilevel discitis is rare, and classically due to granulomatous organisms like Mycobacterium tuberculosis, brucella and fungal species.

CONCLUSION

We report a case of non-contiguous multilevel synchronous bacterial discitis involving cervical, thoracic and lumbar discs, attributable to Staphylococcus aureus.

Epidural tuberculosis involving the entire spine

We discuss an elderly male who developed severe back pain, rapidly progressing paraparesis and urinary retention consequent to L5-S1 spinal tuberculosis with dissemination of epidural tubercular abscess and granulation tissue to the cervical, thoracic, lumbar and sacral region. The initial diagnosis of lumbo-sacral pathology with high thoracic extension was tackled by an L5 laminectomy and decompression along with saline flushing and evacuation of the thoraco-lumbar and sacral epidural abscess with the aid of a catheter passed superiorly and inferiorly. He developed neck pain and upper limb weakness subsequently and was found to have extensive extradural cervical compression by granulation tissue. He underwent C4-7 laminectomy and decompression of the cord. He was started on four-drug anti-tubercular treatment. At 6-month follow-up, he had marked neurological improvement. MRI screening of the entire spine showed complete resolution of the disease. Contiguous epidural involvement of the entire spine by tubercular pathology has never been reported before. We suggest that screening of the entire spine should be considered in select cases of spinal tuberculosis based on symptomatology.

Spondylodiscitis (disc space infection) associated with negative microbiological tests: comparison of outcome of suspected disc space infections to documented non-tuberculous pyogenic discitis

Discitis, an infection of the disc space, is an uncommon diagnosis that, if missed, can lead to spinal deformity and neurological deterioration, although as many as 30% of these patients will have negative microbiological cultures. It was unclear, however, whether the prognosis differed between patients who had positive or negative cultures. A retrospective case note review was carried out to assess the differences in presentation and outcome between these two groups. There were 26 and 43 patients in the negative and positive groups, respectively. Those with a positive culture were more likely to present with pyrexia, have a neurological deficit and not be independently mobile at presentation. The mean CRP recorded at the time of presentation was 96 and 157 in the negative and positive groups respectively (p = 0.004). Similarly, the mean ESR in the positive group was 88 compared with 69 in the negative group (p = 0.02). In conclusion, these patients may be at different ends of a clinical spectrum: those patients with a positive culture having a greater local and systemic inflammatory reaction to the disc space infection.

Current therapeutic strategy in spinal brucellosis

Brucellosis is a systemic disease and may affect many organ systems. However, musculoskeletal involvement represents 10-85% of the focal complications. Involvement of the spine is one of the most common localized forms of human brucellosis, especially in elderly patients. It is a destructive disease that requires a correct and early diagnosis, and immediate treatment. However, controversy remains over the optimal duration and antimicrobial regimen required for the treatment of spinal brucellosis. Relapses and sequelae are still reported. In recent years, in order to improve outcomes, alternative regimens have been investigated. However, the classical regimen (doxycycline, 100mg twice daily, for at least 12 weeks combined with streptomycin, 1g daily, for the first 2 or 3 weeks) remains the first choice of antibiotic therapy. Alternative therapies (rifampin, fluoroquinolones, co-trimoxazole) should be considered when adverse reactions or contraindications to the above drugs (ototoxicity, nephrotoxicity, pregnancy, etc.) are reported.

Acute pyogenic diskitis (spondylodiskitis) in adults

Most cases of back pain are the result of degenerative changes in the spine or are related to musculoskeletal elements. Pyogenic infections of the back can be subcategorized into cases involving the paraspinal epidural space, vertebral bodies, or the intervertebral disk spaces. Any region of the spine may be the site of diskitis, although the process most commonly involves the lumbar spine. Most cases of diskitis are managed with conservative therapy, including antibiotics and spinal immobilization using braces or corsets. Surgical therapy is generally reserved for patients with neurological complications, spinal instability, or progressive spinal deformity or those who fail to respond clinically to antibiotic therapy alone.

Spontaneous infective spondylitis and mycotic aneurysm: incidence, risk factors, outcome and management experience

Infective spondylitis occurring concomitantly with mycotic aneurysm is rare. A retrospective record review was conducted in all cases of mycotic aneurysm from January 1995 to December 2004, occurring in a primary care and tertiary referral center. Spontaneous infective spondylitis and mycotic aneurysm were found in six cases (10.3% of 58 mycotic aneurysm patients). Neurological deficit (50% vs. 0; P < 0.001) is the significant clinical manifestation in patients with spontaneous infective spondylitis and mycotic aneurysm. The presence of psoas abscess on computed tomography (83.3% vs. 0; P < 0.001) and endplate destruction on radiography (50% vs. 0; P < 0.001) are predominated in patients with spontaneous infective spondylitis and mycotic aneurysm. Of these six patients, four with Salmonella infection received surgical intervention and all survived. Another two patients (one with Streptococcus pyogenes, another with Staphylococcus aureus) received conservative therapy and subsequently died from rupture of aneurysm or septic shock. Paravertebral soft tissue swelling, presence of psoas abscess and/or unclear soft tissue plane between the aorta and vertebral body in relation to mycotic aneurysm may indicate a concomitant infection in the spine. In contrast, if prevertebral mass is found in the survey of spine infection, coexisting mycotic aneurysm should be considered.

Vertebral osteomyelitis caused by Actinobaculum schaalii: a difficult-to-diagnose and potentially invasive uropathogen

We report the first case of vertebral osteomyelitis caused by Actinobaculum schaalii and review all cases of A. schaalii identified at our institution between 2002 and 2005. A. schaalii causes urinary tract infections - especially in elderly people - occasionally with septic complications.

Pasteurella dagmatis: une cause inhabituelle de spondylodiscite

Vertebral osteomyelitis is a quite rare but severe cause of back pain in adults. Various causative organisms have been reported. Pasteurella species have rarely been isolated. We report here a case of vertebral osteomyelitis and consecutive cauda equina syndrome due to Pasteurella dagmatis in a 60-year-old diabetic man.

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively

STUDY DESIGN

Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively.

OBJECTIVE

To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature.

SUMMARY OF BACKGROUND DATA

Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively.

METHODS

A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months.

RESULTS

All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases.

CONCLUSIONS

We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Implant-related infection model in rat spine

OBJECTIVE

The rate of postoperative infections is approximately 1% in spine surgery. However, when metal implants are used, postoperative infection rates significantly increase and were reported between 2.1 and 8.5%. This study aim to set up an infection model in the rat spine with a metal implant.

MATERIALS AND METHODS

Forty white male Sprague Dawley rats were randomly divided in four groups. In all rats, under operation microscope, a 3 mm titanium microscrew was implanted in the thoracolumbar area (T10-L1) after laminar decortication. In Group I (control group), sterile isotonic solution and in other three groups, different concentrations of Staphylococcus aureus [Group II: (10(2)), Group III: (10(3)), Group IV: (10(6))] were squirted on the decorticated lamina site. All animals were sacrificed after 2 weeks, and then blood cultures and cultures from fascia, muscle and bone were obtained. Bacterial number in each tissue was measured as colony-forming unit per gram tissue. Titanium microscrews were placed in 0.5 ml tryptic soy broth and vortexed than plated on trypticase soy agar to determine bacterial growth. Two animals from each group were subjected to histological examination.

RESULTS

Blood cultures obtained by intra-atrial puncture after 2 weeks were negative in all groups indicating no systemical infection developed. Bacterial cultures were negative in all specimens of Group I (control group). A significant osseous infection was confirmed in Groups II, III and IV. Comparison of bacterial counts in bone cultures showed no significant difference between Group III (10(3) CFU/10 microl) and Group IV (10(6) CFU/10 microl) (P > 0.05), while both groups had significantly higher counts than Group II (10(2) CFU/10 microl) (P > 0.05). Microscopic findings of supurrative inflammation were present only in Group IV (10(6) CFU/10 microl).

CONCLUSIONS

This study shows that inoculation of S. aureus in 10(6) CFU/10 microl concentration at the decorticated lamina after implantation of a titanium screw in rat spine is a reproducible model for spinal infection and can be used for the animal model of prophylaxis and treatment and of postoperative infection.

Bone infection in cat-scratch disease: A review of the literature

OBJECTIVE

To describe the main features of bone infection associated with Cat-scratch disease (CSD).

METHODS

We searched for articles indexed in the international literature databases by using the following key words: "Bartonella", "bone", "cat-scratch", "osteomyelitis" and "osteolytic".

RESULTS

Cases of 47 patients were reviewed. The median age was 9 years, with an equal sex distribution. Bone pain and fever were the main symptoms. The presence of fever and increased age were more common in patients with bone infection than classically reported in uncomplicated (i.e. nodal) CSD. The vertebral column and pelvic girdle were the most common sites of infection. Radiological examination typically confirmed bone osteolysis. All patients recovered without complications or chronic infection, although they received a various combination antibiotic regimen and duration therapy. The mechanism by which infection might spread to the bone is via the haematogenous route, accounting for most of the disseminated cases and via the lymphatic route, for those with regional limited extension.

CONCLUSIONS

Bone infection is rare but should be considered when bone pain and fever are present in a patient with nodal CSD. The prognosis is good, whatever treatment is given. Thus bone biopsy should be recommended only in a difficult diagnostic setting, when other bacteria or malignant disease are suspected.

First report of Mycobacterium bovis DNA in human remains from the Iron Age

Tuberculosis has plagued humankind since prehistoric times, as is evident from characteristic lesions on human skeletons dating back to the Neolithic period. The disease in man is due predominantly to infection with either Mycobacterium tuberculosis or Mycobacterium bovis, both members of the M. tuberculosis (MTB) complex. A number of studies have shown that when conditions permit, surviving mycobacterial DNA may be amplified from bone by PCR. Such ancient DNA (aDNA) analyses are subject to stringent tests of authenticity and, when feasible, are invariably limited by DNA fragmentation. Using PCRs based on single-nucleotide polymorphic loci and regions of difference (RDs) in the MTB complex, a study was made of five Iron Age individuals with spinal lesions recovered from the cemetery of Aymyrlyg, South Siberia. A sensitive screening PCR for MTB complex mycobacteria was positive in four out of the five cases. Genotyping evidence indicated that all four cases were due to infection with M. bovis rather than M. tuberculosis and the data were consistent with the proposed phylogenetic model of the MTB complex. This is believed to be the first report of M. bovis causing Pott's disease in archaeological human remains. The study shows that genotyping of ancestral strains of MTB complex mycobacteria from contexts of known date provides information which allows the phylogeny of the model to be tested. Moreover, it shows that loss of DNA from RD4, which defines classic M. bovis, had already occurred from the genome over 2000 years before the present.

The Incidence of Multiple Level Noncontiguous Vertebral Tuberculosis Detected Using Whole Spine MRI

The commonest site of osseous tuberculosis is the spine. Most vertebral lesions are contiguous. Current research indicates the incidence of multiple level noncontiguous vertebral tuberculosis is 1.1% to 16%. The aim of this study was to identify the incidence of multiple level noncontiguous vertebral tuberculosis using whole spine magnetic resonance imaging (MRI). A retrospective review was undertaken of case notes and whole spine MRI studies of all acute spinal infection cases that presented to a regional Spinal Unit over 3 years. Patients were included if spinal infection was identified by whole spine MRI and confirmed as tuberculosis by a combination of histology and microbiology. The incidence of multiple level noncontiguous vertebral tuberculosis was 71.4%. This is higher than previously quoted when MRI is not undertaken. Tuberculosis may affect the spine at multiple noncontiguous sites more frequently than thought previously. A large proportion of the affected noncontiguous sites may also be asymptomatic. We currently perform whole spine MRI on all patients with suspected spinal infection to aid detection of multiple level noncontiguous tuberculosis.

Postoperative infections of the thoracic and lumbar spine: a review of 18 cases

We retrospectively reviewed 18 consecutive patients (age range, 19-81 years; average age, 55 years) with postoperative infections of the spine. Postdiscectomy-laminectomy infections confined to the disc space (n = 2) were treated with percutaneous transpedicle drainage. Open débridement was performed in patients with an epidural or paraspinal abscess (n = 3). Infections after posterior instrumentation that manifested during the first postoperative month were treated with single (n = 3) or multiple débridements and delayed closure (n = 7), with preservation of instrumentation. Infections that presented more than 9 months after the initial operation (n = 3) were treated with open débridement and removal of instrumentation. The minimum followup was 1 year (mean 2 years, range, 1-4 years). Infections in 17 of the 18 patients resolved effectively and one patient with metastatic cancer died of sepsis. Transpedicle drainage resulted in immediate relief of back pain. Instrumentation can be retained safely in patients with infections that manifest during the first month after implantation. Single surgical débridement is effective in selected cases. After repeated débridements, the presence of healthy granulation tissue in the wound and decreasing C-reactive protein activity were associated with safe and effective wound closure. Despite radiographic evidence of hardware loosening in infections manifested more than 9 months after implantation, we removed hardware without destabilizing the spine.

Diagnostic performance of pyogenic vertebral osteomyelitis

OBJECTIVE

Early diagnosis of pyogenic vertebral osteomyelitis (PVO) is frequently difficult. There are, however, few studies that have investigated the diagnostic performance of PVO in Japan. Our aim was to analyze the diagnostic performance and identify clinical factors associated with the diagnostic delay of PVO.

MATERIALS AND METHODS

We performed hospital-based retrospective case analysis. All patients with PVO were identified from the computerized medical database at Okinawa Chubu Hospital in Okinawa, Japan, from January 1985 to December 2004. We collected the following data; baseline information; laboratory tests; clinical and microbiologic outcomes; and diagnostic process. We used multivariable-adjusted linear regression to identify significant factors associated with patient and hospital delay to the diagnosis of PVO.

RESULTS

We reviewed total of 209,428 patients hospitalized during the 20-year study period. Of those, we identified 51 patients with PVO. Eighty percent of these patients were misdiagnosed at their initial clinical encounters. Median duration from the symptom onset to the diagnosis was 19 days. Median durations of patient factor and hospital factor that contributed to the total delay were 1 and 8 days, respectively. Significant patient factor that contributed to delay was cognitive dysfunction.

CONCLUSIONS

Cognitive dysfunction is a risk factor for patient delay for visiting physicians in patients with PVO. Diagnosis of PVO is difficult at the initial clinical encounter. High index of suspicion is needed for more rapid diagnosis of PVO.

Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center

STUDY DESIGN

We performed a retrospective review of 48 cases of pyogenic spinal infection presenting over a 12-year period to the National Spinal Injuries Unit (NSIU) of the Republic of Ireland. The NSIU is the tertiary referral center for all adult spinal injuries and diseases of the spine warranting surgical intervention in the Republic of Ireland.

OBJECTIVES

The objective of this study was to analyze the presentation, etiology, management, and outcome of nontuberculous pyogenic spinal infection in adults.

SUMMARY OF BACKGROUND DATA

Pyogenic spinal infection encompasses a broad range of clinical entities, including spondylodiscitis, septic discitis, vertebral osteomyelitis, and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention.

METHODS

The medical records, radiologic imaging, and bacteriology results of 48 patients with pyogenic vertebral osteomyelitis from 1992 through 2004 were reviewed. The Hospital Inpatient Enquiry (HIPE) System and the NSIU Database were used to identify our study cohort.

RESULTS

The average age of presentation was 59 years with an even distribution between males and females. Most patients (21 of 48) were symptomatic for between 2 and 6 weeks before presenting to hospital. The most frequently isolated pathogen was Staphylococcus aureus, in 23 of 48 cases (48%); 35 of 48 cases (73%) were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 13 of 48 cases (27%), surgical intervention was required because of neurologic compromise or mechanical instability.

CONCLUSIONS

In the majority of cases, conservative management of pyogenic spinal infection with antibiotic therapy and spinal bracing is very successful. However, in a minority of cases, surgical intervention is warranted and referral to a specialist center is appropriate.

Brucellar spondylodiscitis: noncontiguous multifocal involvement of the cervical, thoracic, and lumbar spine

Brucellosis is a zoonosis of worldwide distribution presenting with a wide clinical spectrum. Brucellosis can involve any organ or system. The axial skeleton is the most common site of involvement with a frequency ranging from 2% to 53%. Multiple-level spinal involvements are rare. This report describes the first case of noncontiguous synchronous multifocal involvement of all cervical, thoracic, and lumbar regions in a patient with brucellar spondylodiscitis.

Doxycycline plus streptomycin versus ciprofloxacin plus rifampicin in spinal brucellosis [ISRCTN31053647]

Background

The optimal treatment regimen and duration of the therapy is still controversial in spinal brucellosis. The aim of this study is to compare the efficacy, adverse drug reactions, complications and cost of ciprofloxacin plus rifampicin versus doxycycline plus streptomycin in the treatment of spinal brucellosis.

Methods

The patients diagnosed as spinal brucellosis between January 2002 to December 2004 were enrolled into the study. Patients were enrolled into the two antimicrobial therapy groups (doxycycline plus streptomycin vs. ciprofloxacin plus rifampicin) consecutively. For the cost analysis of the two regimens, only the cost of antibiotic therapy was analysed for each patient.

Results

During the study period, 31 patients with spinal brucellosis were enrolled into the two antimicrobial therapy groups. Fifteen patients were included in doxycycline plus streptomycin group and 16 patients were included in ciprofloxacin plus rifampicin group. Forty-two levels of spinal column were involved in 31 patients. The most common affected site was lumbar spine (n = 32, 76%) and involvement level was not different in two groups. Despite the disadvantages (older age, more prevalent operation and abscess formation before the therapy) of the patients in the ciprofloxacin plus rifampicin group, the duration of the therapy (median 12 weeks in both groups) and clinical response were not different from the doxycycline plus streptomycin. The cost of ciprofloxacin plus rifampicin therapy was 1.2 fold higher than the cost of doxycycline plus streptomycin therapy.

Conclusion

Classical regimen (doxycycline plus streptomycin), with the appropriate duration (at least 12 weeks), is still the first line antibiotics and alternative therapies should be considered when adverse drug reactions were observed.

The Use of External Fixation for the Treatment of Spine Infection With Actinomyces Bacillus

OBJECTIVE

External fixation can be used for stabilization of the spine in salvage cases, especially in cases of infection of the spine. The advantages of this method are avoiding the needs for internal fixation devices and for postoperative bracing. The literature on this is scant. Reported is a rare case of osteomyelitis of the D2 vertebra with an epidural abscess caused by Actinomyces israelii that spread from the lung and was treated by decompression and external fixation.

METHODS

A 51-year-old man with right upper lobe pneumonia due to A. israelii coccobacillus developed osteomyelitis of the D2 vertebra and an epidural abscess with a gradual paraparesis. He underwent a laminectomy of D1-D3 and 3 weeks later stabilization of the upper thoracic spine using a tubular external fixator that was inserted from C7-D1 to D3-D4. The patient was treated with antibiotic intravenously and later orally. After 2 months, the external fixator was removed.

RESULTS

At the last follow-up, the patient had no fever, the erythrocyte sedimentation rate and C-reactive protein level had normal values, and there was only a slight limitation in the range of motion of the cervical paraparesis. Radiography and magnetic resonance imaging demonstrated stabilization of the affected segment without any sign of active osteomyelitis. There were no complications associated with the use of the external fixator.

CONCLUSIONS

The use of external fixation offers an appropriate alternative for stabilization of the spine as a salvage procedure. The procedure could be performed easily and without any major complications. Especially for the treatment of complicated cases of spinal infection, the use of an external fixator can be of great benefit.

[Elastic materials in surgery for inflammatory diseases of the vertebral column]

When 17 patients were surgically treated for spinal tuberculosis and osteomyelitis, anterior spine fusion was performed by A. Ye. Garbuz's procedure that was based on the replacement of a spinal defect by a carbon-carbonic implant that had rifampicin containers in the frontal sections, as well as by autologous bone grafts. The carbon-carbonic implants reliably fix an operated spinal portion, prevent the progression of kyphotic deformity, and create good conditions for autologous bone grafts to knit. An osteocarbonic block forms in the late postoperative period.

[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.

[Posteriorinstrumental spinal fixation in tuberculous spondylitis and osteomyelitis of the vertebral bodies]

The short- and long-term results of surgical treatment were studied in 74 patients with tuberculous spondylitis and in 20 patients with chronic osteomyelitis of the vertebral column. All the patients underwent radical reconstructive operations on the anterior vertebral column if they had an active inflammatory process. The operations were supplemented by an interstitial posterior instrumental fixation with the Hurrington manipulation reduction frames or the plates, developed at the Central Institute of Traumatology and Orthopedics, in 11 cases and with the Cotrel-Dubosse tools in 28 cases. The Cotrel-Dubosse tools were shown to have significant advantages in correcting kyphosis and preventing graft resorption and chronic pain syndrome in tuberculous spondylitis.

Three cases of vertebral osteomyelitis caused by Streptococcus dysgalactiae subsp. equisimilis

Three cases of vertebral osteomyelitis caused by Streptococcus dysgalactiae subsp. equisimilis (Strep. equisimilis) are presented here. All three cases presented with fever, back pain, general malaise and weight loss for at least 4 weeks. Diagnosis was established by culture of a spinal biopsy and/or positive blood cultures together with radiological findings. In all three cases, 6-12 weeks of antibiotics were curative without recourse to surgery. The ability of Strep. equisimilis to cause vertebral osteomyelitis is highlighted. The need is emphasized for biopsy and microbiological investigation in patients presenting with back pain, fever, weight loss and evidence of a spinal lesion on imaging, even if neoplastic disease is suspected. Prolonged antibiotic therapy (at least 6 weeks) seems to be indicated.