A.M. Cerván

Surgical treatment of spondylodiscitis. An update

ConceptSpondylodiscitis refers to an infection affecting the intervertebral disk, the vertebral body or the posterior arch of the vertebra being aetiologically, pyogenic, granulomatous (tuberculosis, brucellosis, or fungal infection) or parasitic.DiagnosisSpondylodiscitis diagnosis is based on clinical symptoms, a combination of erythrocyte sedimentation rate with C-reactive protein (CRP) tests and, less useful, leukocytosis. Blood culture is also a very cost-effective method of identifying organisms. Plain radiographs are useful, however changes may take several months to appear. Radionuclide tests are currently less used; nevertheless, fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) shows encouraging results particularly when magnetic resonance images (MRI) are unconvincing in the distinction between degenerative changes and infection. MRI with gadolinium enhancement is the choice for image diagnosis.ManagementMedical management is usually the basis for treatment, alone or in combination with surgery. Surgical approach, either by endoscopy or open, is indicated for biopsy when clinical evolution is unsatisfactory and no micro-organism has been isolated, and also whenever a root, spinal cord or dural compression is seen on MRI; spinal instability or severe deformity are also clear indications for surgical treatment. Less invasive surgery either CT-scan guided or, particularly, by endoscopy has good results. However open surgery is still the standard. The anterior approach allows for anterior disc and bone debridement. The posterior approach is indicated when posterior elements are involved or in the presence of an epidural abscess. Although good results have been claimed, the use of instrumentation in the presence of an infected focus is controversial, as the use of cages or BMPs are.

Spondylodiscitis in patients under haemodyalisis

PurposeThe purpose of this study was to reach conclusions about the diagnosis and treatment of a series of patients with spondylodiscitis under haemodialysis treatment.MethodsWe collected and studied 23 patients included in a prospective database from two neighbouring hospitals. Descriptive statistical analysis was performed.ResultsThe diagnosis was frequently made very late and early negative cultures were not uncommon; magnetic resonance images allowed for an early diagnosis with accurate anatomical information. Empirical antibiotic treatment with prompt surgery produced good results in patients under risk of, or having neurological problems. Surgical approaches did not differ from pyogenic or tuberculous spondylodiscitis. Age in our series was not a predictive issue.ConclusionsWhenever a patient under haemodialysis has symptoms of spinal disease, particularly back pain with fever, they should undergo an MRI. If diagnosis of spondylodiscitis is made prompt empirical antibiotherapy should be instituted. Blood cultures should be performed and tissue samples taken for cultures; however, culture outcome must not delay therapy. Early surgical decompression leads to good results.

Surgical Infection after Posterolateral Lumbar Spine Arthrodesis: CT Analysis of Spinal Fusion: SSI AFTER POSTEROLATERAL LUMBAR SPINE ARTHRODESIS

To determine the incidence of infection after instrumented lumbar spine surgery, the demographic and surgical variables associated with acute infection, and the influence of infection and debridement on the consolidation of spinal fusion.

Spinopelvic injuries. Facts and controversies

Spinopelvic injuries result from high energy trauma with overloading through the sacrum. These lesions can accomplish either bone fractures, ligament injuries or, most commonly, both. They may be accompanied with other associated life threatening injuries and cause biomechanical instability with potential fracture non-union, mal-union and subsequent lifetime pain and disability. Surgical stabilization of spinopelvic injuries requires planning in order to apply the appropriate osteosynthesis principles (compression; neutralization; buttressing and tension band). In general terms simple sacral fractures can be treated under compression by iliosacral screws. However, as more complex ones cannot be compressed, they need vertical support and neutralization of shearing forces (neutralization and buttressing principles). For that purpose, spinopelvic instrumentations appear to be the current appropriate technique of stabilization. In the herein paper the general principles of sacral fracture osteosynthesis are discussed, as well as its application to spinopelvic injuries. Controversies on positioning, surgical approach, per-operative traction, sacral laminectomy, type of biomechanical construct, length of fixation, screws length, mode of weight bearing, and osteosynthesis hardware removal are discussed.

Medical Therapy of Neurobrucellosis

Antibiotics are the mainstay of brucellosis treatment; several dual or triple antibiotic combinations for spinal brucellosis have been compared in different studies. In uncomplicated brucellosis, the rifampicin plus doxycycline regimen is the most accepted treatment, but the scientific community is also in favor of streptomycin plus doxycycline, possibly because of its lower price and ease of administration. However there is still no consensus on the best treatment regimens and its duration. The treatment with the combination of ceftriaxone or trimethoprim/sulfamethoxazole, doxycycline, and rifampicin is effective in neurobrucellosis cases that affect the central nervous system and should be prolonged for no less than 3 months. Surgery usually is unnecessary for brucellosis spondylodiscitis. The surgical intervention is reserved for biopsy, severe neurological impairment, or spinal stabilization.

Allograft plus OP-1 enhances ossification in posterolateral lumbar fusion: A seven year follow-up

PURPOSE To study the results of the combination of allograft plus BMP-7 in comparison with allograft alone in posterolateral lumbar arthrodesis. PATIENTS AND METHODS A blinded controlled consecutive prospective cohort of skeletally mature patients study. One hundred and ten patients underwent posterolateral lumbar instrumented arthrodesis. Allograft randomly compacted onto either the right or the left side of the articular and the posterior aspect of the transverse processes of lumbar spine. The same procedure performed on the contralateral side, but allograft was previously mixed with osteogenic protein (OP-1). Clinical, x-ray and CT-scan long follow-up performed. Univariable and multivariable logistic regression analyses. RESULTS More bone continuity was found with allograft plus OP-1 than with allograft alone (p>0.0038). The amount of bone mass was greater on the OP-1 side (p<0.001). No local or systemic adverse effect were noted. CONCLUSIONS Allograft on one side plus allograft with BMP-7 on the other achieved a fusion rate of 93 per cent. Allograft combined with BMP-7 was more effective than allograft alone.

Concordancia en el diagnóstico radiológico de las fracturas del raquis toracolumbar

INTRODUCTION Thoracolumbar spine fractures are frequent and severe. Early diagnosis and appropriate treatment to obtain good clinical results is essential, with many classifications being proposed for this purpose. OBJECTIVE To determine the external validity of radiographic and computed tomography (CT) measurements for the most used classifications, and decide on the type of treatment required. The working hypothesis is the existence of external validity of radiographic measurements. MATERIAL AND METHOD A sample of patients with thoracolumbar fracture was selected. Three spine specialists and a resident performed measurements on anteroposterior and lateral radiographic images as well as coronal, sagittal and axial CT slices. Fractures were classified as stable or unstable, evaluating the degree of intra-and interobserver agreement based on a standard observer. Sagittal index of Farcy, lateral wedging, Beck Index, traumatic regional angulation and channel occupancy were studied. RESULTS All indicators studied, except the lateral wedging, showed a high degree of concordance. CONCLUSIONS Instability determinants studied with radiographs and CT, which had obtained statistical significance, are reliable and accurate for the classification of thoracolumbar fractures and, therefore, to indicate an appropriate treatment.

Brucellosis – Granulomatous Spine Infection

Brucellosis mainly affects the musculoskeletal system, with the spine as the most com‐ mon location. Diagnosis is based on clinical symptoms, but in some cases, they may be lacking. Laboratory diagnosis is mainly made on the combination of high erythro‐ cyte sedimentation rate (ESR) together with high levels of C-reactive protein (CRP) and leukocytosis. Blood culture is a very cost-effective investigation; plain radio‐ graphs may be useful, but magnetic resonance images (MRI) with gadolinium en‐ hancement is the choice for diagnosing osteoarticular and spinal complications of human brucellosis. MRI diffusion-weighted imaging fast sequence is the most sensi‐ tive for differentiating acute and chronic forms of spondylodiscitis. The basis for treat‐ ment is usually the medical management. The indications for surgical treatment (endoscopy or open) are when: no microorganism has been isolated, spinal cord or dural compression is seen in MRI, or theres spinal instability or severe deformity. Open surgery is the standard: the anterior approach allows for anterior disc and bone debridement. If there is an epidural abscess or posterior elements are involved its in‐ dicated as a posterior approach. To prevent relapses and reduce the rate of sequelae, its necessary to have an appropriate duration of antimicrobial therapy and a timely indication to perform surgery.