Wayne N. Crow

Hematogenous pyogenic facet joint infection.

Study Design. Retrospective. Objectives. To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections. Summary of Background Data. There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases. Methods. This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment. Results. A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37). Conclusions. Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.

Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis.

The natural history of uncomplicated hematogenous pyogenic spondylodiscitis is self-limiting healing. However, a variable degree of bone destruction frequently occurs, predisposing the spine to painful kyphosis. Delayed treatment may result in serious neurologic complications. Early debridement of these infections by percutaneous transpedicular discectomy can accelerate the natural process of healing and prevent progression to bone destruction and epidural abscess. The purpose of this manuscript is to present our technique of percutaneous transpedicular discectomy (PTD), to revisit this minimally invasive surgical technique with stricter patient selection, and to exclude cases of extensive vertebral body destruction with kyphosis and neurocompression by epidural abscess, infected disc herniation, and foraminal stenosis. In a previously published report of 28 unselected patients with primary hematogenous pyogenic spondylodiscitis, the immediate relief of pain after PTD was 75%, and in the longterm follow-up, the success rate was 68%. Applying stricter patient selection criteria in a second series of six patients (five with primary hematogenous spondylodiscitis and one with secondary postlaminectomydiscectomy spondylodiscitis), all patients with primary hematogenous spondylodiskitis (5/5) experienced immediate relief of pain that remained sustained at 12–18 months follow-up. This procedure was not very effective, however, in the patient who suffered from postlaminectomy infection. This lack of response was attributed to postlaminectomydiscitis instability. The immediate success rate after surgery for unselected patients in this combined series of 34 patients was 76%. This technique can be impressively effective and the results sustained when applied in the early stages of uncomplicated spondylodiscitis and contraindicated in the presence of instability, kyphosis from bone destruction, and neurological deficit. The special point of this procedure is a minimally invasive technique with high diagnostic and therapeutic effectiveness.

Portal Venous Thrombosis: Percutaneous Therapy and Outcome

PURPOSE To study the efficacy of percutaneous treatment for portal vein thrombosis (PVT). MATERIALS AND METHODS Of 20 patients who were evaluated for symptomatic portal occlusion, 14 were successfully treated with use of percutaneous techniques. In patients with noncavernomatous PVT (n = 15), the initial treatment was to increase portal output by creating a transjugular intrahepatic portosystemic shunt (TIPS), which was successful in 12 cases. Methods to decrease arterial input to the portal system (hepatosplenic arterial embolization) were used as primary therapy in two patients and in an additional two patients with continued symptoms, despite a functioning TIPS. RESULTS All TIPS survivors had patent shunts, although patients with complete PVT required more frequent revisions compared to patients with nonocclusive PVT. Hepatosplenic arterial embolization controlled symptoms in the four patients who were treated, but both patients with patent TIPS died of liver failure after embolization. Of the 14 patients treated, eight died at a mean of 6.2 months (six from hepatoma). CONCLUSION TIPS is effective in patients with noncavernomatous PVT, although patients with complete thrombosis experience recurrent shunt occlusions and also may develop hepatoma. If TIPS fails, or if symptoms recur, hepatosplenic arterial embolization may be an option.

Percutaneous Transpedicular Management of Discitis

PURPOSE To present the technique of percutaneous transpedicular biopsy and debridement of discs in diagnosis and management of discitis. MATERIALS AND METHODS Fifteen patients underwent disc biopsy through a transpedicular approach with local anesthesia and fluoroscopic guidance. An attempt was made to debride the disc as much as possible. A surgical vacuum drain was deployed through the transpedicular tract when there was persistent drainage. RESULTS Fifteen patients underwent percutaneous transpedicular disc biopsy and debridement of disc for suspected discitis. Three patients underwent biopsy only and 12 underwent percutaneous discectomy. Six patients had at least one positive culture. Eight patients who underwent discectomy had immediate improvement of pain or neurologic symptoms, obviating emergency surgical debridement of the disc. Four patients did not improve and underwent surgical debridement and fusion. CONCLUSIONS Transpedicular biopsy of the disc is an effective technique for adequate tissue retrieval and diagnosis of discitis. Adequate debridement in selected patients with antibiotic therapy may be definitive. Epidural extension of discitis and massive vertebral destruction precludes percutaneous treatment.

Traumatic atlanto-occipital dislocation : MRI and CT

Abstract CT and MRI were employed to help characterize an atlanto-occipital dislocation injury, providing useful information for planning surgical stabilization and directing rehabilitation.

Granulocytic sarcoma in childhood acute myelogenous leukemia

A 12-year-old boy with acute myelogenous leukemia developed acute weakness and paresthesias of the lower extremities after lumbar puncture. Computed tomography and magnetic resonance imaging revealed 2 large paraspinal masses (granulocytic sarcoma) causing spinal cord compression. Treatment with corticosteroids, radiation therapy, and chemotherapy caused complete resolution of symptoms; there was no evidence of tumor on subsequent magnetic resonance imaging or at autopsy. Granulocytic sarcomas (chloromas) rarely involve the nervous system in patients with acute myelogenous leukemia, although with increased survival it is apparent that the incidence may be greater than previously believed. Central nervous system prophylaxis was not administered to our patient but may be recommended for future patients if systemic disease can be controlled. General features of central nervous system complications of acute myelogenous leukemia, characteristics of granulocytic sarcoma, and review of current radiographic techniques used in the evaluation of these tumors are discussed.

Normal in vivo eye dimensions by computed tomography.

In Win measurements of the eye were obtained in 55 normal adults using computed tomography. Means and standard deviations were established for the maximum transverse and the maximum anteroposterior dimensions. Our data indicate that the widely used methods of Sweet and Pfeiffer-Comberg (for intraorbital foreign body localization) underestimate the actual in vivo dimensions of the eye.

Preliminary results of an incremental intracarotid amobarbital procedure: Evaluation of language and memory without sedation

Abstract To evaluate the effects of performing the intracarotid amobarbital procedure (IAP) using an incremental injection, the results obtained using this technique in seven patients were compared to the findings in a second group of seven patients who received a bolus injection of amobarbital, which was typically 100 mg. Videotapes of each IAP were rated by two observers for level of sedation using a modified version of the Reaction Level Scale. The bolus procedure used a higher dosage and produced significantly greater sedation as compared to the incremental IAP. The incremental IAP also revealed linguistic errors and/or speech arrest, which identified the hemisphere specialized for language. Memory for material introduced during the drug phase was significantly impaired in the epileptogenic hemisphere as compared to the intact hemisphere in the group receiving an incremental injection of sodium amobarbital. Pending replication of this preliminary study, these preliminary findings provide support for the efficacy of using incremental IAP to mitigate sedation.