Case Report on Pott’s Spine

Introduction: Extra spinal infection causes Pott's illness, which is a spine infection. This condition is extremely rare. It is also called as tuberculosis spondylitis. Due to haematogenous spread over sites, it often involves the lungs and multiple vertebrae. It causes a kind of tuberculous arthritis of the invertebral disc space. The vertebral body's front part, near to the plate underneath the chondral i.e. subchondral plate, is the most prevalent location of involvement in the lower thoracic vertebrae. If anyone vertebra gets affected the disc is normal and if both it cannot receives nutrients, and collapses and spinal damage that results in kypotic spine deformity. 45 years old male patient admitted to AVBRH with the chief complaints of weakness of bilateral lower limb since 1 month, back pain, loss of weight, and loss of appetite. Clinical Findings: Weakness of bilateral lower limb since 1 month, back pain, loss of weight, loss of appetite. Diagnostic Evaluation: Generally, we examine medical history, symptoms, and physical examination of a patient. The patient has been undergone with the investigation like x-ray, MRI, CT scan, CBC, ESR and mantox test. Patient has elevated haemoglobin level i.e. 8.9%. RBCs – normocytic mildly hypochromic platelets. Patient also has elevated sodium and potassium level. Conclusion: Patient has undergone surgical management i.e. spinal fixation. Patient showed minor signs of progress and thus he was asked to undergo the medical management and was kept under observation.

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection

Introduction: Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods: We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results: In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38-70 and 51.5 (42-59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100-100%); 56% (95% CI, 48-64%), and 40% (95% CI, 36-46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829-0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84-98%), and 98% (95% CI, 94-100%), respectively. Conclusion: The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.

Removal of instrumentation for postoperative spine infection: systematic review

OBJECTIVE Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient’s spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation. METHODS PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction. RESULTS Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections. CONCLUSIONS The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

Imaging Assessment of the Postoperative Spine: An Updated Pictorial Review of Selected Complications

Imaging of the postoperative spine requires the identification of several critical points by the radiologist to be written in the medical report: condition of the underlying cortical and cancellous bone, intervertebral disc, and musculoskeletal tissues; location and integrity of surgical implants; evaluation of the success of decompression procedures; delineation of fusion status; and identification of complications. This article presents a pictorial narrative review of the most common findings observed in noninstrumented and instrumented postoperative spines. Complications in the noninstrumented spine were grouped in early (hematomas, pseudomeningocele, and postoperative spine infection) and late findings (arachnoiditis, radiculitis, recurrent disc herniation, spinal stenosis, and textiloma). Complications in the instrumented spine were also sorted in early (hardware fractures) and late findings (adjacent segment disease, hardware loosening, and implant migration). This review also includes a short description of the most used diagnostic techniques in postoperative spine imaging: plain radiography, ultrasound (US), computed tomography (CT), magnetic resonance (MR), and nuclear medicine. Imaging of the postoperative spine remained a challenging task in the early identification of complications and abnormal healing process. It is crucial to consider the advantages and disadvantages of the imaging modalities to choose those that provide more accurate spinal status information during the follow-up. Our review is directed to all health professionals dealing with the assessment and care of the postoperative spine.

#97: Rapid, Noninvasive Detection of Kingella kingae Pediatric Vertebral Infections Using a Microbial Cell-free DNA Sequencing Test for Pathogen Identification

Background Kingella kingae is a recognized cause of bone and joint infections (BJI) in infants. The diagnosis of Kingella kingae BJI can be challenging due to its fastidious growth with conventional culturing methods even when infected tissue is obtained. Kingella kingae spinal infections are likely an underdiagnosed entity given the limitations of culture-based methods and the reluctance to biopsy spinal locations of infection (in favor of empiric treatment). This approach often necessitates MRSA coverage. A sensitive, rapid, noninvasive diagnostic approach to pediatric vertebral infections would enable targeted therapy. Detection of circulating microbial cell-free DNA (mcfDNA) in the plasma originating from areas of sequestered infection through next-generation sequencing (NGS) has shown utility in pediatric pneumonia (Farnaes et al. DMID 2019) and a wide variety of infections in the immunocompromised host (Rossoff et al. OFID 2019) and potentially offers promise in resolving the etiology of pediatric vertebral infections. Methods The Karius test is a CLIA-certified/CAP-accredited NGS plasma test that detects circulating mcfDNA in the blood. After mcfDNA is extracted and NGS performed, human sequences are removed and remaining sequences are aligned to a curated pathogen database of &gt;1400 organisms. Organisms present above a statistical threshold are reported and quantified. The time to result reporting is on average 24 hours from sample receipt. Karius Test results over the prior 2 years were reviewed for detections of Kingella kingae in the context of spinal infections. Clinical chart review was performed by the treating pediatric infectious diseases physicians at each participating institution after IRB notification and approval. Results Six cases of Kingella kingae pediatric vertebral infections were identified across five institutions; clinical data were available for five cases across four institutions (see Table). Four cases were male; the average age was 15.3 months. Four of five cases had an antecedent URI. The clinical presentations were characterized by decreased mobility and relatively bland inflammatory response (lack of fever, bland inflammatory markers). The lumbar region was the most commonly affected vertebral location (80%). Blood cultures were negative in all cases; empiric anti-MRSA therapy was initiated in all cases. The time to result of Kingella kingae mcfDNA detection in the plasma was one day from sample receipt in all cases. McfDNA from co-pathogens were detected in 66.7% of cases (Haemophilus influenzae was the most common). The detection of Kingella kingae by the Karius test influenced a decision to narrow coverage in 80% of cases and a decision to forego biopsy in 60% of cases. Conclusion Plasma NGS for circulating mcfDNA offers a rapid, noninvasive means of detecting Kingella kingae pediatric vertebral infection. This culture-independent approach may enable specific diagnosis despite antibiotic pretreatment and obviate the need for an invasive procedure. Accurate identification of Kingella kingae has important implications on antibiotic stewardship enabling targeted therapy without the reliance on empiric MRSA coverage. Given the capacity to detect over 1400 organisms from a single sample NGS for mcfDNA offers a means to detect a broad variety of pathogens known to have predilection to cause pediatric spine infection.

Comparison of MRI, [18F]FDG PET/CT, and 99mTc-UBI 29-41 scintigraphy for postoperative spondylodiscitis—a prospective multicenter study

Purpose Postoperative infection still constitutes an important complication of spine surgery, and the optimal imaging modality for diagnosing postoperative spine infection has not yet been established. The aim of this prospective multicenter study was to assess the diagnostic performance of three imaging modalities in patients with suspected postoperative spine infection: MRI, [18F]FDG PET/CT, and SPECT/CT with 99mTc-UBI 29-41. Methods Patients had to undergo at least 2 out of the 3 imaging modalities investigated. Sixty-three patients enrolled fulfilled such criteria and were included in the final analysis: 15 patients underwent all 3 imaging modalities, while 48 patients underwent at least 2 imaging modalities (MRI + PET/CT, MRI + SPECT/CT, or PET/CT + SPECT/CT). Final diagnosis of postoperative spinal infection was based either on biopsy or on follow-up for at least 6 months. The MRI, PET/CT, and SPECT/CT scans were read blindly by experts at designated core laboratories. Spine surgery included metallic implants in 46/63 patients (73%); postoperative spine infection was diagnosed in 30/63 patients (48%). Results Significant discriminants between infection and no infection included fever (P = 0.041), discharge at the wound site (P < 0.0001), and elevated CRP (P = 0.042). There was no difference in the frequency of infection between patients who underwent surgery involving spinal implants versus those who did not. The diagnostic performances of MRI and [18F]FDG PET/CT analyzed as independent groups were equivalent, with values of the area under the ROC curve equal to 0.78 (95% CI: 0.64–0.92) and 0.80 (95% CI: 0.64–0.98), respectively. SPECT/CT with 99mTc-UBI 29-41 yielded either unacceptably low sensitivity (44%) or unacceptably low specificity (41%) when adopting more or less stringent interpretation criteria. The best diagnostic performance was observed when combining the results of MRI with those of [18F]FDG PET/CT, with an area under the ROC curve equal to 0.938 (95% CI: 0.80–1.00). Conclusion [18F]FDG PET/CT and MRI both possess equally satisfactory diagnostic performance in patients with suspected postoperative spine infection, the best diagnostic performance being obtained by combining MRI with [18F]FDG PET/CT. The diagnostic performance of SPECT/CT with 99mTc-UBI 29-41 was suboptimal in the postoperative clinical setting explored with the present study.