Frequency of various forms of spondylodiscitis on spinal column segments

Introduction: The term spinal infections or spinal column infections usually include processes localized in various parts of spinal column, parts of vertebrae as well as in intervertebral disc. There are three main types of spondylodiscitis. Bacterial spondylodiscitis (vertebral osteomyelitis) is inflammatory process usually involving two (neighboring) vertebrae and intervertebral disc causing the space for the disc between the vertebrae to be narrowed down. The aim of this paper is to present the frequency of various forms of spondylodiscitis on spinal column segments following laboratory, microbiological and radiological diagnostic procedures.Patients and methods: Descriptive research method was used in the work, as it was deemed appropriate for this type of research analysis. Diagnostic procedures used include: laboratory tests, microbiological analysis, MRI scans of cervical spine, MRI scans of thoracic spine, MRI scans of L/S spinal column.Results: Out of 307 patients included in the research, in 109 occurrences spondylodiscitis was verified on various parts of spinal column. Brucellosis spondylodiscitis represents the most frequent form (in 86% of patients), and the majority of occurrences was localized at lumbosacral part of spinal column. During the research, quite unusually, there was also one occurrence of spondylodiscitis with paravertebral abscess on cervical part of spinal column. It is also a type of brucellosis spondylodiscitis. The use of magnetic resonance imaging appears to be gold standard in diagnostics of spondylodiscitis, especially following the application of contrast agent and the use of T1 FS (fat saturation) sequences along with standard tomograms in times T1 and T2. The majority, up to 262 (85.3%) of Elisa tests were related to brucellosis. In 245 out of 307 cases, the result was positive, that is in direct relation to the fact that various forms of brucellosis are present in the areas being examined.Conclusion: Research results indicated that spondylodiscitis was diagnosed in all segments of spinal column. The most frequent occurrences are on L/S part of spinal column and the most frequent form of brucellosis is spondylodiscitis.

Simultaneous-onset infectious spondylitis with vertebral fracture mimicking an acute osteoporotic vertebral fracture erroneously treated with balloon kyphoplasty: illustrative case

BACKGROUND Early balloon kyphoplasty (BKP) intervention for acute osteoporotic vertebral fracture (OVF) has been reported to be more effective than the conservative treatment. However, complications of early BKP intervention are still unknown. OBSERVATIONS A 71-year-old patient with OVF of L2 underwent BKP 2 weeks after symptom onset. Preoperative magnetic resonance imaging (MRI) and radiograph were compatible with new L2 OVF. Although computed tomography (CT) images revealed the atypical destruction of lower endplate of L2 as OVF, L2 BKP was planned. After BKP, his back pain improved dramatically. Two weeks after BKP, his lower back pain recurred. MRI and CT confirmed the diagnosis of infectious spondylitis with paravertebral abscess formation. With adequate antibiotic treatment and rehabilitation, he was symptom-free and completely ambulatory without signs of infection. LESSONS Signal changes on the fractured vertebral bodies during initial MRI and fractured vertebral instability on radiograph can mislead the surgeon to interpret the infection as a benign compression fracture. If the patients exhibit unusual destruction of the endplate on CT imaging, “simultaneous-onset” spondylitis with vertebral fracture should be included in the differential diagnosis. To determine the strategy for OVF, preoperative biopsy is recommended if simultaneous-onset spondylitis with vertebral fracture is suspected.

Approach for tuberculosis-associated immune reconstitution inflammatory syndrome in an HIV-negative patient

A male refugee from the Middle East was diagnosed with pulmonary tuberculosis and Pott’s disease with paravertebral abscess. After starting the standard regimen, the sputum culture converted to negative and the patient’s general condition improved. Six weeks later, the patient presented with clinical worsening of known symptoms, new appearance of focal neurological deficits and progress of radiological features showing progression of the paravertebral abscess. Immune reconstitution inflammatory syndrome with Mycobacterium tuberculosis (TB-IRIS) was presumed, and treatment with high-dose steroids was started. Due to recurrent relapses while tapering, corticosteroids had to be given over a prolonged period. After treatment completion, the patient was in a good general condition, abscesses had decreased and neurological deficits were in complete remission. This case presents the rare manifestation of TB-IRIS in HIV-negative patients and its management in a high-income country.

Multi-stage treatment of non-specific spondylodiscitis of the cervical spine

The objective is to present a clinical case of successful treatment of a patient with recurrent spondylitis at the cervical level.Clinical case. A 65-year-old patient was diagnosed with purulent spondylodiscitis at the level of C6-C7 vertebrae with the epidural and paravertebral abscesses and spinal cord compression. Emergency left colotomy, paravertebral abscess dissection, corporectomy of the C6 vertebra, abscess removal, anterior spondylodesis with bone autograft and titanium plate were performed. Massive antibacterial therapy was prescribed. After the operation, the volume of movement in the left limbs was restored, and on the 15th day after the operation, the patient was discharged. On the 36th day after discharge, she was hospitalized again with hematuria. A recurrence of suppuration in the area of the operation and phlegmon of both feet was revealed. Revision of the surgical wound and rehabilitation of the purulent focus on the neck, surgical intervention for phlegmon were performed. In purulent foci, Staphylococcus aureus was verified, which is sensitive to the main antibacterial drugs. Antibacterial therapy was continued, then, after changing the microflora in the wound, other antibiotics were prescribed. There was a pain in the area of the left spinal root C5. The connection of the fistula course with the titanium plate, the increase of pathological kyphosis at the level of the overlying vertebrae was found. The wound was examined, the titanium plate was removed, and the halo device was applied to correct the pathological kyphosis. After the operation, the radicular pain syndrome regressed, and the axis of the cervical spine was restored. After 1 month, the posterior combined fixation of the cervical spine at the C3-Th7 level was performed, and the halo device was dismantled. After 6 months, the patient was stopped wearing the Philadelphia neck collar, no recurrence of suppuration was observed, and a complete regression of neurological disorders was noted. After 1 year, a complete bone block is preserved between the C4-C7 vertebrae.Conclusion. The presented clinical case clearly illustrates the complexity of managing patients with inflammatory diseases of the cervical spine. Currently, there is no single treatment strategy for patients with spondylitis.

POS1277 NON-CONTIGUOUS MULTIFOCAL SPONDYLODISCITIS: A CASE SERIES AND REVIEW OF LITERATURE

Background:Spondylodiscitis is an infective process of the disc and the two adjacent vertebrae. It is quite a rare disease accounting for 2–7% of all cases of septic osteomyelitis. These spinal infections touch commonly a single level, the lumbar spine being the most affected. Non-contiguous spine level involvement is seldom reported in the literature. This last group is for the most part imputable to granulomatous organisms [1,2].Objectives:Study the clinical, microbiological, radiological, therapeutic and evolutional characteristics of non-contiguous multi-levels spondylodiscitis.Methods:We conducted a retrospective descriptive study over twenty-one years in the Department of Rheumatology. The diagnosis of spondylodiscitis was based on combination of clinical, biological and radiological arguments.Results:Eight patients had non-contiguous multi-levels infectious spondylodiscitis. There were 6 men and 2 women. The mean age was 53.3±26.2 years. The mean delay from onset of symptoms to diagnosis was 134.6±77.6 days. Back pain was the most common symptom. All patients had spinal syndrome. The Signs of spinal cord compression were observed in 3 patients. C-reactive protein levels were elevated in 6 patients (mean: 56 ± 30.8 mg/L). Plain radiography, performed in all cases, showed pathological pictures in 7 patients. Magnetic resonance imaging was performed in 6 patients. Vertebral levels affected were thoracic / lumbar in 6 cases, cervical/thoracic in 1 case and cervical/lumbar in 1 case. The paravertebral abscess was associated to the disc involvement in 3 cases. Epiduritis was associated in 3 cases. Pathogens were isolated in all cases. Tuberculosis was the most common cause. The leading causative agents in non-tuberculosis spondylodiscitis were staphylococcus aureus, brucella and streptococcus B. Two microorganisms combined were found in two cases (mycobacterium tuberculosis associated to Escherichia coli in one case and mycobacterium tuberculosis associated to Brucella in another). Medical treatment was adapted to the microbial culture and the sensitivity profile of the etiological agent. After therapy, 7 patients had regression of symptoms and 1 patient had a permanent neurological impairment.Conclusion:Multilevel spondylodiscitis involving non-contiguous spine segments is rare. Although atypical organisms are generally held to be responsible, the common bacteria such as Streptococcus B or Staphylococcus aureus should not be overlooked.References:[1]Zimmerli W. Clinical practice.Vertebral osteomyelitis. N Engl J Med 2010 Mar;362(11):1022–9.[2]Cottle L, Riordan T. Infectious spondylodiscitis. J Infect 2008; 56(June (6)):401–12.Disclosure of Interests:None declared

Pott’s Disease with Incidentally Discovered Multiple Brain Tuberculomas in a Previously Healthy 10-Year-Old Girl

Pott’s disease (PD) represents the most common form of spinal tuberculosis. Its association with brain tuberculomas is extremely rare. Herein, we report a previously healthy child with PD and concurrent multiple brain tuberculomas who was successfully treated with antituberculous therapy, surgical drainage of the paravertebral abscess, and adjuvant steroid therapy.

Q Fever Vertebral Osteomyelitis Complicating Vertebroplasty

Query (Q) fever is a zoonotic bacterial infection caused by Coxiella burnetii. In a minority of patients, chronic disease can occur after acute infection. Endocarditis and infections of aneurysms or vascular prostheses are the most common forms of chronic Q fever in adults. We report a case of an elderly female patient with chronic Q fever vertebral osteomyelitis at the site of her previous cement vertebroplasty, complicated by paravertebral abscess. Patient treatment required prolonged drainage in addition to the long duration of antibiotic treatment by doxycycline and hydroxychloroquine. Osteomyelitis is a rare clinical presentation in adults with chronic Q fever. However, it is important to consider Q fever in the differential diagnosis of culture-negative osteomyelitis, especially in countries where C. burnetii is endemic, such as Israel.

The Contribution of SPECT/CT Bone Scintigraphy in the Localization of an Infective (Purulent) Sacroiliitis – A Case Report

BACKGROUND: Infectious sacroiliitis (ISI) is an inflammation of one or both of the sacroiliac (SI) joints, relatively rare disorder, affecting between 1% and 2% of all patients with septic arthritis. The variety of symptom presentation makes the diagnosis quite challenging. Combination of laboratory hematological tests, together with diagnostic imaging tools, such as magnetic resonance imaging (MRI), computed tomography (CT), and bone scan (BS), as well as microbiological tests contribute the final diagnosis, which may take up to several months. CASE REPORT: We present a case of a 33-year-old male patient with a history of lower back pain with propagation of the pain in the right leg, accompanied by febrility and hematuria. Laboratory tests showed high values of C-reactive protein, high degradation products and hyperkalemia, leading to a diagnose of acute renal failure stage 3. MRI of the lower spine and pelvis revealed hetero- signal change more to the right where the spinal canal was expanded, accumulating contrast and involved the caudate and the right radix. Тhe displayed sequences were accompanied by an altered morphology of the spinal musculature, with intense accumulation of contrast in parts of the muscle. Paravertebral abscess was detected in the intercaudal and iliac muscles, along with inflammatory edema of the right SI with a suspicion of a sacroiliitis. One week after, a three phase BS showed positive accumulation in the right SI joint in all three phases. The SI index for the right SI joint was 2.09, while for the left SI joint was 1.125. The patient underwent surgical intervention for drainage of the paravertebral abscess. CONCLUSION: The condition of ISI may be sometimes very difficult to be recognized in many patients. Considering the diversity of the clinical manifestations, it is of great importance to select the right imaging modality. The nuclear medicine technique triple phase bone and the hybrid imaging SPECT/CT have been suggested to improve the sensitivity and specificity of the bone scan, providing better characterization of equivocal lesions, especially in the acute form for disease localization.