P097 Diagnostic dilemma of acquired non-traumatic spinal deformation: Pott's disease; histiocytosis or psoriatic rheumatism? About a case

Background Non-traumatic acquired spinal deformities represent a separate entity within the axial pathologies in children. Their causes are variable (neurological, muscular, infectious, especially Pott's disease, inflammatory or tumoral). The etiological diagnosis can be clinically oriented by pain, medical history, especially rheumatic. The contribution of the CT scan is crucial, as it localizes the lesion, specifies its nature, but above all it helps the histological diagnosis by guided biopsies. Our case illustrates the difficulties in diagnosing the aetiology of spinal acquired deformity in a girl with a multi-evocative context. Observation A 14 years-old girl complains for a few months of a dorso-lumbar spinal pain and a vicious attitude. Her medical history includes femoral thrombophlebitis and psoriasis. She had no trauma or fever. Clinically, the general state is preserved, with no local inflammatory signs, a kyphotic attitude with an analgesic lumbar support was noted. The rest of the locomotor exam was normal. CT scan shows cancellous body geodes with a double mirror. Discussion Acquired spinal deformities are always secondary to general disease. The fever may point to bacterial infections, especially tuberculosis (Pott's disease), but also non-infectious causes such as a rheumatic disease. For our patient, psoriasis argues for the latter possibility. However, the rarity of isolated disco-vertebral involvement and the severity of the lytic lesions are against this diagnosis. The histopathological exam showed an eosinophilic granuloma, confirming the histiocytosis X diagnosis. The cortico-response strengthen the diagnosis. The course was marked by the bone remodeling with the posture correction. Conclusion A clinical, radiological, and histological analysis allow the etiological orientation in front of acquired spinal deformity.

1363. Most Psoas Abscesses are Pyogenic; not Tuberculous: Experience from South India

Background It is a common belief that psoas abscess in patients from developing countries like India are mostly tubercular in origin. However, most of the diagnosis of a tubercular psoas abscess are based on radiological features and are not confirmed microbiologically. It is possible that many cases of pyogenic psoas abscesses are misdiagnosed as tubercular due to lack of good quality microbiology lab facilities in developing nations. We studied the microbiology of psoas abscess in patients admitted to KIMSHealth, a tertiary care hospital in Kerala, South India. Methods Clinical details of patients with a diagnosis of psoas abscess over a 6-year period (2015 – 2020) were retrieved from electronic medical records. Microbiological investigations done included bacterial culture of the pus, fungal culture, mycobacterial culture, cartridge based nucleic acid amplification test for Mycobacterium tuberculosis and blood cultures. Results 21 patients who had complete clinical details were included. 15 of them were males and the median age was 58 years. Diabetes mellitus was the most common comorbidity (52%). Fever (61.9%) and back pain (52.4%) were the most common symptoms. The abscess was left sided in 11 patients, right sided in 7 and bilateral in 3. Vertebral involvement was present in 9 patients while hip joint was involved in 3 patients. A microbiological diagnosis was made in 14 patients (66%). Most commonly isolated organism was Staphylococcus aureus (8 patients,MSSA:6, MRSA:2) followed by E.coli (3)and Klebsiella pneumoniae (2). Blood cultures were positive in 5 patients. Anti-tuberculous therapy was started in only one patient, which was based on characteristic histopathology and negative bacterial cultures. Rest of the culture negative cases were also treated as pyogenic abscesses with antibiotics. Surgical drainage was done for 7 patients and pig tail drainage for 3 patients, while percutaneous aspiration was done for 9 patients. All 19 patients who followed up had clinical resolution, while two were lost to follow-up. Conclusion Contrary to what is believed, we observed that most psoas abscesses are pyogenic in origin. Our observations reiterates diligent microbiological investigations in all cases of psoas abscess to avoid empiric anti-tuberculous therapy. Disclosures All Authors: No reported disclosures

Laparoscopic transdiaphragmatic approach to a thoracic paravertebral hydatid cyst presenting with compression myelopathy

An elderly gentleman presented with heaviness over the right side of the chest, lower back pain and difficulty in walking for the last 6 months. He also reported of progressive weakness of the left leg associated with tingling and numbness for 2 months. Imaging studies revealed a large hydatid cyst in the right thoracic cavity compressing the spinal cord. The patient was prescribed a 14-day course of albendazole therapy. He underwent laparoscopic transdiaphragmatic deroofing and evacuation of the cyst. Postoperative recovery was uneventful. The patient started showing symptom relief from day 1 of surgery and by day 3, his right leg strength and sensation recovered remarkably. Echinococcal cyst is a zoonotic disease that can affect any part of the body. Vertebral involvement and spinal cord compression is a rare manifestation of echinococcal disease. Such cases pose diagnostic and therapeutic challenges and require a multidisciplinary approach to treat them successfully.

Skeletal Sarcoidosis

Osseous sarcoidosis is an uncommon manifestation, reported in 3–13% of patients with sarcoidosis. Although older literature suggested that hands and feet are most commonly affected, axial bone involvement may be more common than previously reported, since earlier studies relied mostly on plain X-rays, which may be less sensitive for axial bone lesions. Newer imaging modalities such as MRI and PET/CT scanning have demonstrated a larger incidence of vertebral involvement. Bone lesions are commonly asymptomatic and patients who have bone involvement may have higher incidences of multi-organ involvement. Osseous sarcoidosis appears to be mainly osteolytic in nature, but the radiographic appearance may be indistinguishable from other osteolytic lesions and therefore a biopsy is usually required to confirm the diagnosis. The histological findings of sarcoidosis in the bone are the same as in other tissues of the body. No general consensus exists for the treatment of bone sarcoidosis but corticosteroids are the most commonly prescribed first-line drugs. Methotrexate is the most widely studied steroid-sparing agent for sarcoidosis and it has been reported useful for a variety of organ symptoms, but especially where there is bone involvement.

Clinical and Para-clinical Features of Brucellosis With and Without Spondylodiscitis

Background: Brucellosis is a common zoonotic disease with protean clinical manifestations. Osteoarticular involvement is the most common complication of the disease. This study aimed to compare the clinical and para-clinical manifestations of brucellosis among the patients with and without spondylodiscitis. Methods: In this comparative and cross-sectional study, 135 patients having brucellosis with and without spondylodiscitis and admitted to Sina hospital in Hamadan, Iran from March 2009 to March 2014 were included. Clinical and para-clinical data of the patients were obtained from their medical records in the hospital based on a designed checklist. Results: Thirty-five patients having brucellar spondylodiscitis (BS) with the mean age of 55.60±14.31 years, and 100 patients having brucellosis without BS with the mean age of 43.27±18.35 years were examined. A significant difference was found between the mean age of the patients with spondylodiscitis and that of those without spondylodiscitis (P<0.001). All patients with spondylodiscitis complained of back pain and vertebral tenderness, while 60% of the patients without BS suffered from back pain but experienced no vertebral tenderness (P=0.003). The most common vertebral involvement in spinal MRI of the patients with BS was L4-L5 (45.7%). Patients with spondylodiscitis had more increased ESR and CRP than those without spondylodiscitis (P<0.001). Conclusion: It is recommended that Brucellar spondylodiscitis be considered in the differential diagnosis of the patients with prolonged fever, back pain, and vertebrae tenderness in the endemic areas.

Pseudomyxoma retroperitonei masquerading as a psoas abscess

A 52-year-old woman was referred to our department with multiple discharging sinuses and swelling in the right flank and iliac region for the past year. Ultrasound revealed a large collection in the right psoas muscle with the sinus tract reaching up to the skin in the right iliac region. Despite repeated attempts at drainage, the collection continued to increase in size. CT was requested and revealed a large heterogeneous irregular collection in the right psoas with fistulous communication with the cecum and skin with the erosion of the overlying ilium. Because of lack of vertebral involvement, enhancing internal septations, non-visualisation of the appendix and feculent material admixed with mucinous discharge from the sinus, pseudomyxoma retroperitonei secondary to ruptured mucinous neoplasm of the appendix was suspected. Mucoid material at the local site was sent for histopathology, which confirmed our suspicion. Our treatment plan after ileostomy was cytoreductive surgery along with adjuvant radiotherapy (40 Gy in 20 fractions) with chemotherapy (5-fluorouracil and folinic acid given for 30 weeks, once a week). However, after ileostomy, the patient refused further treatment, citing financial reasons.

Defining mechanical instability in tuberculosis of the spine: a systematic review

Over the years, a number of authors have used different working definitions of instability in tuberculosis of the spine (TB spine). However, no clear consensus exists to define instability in TB spine. The current systematic review addresses the question ‘What defines instability in TB spine’? A comprehensive medical literature search was carried out to identify all the studies which defined instability in the setting of spinal TB. The extracted data included the clinical, X-ray and CT or MRI-based definitions. The current review identified lesser age, junctional region of the spine, mechanical pain and ‘instability catch’, kyphotic deformity above 40 degrees, pan-vertebral or bilateral facetal involvement and multifocal contiguous disease involving more than three vertebrae as predictors for spinal instability in the dorso-lumbar spine. Cervical kyphosis more than 30 degrees and facetal or pan-vertebral involvement were found to be the factors used to define instability in subaxial cervical spine. With respect to C1–C2 TB spine, migration of the tip of the odontoid above the McRae or McGregor line or anterior translation of C1 over C2 were considered as determinants for instability. Although definitive conclusions could not be drawn due to lack of adequate evidence, the authors identified factors which may contribute towards instability in TB spine. Cite this article: EFORT Open Rev 2021;6:202-210. DOI: 10.1302/2058-5241.6.200113

Retropharyngeal chordoma extending to the spinal cord, mimicking a neurogenic tumor: a case report and literature review

Chordomas are rare, locally aggressive bone malignancies with poor prognoses. However, those with minimal or no bone involvement are more easily resectable because of their well-delineated margins and thus have better prognoses. Such extraosseous chordomas of the spine are localized both intradurally and extradurally. Only a few case reports have focused on extraosseous, extradural spinal chordomas. Radiologically, this type of chordoma has a dumbbell shape; however, dumbbell-shaped spinal tumors are traditionally thought to be neurogenic tumors (i.e., schwannomas or neurofibromas). We herein report a unique case involving a woman with a dumbbell-shaped extraosseous chordoma protruding predominantly into the retropharyngeal space. A 44-year-old woman presented for evaluation of a left submandibular mass. A T2-hyperintense, gadolinium-enhancing mass was found in her cervical spinal canal, protruding through the C2/3 neural foramen into the retropharyngeal space with minimal vertebral involvement. The initial diagnosis was a neurogenic tumor, most likely a schwannoma. After subtotal removal, the pathologic diagnosis was a chordoma. Because chordomas and schwannomas have significantly different prognoses, caution is warranted when a dumbbell-shaped tumor is identified in the spine with minimal or no vertebral deterioration on radiology. This report also provides the first thorough review of extraosseous dumbbell-shaped intraspinal–extraspinal chordomas.

Comparison Between Pyogenic Postoperative and Native Vertebral Osteomyelitis : Clinical Features, Curative Effect and Analysis of Prognostic Factors

BackgroundPyogenic spondylodiscitis(PS) is a potentially life-threatening infection burdened with high morbidity rates. Despite the rising incidence, the proper diagnosis and treatment of PS are still controversial. Postoperative Vertebral Osteomyelitis(PVO) is a clinical challenge, for there were few reports about the treatment results of PVO before, and further more few studies have compared PVO with native vertebral osteomyelitis(NVO). The purpose of this study was to compare and describe the microbiology, clinical characteristics, treatment and curative effect between PVO and NVO, and analyze the prognostic factors as well. MethodsThe clinical data of 52 patients with pyogenic spondylitis admitted to the Spine Surgery Department of the First Affiliated Hospital of Xinjiang Medical University from January 2010 to December 2019 were retrospectively analyzed. There were 30 patients in native vertebral osteomyelitis (NVO) group, including 18 males and 12 females, with an average age of 50.47 ± 20.45 years old (aged from 15 to 73); 22 patients in postoperative vertebral osteomyelitis (PVO) group, including 13 males and 9 females, with an average age of 51.45 ± 16.97 years old (aged from 14 to 73). In Group NVO, 23 cases (76.7%) were located in lumbar vertebrae, 5 cases (16.7%) in thoracic vertebrae and 2 cases (6.7%) in cervical vertebrae; in Group PVO, 16 cases (72.7%) in lumbar vertebrae and 6 cases (27.3%) in thoracic vertebrae. 29 patients had had neurological dysfunction before surgery was taken. There were 26 cases of grade D (16 cases in Group NVO and 10 cases in Group PVO) and 3 cases of grade C (1 case in Group NVO and 2 cases in Group PVO), following the instructions of American Spinal Injury Association (Asia) neurological function classification. All patients were given bed rest, nutritional support and antibiotic therapy; surgical treatment for patients with poor outcomes or aggravated symptoms. Patients were followed up at 1, 3, 6 and 12 months after surgery, including leukocyte count, ESR and CRP, X-ray, CT three-dimensional reconstruction and MRI were performed. The changes of visual analogue scale (VAS) and Asia neurological function classification were observed to evaluate the clinical efficacy simultaneously. ResultsAll patients were followed up for 12-24 months. Till the last follow-up, 3 patients in Group NVO recurred, the recurrence rate was 10% (3 / 30), 9 patients in Group PVO recurred, the recurrence rate was 40.1% (9 / 22), the recurrence rate of Group PVO was higher than that of Group NVO, the difference was statistically significant (P = 0.009). Both groups were treated with intravenous and oral antibiotics, and the time of antibiotic treatment in Group PVO was longer than that in Group NVO, however the difference was not statistically significant (P = 0.094, P = 0.062). Among 44 patients with spinal internal fixation, 13.6% (1 NVO, 5 PVO) had recurrent infection after internal fixation. Therefore, we took re-operation to remove the internal fixator for infection control, patients recovered after conservative treatment such as immobilization and systemic anti infection. The numerical value of leukocytes, C-reactive protein, ESR and VAS scores of the two groups were significantly lower than those before surgery, the difference was statistically significant (P < 0.001). In Group NVO, 16 cases recovered from Asia grade D to grade E, 1 case from grade C to grade D; 10 cases in Group PVO recovered from grade D to grade E and 2 cases recovered from grade C to grade D. There was no significant difference between these two groups (P > 0.05). By univariate analysis, multiple vertebral involvement and abscess formation (P = 0.003, P = 0.025) were significantly associated with PS recurrence; there was a tendency for PS recurrence among microbial infection (OR = 1.889), spinal prosthesis (OR = 7.083) and allogenic bone (OR = 2.032), yet not obvious. By multivariate analysis, we found that multiple vertebral involvement (OR= 12.656, 95% CI: 1.536-104.303, P = 0.018) was a risk factor for PS recurrence. ConclusionThe treatment of PVO is more challenging than NVO, especially in the cases of spinal implant infection. Although the antibiotic treatment time of PVO is longer than that of NVO, the recurrence rate of PVO is higher. Longer antibiotic therapy and, if necessary, surgical debridement or removal of implants are important approaches to successful treatment of PVO.