Titanium cages in the surgical treatment of severe vertebral osteomyelitis

The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12–56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2° (range –20° to 64°) by 9.4° to –0.2° (range –32° to 40°) postoperatively and lost 0.9° during follow-up . All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0–22) in the Roland–Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.This article is dedicated to Professor Dr. Winfried Winkelmann, Head of the Department of Orthopedics, University Hospital of Münster, on the occasion of his 60th birthday, with best wishes and many thanks for all his support.     

Aspergillus chest wall osteomyelitis: surgical and medical management

This case report details the case of a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and was refractory to medical and surgical treatment which included long-term antibiotics, five separate intraoperative debridements and reconstruction with vascularized omentum over a 2 year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management of the infected chest wall. The organism isolated from intraoperative cultures yielded Aspergillus fumigatus. The surgical management of osteomyelitis and costochondritis in this location is reviewed accompanied by a literature review on this rare cause of chronic chest wall infection.     

Effectiveness of Bombesin and Saccharomyces boulardii Against the Translocation of Candida albicans in the Digestive Tract in Immunosuppressed Rats

Purpose We investigated the effects of bombesin on disseminated candidiasis, and compared the effectiveness of bombesin with Saccharomyces boulardii against Candida albicans translocation from the gastrointestinal tract in immunosuppressed rats.Methods Sixty rats were divided into five groups of 12. Group 1 was given only a laboratory pellet diet and water during the experiments; the other four groups were orally inoculated with C. albicans; and groups 3, 4, and 5 were also given prednisolone intraperitoneally. The treatment groups consisted of group 4, given S. boulardii orally, and group 5, given bombesin subcutaneously. The rats were killed after 10 days, and the large bowel, liver, spleen, and kidneys were removed for microbiological and histopathological examination. Blood samples were taken to measure tumor necrosis factor-α (TNF-α) and interleukin-1 β (IL-1β) levels, and the results were compared.Results The number of translocated C. albicans colonies from the gastrointestinal tract and the serum TNF-α and IL-β levels were significantly lower in groups 4 and 5 than in group 3 (P < 0.05). Histological analysis revealed that the bombesin-treated group (group 5) had significantly less mucosal ulceration and submucosal inflammation in the large bowel, less inflammation and necrosis in the liver, and less inflammation of the Bowman capsules in the kidney than the S. boulardii-treated group (group 4) (P < 0.05).Conclusions These findings show that both S. boulardii and bombesin inhibit the translocation of C. albicans from the gastrointestinal tract, although mucosal ulceration, submucosal inflammation in the large bowel, and dissemination in the liver and kidneys were significantly less severe in the bombesin-treated immunosuppressed rats.     

Candida albicans: the estrogen target for vaginal colonization

BACKGROUND: Estradiol (E(2)) stimulates colonization of the vagina by Candida albicans. Although this yeast expresses an estrogen-binding protein (EBP), the cellular target for estrogenic modulation of this infection is unresolved. Findings support direct E(2)-induced C. albicans growth as well as indirect effects via E(2)-induced changes in the vaginal epithelium. Our primary goal was to pursue the issue of direct versus indirect estrogen action on vaginal candidiasis using diethylstilbestrol (DES), an efficacious mammalian estrogen receptor agonist, which exhibits no detectable affinity for the EBP of C. albicans. METHODS: We used both in vitro and in vivo experimentation with an EBP-positive strain of C. albicans isolated from the human vagina. Ligand-binding studies were performed with steroidal and nonsteroidal estrogens and anti-estrogens using the soluble EBP from both the yeast and the rat uterus. Mature ovariectomized rats were treated with either E(2) or DES for 7 days before and after C. albicans inoculation into the vaginas. Subsequent estrogen-sensitive colonization was quantified based on cultures of vaginal homogenates on Sabouraud dextrose (SD) agar pour plates. RESULTS: We confirmed that our isolate of C. albicans contained a high-affinity EBP, with no detectable affinity for DES. Vaginal colonization by C. albicans was 8.6-fold greater in response to in vivo treatment with E(2) than with the comparable dose regimen of DES. CONCLUSIONS: The mechanism for estrogen-sensitive vaginal colonization by C. albicans includes a functional ligand-EBP interaction within the yeast.     

Implant-related infection model in rat spine

Objective The rate of postoperative infections is approximately 1% in spine surgery. However, when metal implants are used, postoperative infection rates significantly increase and were reported between 2.1 and 8.5%. This study aim to set up an infection model in the rat spine with a metal implant. Materials and methods Forty white male Sprague Dawley rats were randomly divided in four groups. In all rats, under operation microscope, a 3 mm titanium microscrew was implanted in the thoracolumbar area (T10-L1) after laminar decortication. In Group I (control group), sterile isotonic solution and in other three groups, different concentrations of Staphylococcus aureus [Group II: (10²), Group III: (10³), Group IV: (10⁶)] were squirted on the decorticated lamina site. All animals were sacrificed after 2 weeks, and then blood cultures and cultures from fascia, muscle and bone were obtained. Bacterial number in each tissue was measured as colony-forming unit per gram tissue. Titanium microscrews were placed in 0.5 ml tryptic soy broth and vortexed than plated on trypticase soy agar to determine bacterial growth. Two animals from each group were subjected to histological examination. Results Blood cultures obtained by intra-atrial puncture after 2 weeks were negative in all groups indicating no systemical infection developed. Bacterial cultures were negative in all specimens of Group I (control group). A significant osseous infection was confirmed in Groups II, III and IV. Comparison of bacterial counts in bone cultures showed no significant difference between Group III (10³ CFU/10 μl) and Group IV (10⁶ CFU/10 μl) (P > 0.05), while both groups had significantly higher counts than Group II (10² CFU/10 μl) (P > 0.05). Microscopic findings of supurrative inflammation were present only in Group IV (10⁶ CFU/10 μl). Conclusions This study shows that inoculation of S. aureus in 10⁶ CFU/10 μl concentration at the decorticated lamina after implantation of a titanium screw in rat spine is a reproducible model for spinal infection and can be used for the animal model of prophylaxis and treatment and of postoperative infection.     

<Emphasis Type="Italic">Candida albicans</Emphasis>-Infected Pancreatic Pseudocyst: Report of a Case

We report the case of a 48-year-old man with a pseudocyst infected by Candida albicans, and review the relevant literature. The patient was successfully treated by a Roux-en-Y cystojejunostomy of the pseudocyst and adjunctive therapy with amphotericin B. Candida species isolated from a pancreatic pseudocyst or abscess should be considered pathogenic, and treated aggressively.     

Candida albicans cerebral granuloma in an immunocompetent patient. A case report

We report a case of temporal lobe granuloma caused by Candida albicans in an immunocompetent patient. This 54-year-old patient had experienced headaches and some memory disorders for two to three months before his admission to the neurosurgical department. Cerebral-computer tomography and magnetic resonance imaging showed a single right-temporal lesion with a large peritumoral edema. We operated on the patient via a temporal approach using neuronavigation and resected the lesion. The anatomopathological result and the cultures of the granuloma showed C. albicans species. The patient received antifungal therapy for three months. No predisposing factors or immunosuppression was found. After seven months, he presented an ischemic cerebrovascular accident of the brain stem and then chronic meningitis complicated by hydrocephalus. The patient's condition progressively deteriorated and he died 18 months later in an other department. C. albicans can be found even in the immunocompetent patient, but is seldom observed. Surgery can provide an accurate diagnosis and therapeutic management in the initial phase, completed by antifungal therapy.     

Photodynamic antimicrobial chemotherapy (PACT) with methylene blue increases membrane permeability in Candida albicans

Photodynamic antimicrobial chemotherapy (PACT) is a potential antimicrobial therapy that combines light and a photosensitizing drug, promoting a phototoxic effect on the treated cells, in general via oxidative damage. In this work we studied the effect of PACT, using methylene blue (MB), on the permeability of Candida albicans membrane. Our results demonstrated that the combination of MB and laser (684 nm) promoted a decrease in Candida growth. The inhibition was more pronounced in the presence of 0.05 mg/ml MB and with an energy density of 28 J/cm². The decrease in Candida growth was associated with an increase in membrane permeabilization. Thus, we suggest that a PACT mechanism using MB can be related to damage in the plasma membranes of the cells.     

脊柱化脓性骨髓炎的诊断及现代外科治疗

[目的]探究脊柱化脓性骨髓炎的特点及外科治疗方法。[方法]39例脊柱化脓性骨髓炎患者均行一期前路病灶清除加椎间植骨术。分析其临床表现、实验室、病原学及影像学特点和疗效。[结果]随访2~17年,平均8.5年。所有患者腰背疼痛均有缓解,其中17例疼痛完全消失,其余22例有时轻微疼痛。下肢神经功能除1例感觉障碍加重,均有不同程度改善,临床症状和体征改善率20%~100%,平均75.6%。所有患者均获得骨性融合,融合时间2~6个月,平均4个月。血沉从术前平均73mm/h恢复到术后平均29mm/h,而C反应蛋白全部恢复正常。无与手术直接相关的死亡及其他并发症。病原学结果:19例(48.7%)患者细菌培养阳性:金黄色葡萄球菌阳性10例,表皮葡萄球菌2例,大肠杆菌2例,绿脓杆菌2例,肺炎链球菌1例,肺炎克雷白杆菌1例,弗氏柠檬酸杆菌1例。[结论]患者本身的基础疾患是导致脊柱化脓性骨髓炎发病的重要因素之一,不仅金黄色葡萄球菌可以致病,某些条件致病菌或非致病菌如大肠杆菌及表皮葡萄球菌等也可以导致脊柱化脓性骨髓炎的发病;C反应蛋白比ESR及白细胞计数更为敏感,可用于脊柱化脓性骨髓炎的诊断及判定疗效的重要参考指标;MRI对脊柱化脓性骨髓炎的诊断更为敏感、特异及准确;一期前路病灶清除植骨术是治疗脊柱化脓性骨髓炎安全有效的手术方法。     

Failure modes in conservative and surgical management of infectious spondylodiscitis

Purpose and methods

We reviewed the management, failure modes, and outcomes of 196 patients treated for infectious spondylodiscitis between January 1, 2000 and December 31, 2010, at the Spinal Unit, Aarhus University Hospital, Aarhus, Denmark. Patients with infectious spondylodiscitis at the site of previous spinal instrumentation, spinal metastases, and tuberculous and fungal spondylodiscitis were excluded.

Results

Mean age at the time of treatment was 59 (range 1–89) years. The most frequently isolated microorganism was Staphylococcus aureus. The lumbosacral spine was affected in 64 % of patients and the thoracic in 21 %. In 24 % of patients, there were neurologic compromise, four had the cauda equina syndrome and ten patients were paraplegic. Ninety-one patients were managed conservatively. Treatment failed in 12 cases, 7 patients required re-admission, 3 in-hospital deaths occurred, and 5 patients died during follow-up. Posterior debridement with pedicle screw instrumentation was performed in 75, without instrumentation in 19 cases. Seven patients underwent anterior debridement alone, and in 16 cases, anterior debridement was combined with pedicle screw instrumentation, one of which was a two-stage procedure. Re-operation took place in 12 patients during the same hospitalization and in a further 12 during follow-up. Two in-hospital deaths occurred, and five patients died during follow-up. Patients were followed for 1 year after treatment. Eight (9 %) patients treated conservatively had a mild degree of back pain, and one (1 %) patient presented with mild muscular weakness. Among surgically treated patients, 12 (10 %) had only mild neurological impairment, one foot drop, one cauda equine dysfunction, but 4 were paraplegic. Twenty-seven (23 %) complained of varying degrees of back pain.

Conclusions

Conservative measures are safe and effective for carefully selected patients without spondylodiscitic complications. Failure of conservative therapy requires surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment, and correction of instability. Surgeons should master various techniques to achieve adequate debridement, and pedicle screw instrumentation may safely be used if needed.     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

Post operative infections of the spine: technique,indications and results of the surgical treatment - A retrospective study of 90 cases

Post operative infection in spine surgery is a well known complication. The authors studied a series of 90 patients in accordance with an homogenous strategy based on the excision of necrotic and infected tissues, associated with appropriate antibiotics.The results are analyzed according to the degree of infection (which is based on the type of germs and their associations), and type of patients, the delay in diagnosis and the anatomical extension of the infected lesions.Making a difference between superficial and deep infection is of no therapeutic value and may lead to wrong and inadequate treatment.One must separate the common infections (which are due to germs as staphylococcus aureus or others from the urinary or digestive tract), and severe infections (which are either due to a per operative massive and deep contamination, or associated with patient's poor general condition).This series is mainly about posterior approaches to the spine, with or without osteosynthesis. Technical problems for treatment depend on the site of infection, particularly at the thoracic kyphosis level, or at the lumbar level where the muscle necrosis can be extensive. At the cervical level, the infection of an anterior approach mandates a check on the respiratory and digestive tracts.Removing the osteosynthesis is not mandatory in post operative spinal infections, as it may induce severe mechanical destabilization. An anterior approach is not necessarily required in the case of a posterior infection, except with massive contamination of an anterior graft. In some cases, posterior lumbar interbody fusion can lead to the indication for anterior cage removal.Pseudarthrosis of an infected spine, initially treated to obtain fusion, is still the worst complication. In case of previous posterior infection, even a severe one, fusion can still be obtained through a secondary anterior or posterior approach for grafting, with or without osteosynthesis.In this series, there was no neurological complication due to infection.However, eight diceases occured in weak patients with neurological involvement. This points out the importance of the general treatment associated with the surgery, and the necessity of a thorough assessment. a thorough assessment.Résumé Les infections post-opératoires représentent une complication largement documentée dans le domaine de la chirurgie du rachis. Les auteurs étudient une série de 90 patients traités selon une stratégie homogène basée sur l'excision des tissus nécrosés et infectés associée à l'utilisation d'un traitement antibiotique adapté. Les résultats sont analysés en fonction du degré d'infection (basé sur le type de germe et leurs associations) de l'état des patients, du délai pour le diagnostic et de l'étendue anatomique des lésions infectieuses. L'opposition entre infection superficielle et profonde semble sans intérêt sur le plan thérapeutique et peut conduire à un traitement insuffisant ou mal adapté.Il est important de séparer les infections classiques (qui sont dûes à des germes comme le staphylocoque doré ou d'autres germes provenant de la sphère urinaire ou digestive) et les infections sévères (qui sont soit dûes à une contamination per-opératoire massive et profonde ou associées à des patients dont létat général est déficient).Cette série est principalement basée sur les abord postérieurs du rachis avec ou sans ostéosynthèse. Les problèmes techniques pour le traitement dépendent du site de l'infection: aux niveaux thoracique et lombaire, la nécrose musculaire peut être très extensive. Au niveau cervical, l'infection d'un abord antérieur impose de vérifier l'intégrité du tractus aéro-digestif.L'ablation initiale du matériel n'est pas nécessaire dans beaucoup de cas d'infections post-opératoires car elle peut induire des destabilisations sévères et des complications mécaniques supplémentaires. Un abord antérieur n'est pas forcément nécessaire en cas d'infection postérieure mises à part les contaminations massives d'une greffe antérieure ou une infection d'une cage intervertébrale réalisée pour une fusion intersomatique par voie postérieure.La pseudarthrose des greffes sur un rachis infecté qui a été traité initialement pour obtenir une fusion reste encore la plus sévère des complications. Dans les cas d'infections postérieures même sévères, la fusion peut être encore obtenue secondairement grâce à un abord antérieur ultérieur ou même un abord postérieur pour des greffes complémentaires avec ou sans ostéosynthèse.Dans cette série, les auteurs ne signalent aucune complication neurologique dûe à l'infection. Néanmoins, 8 décès sont à déplorer chez des patients fragiles avec signes neurologiques initiaux. Ceci souligne l'importance du traitement général associé à la chirurgie et la nécessité d'un bilan complet de ces malades.EBJIS Congress, Leuven     

The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis, treatment and therapeutic outcomes

Purpose

The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) is increasing. We performed a retrospective cohort study of patients with this type of infection in an effort to gain an improved understanding of the current clinical presentation, management and outcome.

Methods

Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from GNB HVO were identified and their microbiological diagnoses were evaluated.

Results

This study identified seventy-nine patients with haematogenous vertebral osteomyelitis (HVO). Of these seventy-nine patients, 10 patients (12.66 %) had Gram-negative organisms isolated. These organisms included Escherichia coli (4), Pseudomonas aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Eight patients were successfully treated with antibiotics and/or surgery. Of the eight patients whose HVO was cured, five had Ciprofloxacin as part of their definitive antibiotic regime.

Conclusion

The treatment of GNB HVO is often challenging because of unpredictable resistance patterns and limited published data on effective treatment regimens. Our study has highlighted the need for prompt microbiological sampling and initiation of early appropriate antibiotic regime. The most effective treatment for GNB HVO was with oral Ciprofloxacin over a period of 6–8 weeks.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Pitfalls in the surgical management of cervical spine injuries

Records of 69 cervical spine injury patients referred to the authors' institution over a 3-year period were reviewed. The senior author documented definite and probable pitfalls occurring in the pre-, intra-, and postoperative management. Diagnosis, traction, bracing, surgical timing, intraoperative technical errors, and incorrect surgical decisions were noted. Of the 69 patients, 39 (56%) suffered a pitfall of management. Twenty-seven patients (39%) accumulated 49 definite pitfalls between them and 12 patients (17%) suffered a total of 20 probable pitfalls. Of the 49 definite pitfalls, 7 (14%) were preoperative, 17 (34%) were those of surgical decision making, 21 (43%) were operative, and 4 (9%) postoperative. Diagnostic errors and incorrect bracing and traction led to neurological worsening. Intraoperatively, technical errors (30%), wrong timing of surgery (24%), and incorrect choice of operation (16%) were the common pitfalls. Postoperative pitfalls consisted of inappropriate bracing (17%). A Cervical Spine Research Society review (1989) rated complications of cervical spine surgery at 6.3% (63/992). In this study, a sizeable portion (56%) of cervical spine injury patients requiring surgery were at a risk of complications. Short of complications, there are areas of management where errors may have less well-documented undesirable effects or increase the potential for morbidity. An awareness of these pitfalls and increased use of non-operative treatment may eliminate up to 73% of the pitfalls and thereby decrease the morbidity associated with the management of cervical spine injuries.     

一期前路病灶清除植骨融合内固定术治疗下颈椎化脓性骨髓炎

目的:探讨一期前路病灶清除、感染椎体次全切、自体髂骨植骨融合、钛板固定术治疗下颈椎化脓性骨髓炎的疗效。方法:2004年1月至2009年6月共收治17例下颈椎化脓性骨髓炎患者,男性14例,女性3例;年龄42~78岁,平均56.5岁。17例患者均有颈痛,9例伴发热,6例伴脊髓损伤,5例伴神经根性损伤。影像学检查13例有硬膜外脓肿形成,4例椎前脓肿形成伴椎体广泛破坏。均于广谱或敏感抗菌素治疗7~14d后行一期前路病灶清除、感染椎体次全切除、自体髂骨植骨融合、钛板内固定术。术后抗菌素治疗12~14周,定期复查血白细胞计数、血沉和C反应蛋白、颈椎正侧位X线片及CT,术后12个月行MRI检查。结果:手术时间50~150min,平均110min,术中无血管及神经损伤发生;术后2例切口浅层感染,经换药后愈合,无食管漏等严重并发症发生。所有患者于术后1周内颈痛缓解,体温恢复正常。13例于术后12周前白细胞计数、血沉、C反应蛋白均降至正常;4例白细胞计数正常,但血沉及C反应蛋白至术后9个月才降至正常。所有患者于术后12个月复查CT,16例植骨融合;1例融合失败,24个月随访时假关系形成。随访18~24个月,平均20.3个月,术前有脊髓和神经根损伤患者神经功能均完全恢复正常,感染均无复发。结论:在规范、有效、充分的围手术期抗菌素治疗期间行一期前路病灶清除、感染椎体次全切除、自体髂骨植骨融合、钛板内固定术是治疗下颈椎化脓性骨髓炎的有效方法。     

Primary tumours in the spine and pelvis in adolescents: clinical and radiological features.

In 34 patients in their two first decades of life with primary bone tumours in the spine and pelvis, the most common benign tumour was histiocytosis X and the most common malignant tumour, Ewing's sarcoma. X-rays were positive in 32 out of 34 cases but of little diagnostic value and primary complaints were without significance. The final diagnosis can only be made after a biopsy.