Dalbavancin treatment for spondylodiscitis: multi-center clinical experience and literature review.

Dalbavancin is a novel lipoglycopeptide antibiotic, characterized by a broad spectrum of activity against Gram-positive cocci. However, its efficacy in spondylodiscitis treatment is not fully established. All adult patients diagnosed with spondylodiscitis and treated with dalbavancin were included across four Italian medical centers from January 2018 to April 2021. We collected clinical and laboratory data, and presented follow-up findings along with a thorough literature review. 13 patients (mean age= 65 years) were included in this study. Dalbavancin was administered as first line treatment in six (46%) of the patients. Reasons for using Dalbavancin included treatment simplification (62%) and clinical failure of previous antibiotics (23%). In general, Dalbavancin was well tolerated with minimal adverse events, and clinical success was achieved in 11/13 (85%) of the patients during hospitalization with additional antibiotics required in the remaining two cases. Five months after discharge, no mortality was observed, however, 42% of patients required additional antibiotics for signs of infection on follow-up imaging. Our study suggests that Dalbavancin could be an effective and safe option in treating spondylodiscitis, however, the scarcity of studies on the topic is concerning. Thus, further studies with large samples and long-term follow-up are warranted to compare the efficacy of Dalbavancin with other available treatment options.

BCG-induced discitis and osteomyelitis in a patient with a history of bladder cancer.

This article describes the diagnosis and treatment of a patient with lumbar discitis and osteomyelitis caused by Bacillus Calmette-Guérin instillation therapy for treatment of superficial bladder cancer. Treatment of this rare condition consists of antituberculosis microbial therapy and one or more IV antibiotics to cover multidrug-resistant bacteria in the bone.

Complications of Intravesical BCG Immunotherapy for Bladder Cancer.

An earlier incorrect version appeared online. This article was corrected on December 14, 2018.

Intradiscal injection of fibrin sealant for the treatment of symptomatic lumbar internal disc disruption: results of a prospective multicenter pilot study with 24-month follow-up.

OBJECTIVE: Assess the safety and efficacy of intradiscal fibrin sealant in adults with chronic discogenic low back pain. DESIGN: Prospective, nonrandomized Food and Drug Administration approved pilot study. SETTING: Three centers in the United States. SUBJECTS: Fifteen adults with chronic, single, or contiguous two-level lumbar discogenic pain confirmed through meticulous provocation discography. INTERVENTIONS: Volume- and pressure-controlled intradiscal delivery of BIOSTAT BIOLOGX(®) Fibrin Sealant with the Biostat(®) Delivery Device into symptomatic lumbar disc(s). OUTCOME MEASURES: Assessments were performed at baseline, 72 hours, and 1, 4, 13, 26, 52, and 104 weeks following intervention. Potential adverse events were evaluated with serial assessment of neurological status, radiographic, and magnetic resonance imaging (MRI). Efficacy measures included serial assessments of low back pain visual analog scale (VAS) measurements and the Roland-Morris Disability Questionnaire (RMDQ). RESULTS: Safety neurological assessments, X-ray, and MRI showed no significant changes. Adverse events were reported in nine subjects. Two instances of low back muscle spasm and one case of discitis were the only events considered related to the procedure or product. EFFICACY: Mean low back pain VAS scores (mm) decreased from 72.4 (95% confidence interval 64.6-80.3) at baseline to 31.7 (17.4-46.1), 35.4 (17.7-53.1), and 33.0 (16.3-49.6); mean RMDQ score improved from 15.2 (12.7-17.7) at baseline to 8.9 (5.3-12.5), 6.2 (3.4-9.1), and 5.6 (2.9-8.4) at 26, 52, and 104 weeks, respectively. CONCLUSION: Intradiscal injection of BIOSTAT BIOLOGX Fibrin Sealant with the Biostat Delivery Device appears safe and may improve pain and function in selected patients with discogenic pain.

[Expression and significance of growth-associated protein 43 in a rat model of intervertebral disc inflammation].

OBJECTIVE: To investigate the expression and significance of growth-associated protein 43 (GAP-43) in the dorsal root ganglion (DRG) and intervertebral disc in the rat model of intervertebral disc inflammation. METHODS: A total of 103 adult male Sprague Dawley rats (weighing, 200-250 g) were randomly divided into the experimental group (n = 48), the control group (n = 48), and the blank control group (n = 7). Fluoro-gold (F-G) as tracer was injected into the L6, 6 intervertebral disc of 3 groups; after 7 days of F-G injection, complete Freund's adjuvant (50 microL) and the same volume of saline were injected in the experimental group (to prepare the model of intervertebral disc inflammation) and the control group, respectively, and the blank control group had no further treatment. After 1, 3, 7, and 14 days, T13-L6 DRG and L5, 6 intervertebral disc of experimental group and control group were harvested to detect the GAP-43 by using fluorescent immunohistochemistry, in situ hybridization, and RT-PCR. The DRG and intervertebral disc of blank control group were also harvested after 8 days of F-G injection. RESULTS: Fluorescent immunohistochemistry results showed that the number of F-G-labeled GAP-43 immunoreaction (GAP-43-IR) cells of the DRGs in the experimental group was significantly higher than that in the control group (P < 0.05) at 3 days, and no significant difference was found at the other time points (P > 0.05). There was no significant difference in the cross-sectional area of F-G-labeled GAP-43-IR cells between the experimental group and the control group at each time point (P > 0.05). The co-expression of GAP-43 with calcitonin gene-related peptide (CGRP) and isolectin B4 (IB4)-binding glycoprotein exhibited that the expression of CGRP was 91.4% +/- 7.4% in the control group and was 87.6% +/- 7.8% in the experimental group, showing no significant difference between 2 groups (P > 0.05). There was no IB4-binding glycoprotein expression in GAP-43-IR cells of the DRGs in 2 groups. The expressions of GAP-43, CGRP, and IB4-positive nerve fibers in the intervertebral disc exhibited that the GAP-43-IR nerve fibers in the experimental group were significantly more than that in the control group (P < 0.05), but no significant difference was found in the expression of CGRP between 2 groups (P > 0.05); and there was no IB4-binding glycoprotein expression in GAP-43-IR nerve fibers of the intervertebral disc in 2 group. In situ hybridization and RT-PCR detection showed that the positive expression cells ratio of GAP-43 mRNA and the level of GAP-43 mRNA were significantly higher in the experimental group than in the control group at 1 day (P < 0.05), and no significant difference was found at the other time points (P > 0.05). CONCLUSION: Intradiscal inflammatory environment may induce the expression of GAP-43, and potentially promote the nerve fiber ingrowth of rat.

Complete Freund's adjuvant-induced intervertebral discitis as an animal model for discogenic low back pain.

BACKGROUND: Although numerous animal models for low back pain associated with intervertebral disk (IVD) degeneration have been proposed, insufficient data have been provided to make any conclusions regarding pain. Our aim in this study was to determine the reliability of complete Freund's adjuvant (CFA) injection into the rat spine as an animal model representing human discogenic pain. METHODS: We studied IVD degenerative changes with pain development after a 10-microL CFA injection into the L5-6 IVD of adult rats using behavioral, histologic, and biochemical studies. Serial histologic changes were analyzed to detect degenerative changes. Expression of calcitonin gene-related peptide (CGRP), prostaglandin E (PGE), and inducible nitric oxide synthase (iNOS) were determined using immunohistochemistry or real-time polymerase chain reaction as support data for pain development. In addition, CGRP immunoreactivity (ir) at the IVD was considered indirect evidence of neural ingrowth into the IVD. RESULTS: There was a significant increase of the hindpaw withdrawal response in the CFA group until 7 wk postoperatively (P < 0.05). Histologic analyses revealed progressive degenerative changes of the disks without any damage in adjacent structures, including nerve roots. In the CGRP-ir staining study, the bilateral dorsal horns and IVD had positive ir after intradiscal CFA injection. CGRP mRNA expression was increased in the dorsal root ganglion (DRG) at 2 and 4 wk, whereas PGE and iNOS mRNAs were markedly increased at 2 wk. The increment of CGRP expression was higher in allodynic rats compared with nonallodynic rats. CONCLUSION: Intradiscal CFA injection led to chronic disk degeneration with allodynia, which was suggested by pain behavior and expression of pain-related mediators. The increment of CGRP, PGE, and iNOS also suggest pain-related signal processing between the IVD and the neural pathway in this animal model. This animal model may be useful for future research related to the pathophysiology and development of novel treatment for spine-related pain.

Discitis after lumbar epidural corticosteroid injection: a case report and analysis of the case report literature.

OBJECTIVE: The primary objective is to document the first case report of discitis after a lumbar epidural corticosteroid injection. The second objective is to analyze the case report literature to identify clinical features and trends of patients with infectious complications after spinal injections. DESIGN: Single case report. A MEDLINE and EMBASE literature search was conducted using key words from the names of commonly performed spinal procedures, including epidural corticosteroid, selective nerve root, transforaminal epidural, facet joint, and sacroiliac joint injections. SETTING: Pain medicine clinic at a tertiary medical center. PATIENT: A 64-year-old man with an 8-year history of left lower extremity radicular pain and recurrent pulmonary infections was referred for a lumbar epidural corticosteroid injection. Six weeks following the injection, the patient returned with a 4-week history of worsening right-sided paraspinous pain without associated recurrent pneumonia. Magnetic resonance imaging revealed a right-sided L5-S1 disc extrusion with discitis and a right L5-S1 discectomy was performed. Cultures of disc material and blood showed growth of coagulase-negative Staphylococcus, and a transesophageal echocardiogram showed no evidence of endocarditis. The patient received 6 weeks of intravenous antibiotics and he had symptomatic recovery at 3-month follow-up. RESULTS: Including our patient, the literature search identified 27 case reports of infectious complications. Similar clinical features and significant trends were evident in five categories including predisposing factors, symptom presentation, diagnostic evaluation, etiological organisms, and treatment outcomes. CONCLUSIONS: The identified clinical features and trends could prove useful to the practitioner when an infectious complication is suspected or has occurred.

[Enterobacter cloacae spondylodiscitis through misuse of high-dose intravenous buprenorphine]. / Spondylodiscite à Enterobacter cloacae par mésusage intraveineux de la buprénorphine haut dosage.

INTRODUCTION: We report a case of Enterobacter cloacae spondylodiscitis related to risk practices in intravenous drug addicts (IVDA). OBSERVATION: The patient, a former heroin addict, was receiving long-term, high-dose buprenorphine maintenance treatment. He had been misusing the treatment, injecting it daily for several months. The clinical course included several uncommon features that are usually found in IVDA patients: subacute infection, apyrexia, and minimal inflammatory syndrome. This infection also led to the discovery of his HIV infection. DISCUSSION: Any dorsolumbar pain in IVDA patients, including those receiving regular drug maintenance treatment and especially those with HIV infection, should suggest spondylodiscitis, because of these patients' enhanced sensitivity to infection and the frequent bacteremia caused by persistent or transitory relapse involving injection (exchange of material, reuse of needles, syringes, cotton swabs, and risk of contamination through the hands or saliva).

Disc inflammation potentially promotes axonal regeneration of dorsal root ganglion neurons innervating lumbar intervertebral disc in rats.

STUDY DESIGN: The expression of growth-associated protein 43 (GAP-43), a marker of axonal growth, in the dorsal root ganglion (DRG) neurons innervating the lumbar intervertebral disc was assessed using the retrograde tracing method and immunohistochemistry. OBJECTIVES: To study whether disc inflammation affects GAP-43 expression in DRG neurons innervating the disc in rats. SUMMARY AND BACKGROUND DATA: Persistent inflammation and nerve ingrowth into the inner layer of degenerated discs can be a cause of discogenic pain. Although the presence of GAP-43-expressing nerve fibers in painful discs has been reported, the expression of GAP-43 in DRG neurons innervating the disc has not been studied. METHODS: Seven days after the application of Fluoro-Gold to the L5-L6 disc, 50 microL of saline (n = 10, control group) or complete Freund's adjuvant (n = 10, inflammatory group) was applied to the disc in rats. Ten days after the Fluoro-Gold application, T13-L5 DRGs were double-stained with GAP-43 and either calcitonin gene-related peptide or isolectin B4 (IB4). RESULTS: The percentage of Fluoro-Gold-labeled neurons that were positive for GAP-43 was significantly higher in the inflammatory group (44%) than in the control group (24%, P < 0.001). In both groups, the majority of GAP-43-positive neurons were small and positive for calcitonin gene-related peptide but not IB4. CONCLUSIONS: The present results suggest that disc inflammation potentially promotes axonal growth of DRG neurons innervating the disc. In light of the strong correlation between the expression of calcitonin gene-related peptide and nerve growth factor receptor, it is most likely that nerve growth factor-sensitive DRG neurons extend their axons following disc inflammation.

Disseminated infection due to Scedosporium apiospermum in a patient with acute myelogenous leukemia.

A 62-year-old man diagnosed with acute myelogenous leukemia which had developed from myelodysplastic syndrome received cytarabine and idarubicine as an induction therapy. The patient developed pneumonia and bacterial sepsis during profound neutropenia. Fever and sepsis improved by using many anti-bacterials and anti-fungals but he became febrile again and complained of severe lumbar pain. 67Ga scintigram showed abnormal uptake in the lumbar vertebra and left sternoclavicular joint, suggesting a diagnosis of discitis and osteomyelitis in the lumbar vertebra and sternoclavicular arthritis. We biopsied the site several times but culture of the biopsy specimen could not isolate any pathogens, and high fever persisted for about 10 months despite administration of various anti-bacterials and anti-fungals. Finally we inserted a catheter into the abscess at the iliopsoas muscle and Scedosporium apiospermum was isolated in the bloody pus obtained from the catheter. Itraconazole and amphotericin B were restarted, and the high fever and lumbar pain improved rapidly. The findings of S. apiospermum infection in this patient emphasizes the importance of being aware of this pathogen in patients with hematologic malignancy during the neutropenic phase.