Ascorbic acid deficiency amongst spondylodiscitis patients.

BACKGROUND: Spondylodiscitis can be a disabling and life-threatening infection. Ascorbic Acid is crucial for neutrophil function and collagen formation. Its association and clinical relevance in spondylodiscitis has not been previously examined. AIMS: To determine the prevalence, characteristics, and clinical outcomes of spondylodiscitis patients with Ascorbic Acid deficiency. METHODS: Sixty-eight consecutive patients admitted with spondylodiscitis, between December 2021 and August 2023 were included. Clinical characteristics, Ascorbic Acid levels and clinical outcomes were evaluated. RESULTS: Thirty-seven patients had Ascorbic Acid levels taken during admission. The median initial Ascorbic Acid level was 15 µmol/L with an IQR 6.5-27 µmol/L. Depletion defined as <28 µmol/L was present in 78% of patients. Deficiency defined as ≤11 µmol/L was present in and 46% of patients. Patients with depletion were more likely to require Intensive Care Admission (absolute risk increase = 24.1%; 2.6%-45.7%). Fifteen patients had repeat serum levels taken during admission with median increase of 17 µmol/L and an IQR 0-26 µmol/L. Patients that received supplementation had a significantly greater increase in Ascorbic Acid levels compared with those that did not receive supplementation (P = 0.002). CONCLUSION: Ascorbic acid deficiency is highly prevalent amongst spondylodiscitis patients. Depletion was associated with worse outcomes. Replacement significantly increased serum levels in comparison to standard hospital diet. The clinical significance of replacement remains to be evaluated.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice.

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). PREOPERATIVE PATIENTS' INFORMATION: Each patient must be informed concerning the risks associated with POP surgery (EO). HEMORRHAGE, HEMATOMA: Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). BLADDER INJURY: When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). URETER INJURY: After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). RECTAL INJURY: Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). VAGINAL WALL INJURY: After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS): Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM: Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). URINARY RETENTION: Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). POSTOPERATIVE PAIN: Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). POSTOPERATIVE DYSPAREUNIA: When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). VAGINAL MESH EXPOSURE: To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). SUTURE THREAD VAGINAL EXPOSURE: For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. BLADDER AND URETERAL MESH EXPOSURE: When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Serious spondylodiscitis, septic sacroiliitis and multiple abscesses after ozone therapy for low back pain: A case report on good response to combined treatment with empiric antibiotic and neridronate.

Ozone therapy is a minimally invasive technique now widely used for the treatment of pain due to herniated discs. In literature there are conflicting results concerning its real effectiveness and few data about its possible complications. In this case report we present a case of spondylodiscitis, septic arthritis and gluteal abscess following the execution of 4 sessions of ozone therapy. Given the impossibility of isolating the etiological agent, an empirical antibiotic therapy with an overall duration of 6 weeks was set up, initially with daptomycin and ceftriazone, to which was added after 2 days metronidazole, administered intravenously; after 20 days the cephalosporin was replaced with oral amoxicillin/clavulanate. Neridronate was added to treat bone edema and to avoid bone erosion. The patient showed improvement of both clinical conditions and inflammation indexes, and was discharged after 4 weeks without further complications at follow-up. Few cases are reported in the literature about spondylodiscitis secondary to ozone treatment, and just 1 case is described about the use of neridronate as additive drug to antibiotic treatment in spondylodiscitis to avoid bone disruption and surgery complications.

Aspergillus terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent host: case report and literature review.

Aspergillus terreus is a fungus responsible for various infections in human beings; however, spine involvement is uncommon. Herein, we report a case of A. terreus spondylodiscitis following acupuncture and acupotomy in an immunocompetent Chinese patient. Admission lumbar magnetic resonance imaging (MRI) revealed infection at the L4/5 level without significant vertebral destruction. After unsuccessful symptomatic and anti-tuberculosis treatments, A. terreus was identified through culture, microscopy of isolate, histological examination and VITEK system. Intravenous voriconazole was then given; however, the patient's spinal condition deteriorated rapidly, resulting in evident destruction of the L4/5 vertebral bodies. Surgeries including L4/5 intervertebral disc debridement, spinal canal decompression, posterior lumbar interbody fusion (PLIF) with allogeneic fibula ring fusion cages, and posterior pedicle screw fixation were then performed. Imaging findings at one-month and six-month follow-up suggested that the patient was successfully treated. This case highlighted two important points: firstly, although acupuncture and acupotomy are generally regarded as safe conservative treatments for pain management, they can still lead to complications such as fungal spinal infection. Therefore, vigilance is necessary when considering these treatments; secondly, PLIF with allogeneic fibula ring fusion cages may be beneficial for A. terreus spondylodiscitis patients with spinal instability.

[Current practice of empiric antibiotic treatment for spondylodiscitis]. / Aktuelle Praxis der empirischen Antibiotikatherapie bei Spondylodiszitis.

BACKGROUND AND RESEARCH QUESTION: In pyogenic spondylodiscitis, infections with coagulase-negative staphylococci must be given increasing importance. Empirical antibiosis is particularly necessary in patients with severe or progressive neurological deficits or hemodynamic instability, as well as in the case of culture-negative spondylodiscitis. It is unclear whether uniform empirical antibiosis standards adapted to the resistance profiles exist in Germany. STUDY DESIGN AND METHODS: A survey on the empirical antibiotic therapy for pyogenic spondylodiscitis was conducted at German university and Berufsgenossenschaft clinics, each in the departments of orthopedics and trauma surgery. The survey results were applied to the resistance profiles of pathogens in 45 spondylodiscitis patients treated in our department between 2013 and 2020. Thus, the potential susceptibility and resistance rates were calculated for the indicated antibiotic therapies. RESULTS: Of the 71 clinics queried, a total of 44 (62.0%) responded. Sixteen different antibiotic therapies were reported as standard regimes. Among these, 14 different combination therapies were reported. The most commonly reported empirical antibiotics, namely amoxicillin/clavulanic acid or ampicillin/sulbactam (29.5%) and cephalosporins (18.2%) showed high potential resistance rates of 20.0% and 35.6%, respectively, in relation to the previously published resistance profile. The highest potential susceptibility rates were achieved with a combination of vancomycin + ampicillin/sulbactam (91.1% sensitive pathogens), vancomycin + piperacillin/tazobactam (91.1% sensitive pathogens), and ampicillin/sulbactam + teicoplanin (95.6% sensitive pathogens). One out of these combinations was reported as standard regime by three clinics (6.8%). CONCLUSION: The nationwide survey of empiric antibiotic treatment for pyogenic spondylodiscitis revealed a large heterogeneity in the standard of care. A combination of a broad-spectrum-ß-lactam antibiotic with an additional glycopeptide antibiotic may be justified.

Development and current use of local antibiotic carriers in spondylodiscitis : Pilot study on reduction of duration of systemic treatment.

BACKGROUND: The current study situation regarding the duration of systemic antibiotic treatment for spondylodiscitis is inhomogeneous and varies between 4-12 weeks. Due to the many undesirable side effects the aim is to achieve complete healing without recurrence or hematogenous scatter within the shortest possible period of time. The present pilot study investigated whether the additional application of a local antibiotic carrier to the surgically treated intervertebral disc space can contribute to a further reduction of treatment duration. MATERIAL AND METHODS: In the pilot study 20 patients with acute spondylodiscitis and indications for surgical intervention were included. Surgical treatment was carried out by dorsal instrumentation, radical debridement of the site of infection, and cage interposition in the affected disc space. The remaining disc space was filled with homologous cancellous bone and antibiotic-loaded calcium sulfate hydroxyapatite pellets. A classification into a long-term and a short-term antibiotic group was performed. Both groups initially received a 10-day parenteral antibiotic administration. This was followed by oral antibiotics for 2 or 12 weeks, depending on the group. During the 12-month follow-up inflammation parameters, the local infection situation as well as the bony fusion and antibiotic tolerance were regularly checked. RESULTS: The average age of the patients was 66.7 ± 11.2 years. Intraoperative detection of pathogens was successful in 65%. In 60% the antibiotic carrier was loaded with gentamicin, in 40% with vancomycin. At follow-up, all patients except one in the short-term antibiotic group had inflammation parameters within the normal range after 3 months. In the long-term antibiosis group, two patients still showed elevated infection values after 3 months, otherwise the values were within the normal range. After 12 months a complete cure of the infection was achieved in all patients. Antibiotic treatment intolerance occurred in 10% of the short-term antibiotic group and in 50% of the long-term group. CONCLUSION: The results of the present pilot study show that with the additional use of absorbable local antibiotic carriers in the surgical treatment of bacterial spondylodiscitis it is possible to shorten the duration of systemic antibiotic treatment to 3 weeks. This can reduce the side effects and incompatibility of treatment and still achieve similar healing results.

Spondylodiscitis due to Cutibacterium acnes following lumbosacral intradiscal biologic therapy: a case report.

A 40-year-old woman with a history of chronic low back pain underwent a fluoroscopically guided intradiscal platelet-rich plasma injection (PRP) at the L5-S1 level. She subsequently developed progressive low back pain, night sweats and decreased ability to ambulate. Laboratory work-up revealed elevated acute phase reactants and imaging revealed L5-S1 intervertebral disc and vertebral end-plate abnormalities highly suggestive of spondylodiscitis. Computed tomography-guided aspiration and biopsy cultures grew Cutibacterium acnes and the patient was subsequently treated with intravenous antibiotics without surgical management. To the best of our knowledge, this is the first published case of lumbar spondylodiscitis following an intradiscal PRP injection, and brings to the forefront several clinically relevant issues including the antimicrobial effects of PRP, the role of C. acnes in spine infections and the ideal treatment protocol for intradiscal biologics in order to minimize morbidity and optimize functional outcomes.

Community acquired Stenotrophomonas maltophilia discitis: Diagnosis aided by shotgun metagenomic sequencing.

We report a rare case of culture negative L4-L5 discitis and epidural abscess in an immunocompetent child who had dry cupping therapy performed to treat low back strain. The causative pathogen was identified as Stenotrophomonas maltophilia by shotgun metagenomic sequencing of spinal cord aspirate after more than one month of unsuccessful empirical treatment with 6 different antibiotics. The patient was successfully treated with Sulfamethoxazole-trimethoprim and minocycline. Cupping therapy is a very popular medical procedure widely used in China, but the potential risk for severe infections such as discitis and epidural abscess described in this case should be recognized.

[Therapy of Spondylodiscitis by Severity]. / Die schweregradorientierte Therapie der Spondylodiszitis ­ eine prospektive Betrachtung anhand von elektronisch basierten Behandlungspfaden.

Spondylodiscitis is a rare but serious infection of the spine. Recognised methods of treatment include immobilisation and systemic antibiotics. However, available data for specific and recommendations for continuing treatment are also rare. The aim of the present study is the optimisation of the therapy of spondylodiscitis using a clinical pathway that depends on a classification of spondylodiscitis. From 1 October 1998 to 31 December 2013, a classification of the severity of spondylodiscitis was established, including specific treatment recommendations. As part of the re-evaluation, the classification of severity was adapted. On this basis, electronically based clinical pathways were developed. A total of 296 cases were included. With a steadily increasing number of treatments, the mean age of the patients increased to 67.3 years. In 34.3% of these patients, spondylodiscitis developed spontaneously and 68.6% of patients did not receive treatment until the diagnosis. In the context of the specific treatment, pain intensity decreased from 6.0 to 3.1 NRS (numeric rating scale). The inflammatory values (CRP) decreased from 119.2 to 46.7 mg/dl. The time from the onset of symptoms to the surgical treatment was almost 65.6 days and has not changed significantly. Nevertheless, the time from admission to surgical treatment could be reduced to less than 3 days. The classification of patients into 3 degrees of severity of spondylodiscitis (SSC) depends on the SponDT: spondylodiscitis diagnosis and treatment. The SponDT describes vertebral destruction and the current neurological status. The severity-adapted therapy was mapped electronically and includes specific surgical care, systemic antibiotic therapy and physical therapy.

Nosocomial spondylodiscitis after intradiscal electrothermal therapy: Case series.

Intradiscal electrothermal therapy (IDET) is a method applied for treatment of pain caused by the disc and involves reaching spinal disc through a catheter under fluoroscopy and solidifying disc interior by heating. We retrospectively evaluated ten patients treated and followed up with diagnosis of nosocomial spondylodiscitis after IDET. Ten patients, to whom IDET was applied for low back pain treatment in a tertiary healthcare organization, came with complaints of fever and low back pain during postoperative process. Appropriate antibiotics treatment was commenced after the reproduction of Pseudomonas aeruoginosa in abscess culture.Even though spondylodiscitis developing after IDET is a rare complication, it is also a clinical condition that needs to be thought in the patients whose complaints increase and clinically do not recover after the procedure. Adherence to rules of the asepsis will reduce the frequency of infection as in all nosocomial infections.

First report on treating spontaneous infectious spondylodiscitis of lumbar spine with posterior debridement, posterior instrumentation and an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin: a case report.

BACKGROUND: Spontaneous infectious spondylodiscitis is a rare, but serious disease with the risk of progressive neurological impairment. The surgical approach to spontaneous infectious spondylodiscitis is in most cases an anterior debridement and fusion, often in staged surgeries. Here we report a case of single-stage posterior debridement and posterior instrumented fusion in combination with an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin. CASE PRESENTATION: A 59-year-old Caucasian man presented with a 6-week history of lumbar pain without sensory or motor disorders of his lower extremities. A magnetic resonance imaging scan of his lumbar spine in T2-weighted sequences showed a high signal of the intervertebral disc L4/L5 and in T1-weighted sequences an epidural abscess at the posterior wall of L4. Additional computed tomography imaging revealed osteolytic destruction of the base plate of L4 and the upper plate of L5. Antibiotic therapy was started with intravenous ciprofloxacin and clindamycin. We performed a posterior debridement via a minimally invasive approach, a posterior percutaneous stabilization using transpedicular screw-rod instrumentation and filled the intervertebral space with an injectable calcium sulfate/hydroxyapatite composite which elutes a high concentration of gentamicin. The patient's lower back pain improved quickly after surgery and no recurrence of infection has been noticed during the 1-year follow-up. Computed tomography at 11 months shows complete bony fusion of L4 and L5. CONCLUSIONS: An injectable calcium sulfate/hydroxyapatite composite releasing a high level of gentamicin can support the surgical treatment of spondylodiscitis in combination with posterior debridement and transpedicular screw-rod instrumentation.

[Diagnostics and treatment of spondylodiscitis].

Spondylodiscitis, infection of the spine and intervertebral discs, is a rare condition with increasing incidence. Early diagnosis can be challenging due to the non-specific symptoms such as back pain and fever. Diagnosis is verified by MRI. Microbial aetiology is pursued by blood cultures or surgical biopsy, however, some cases remain culture-negative. Long-term antibiotic treatment is standard of care. Some patients receive surgical treatment. One-year mortality is up to 20%. Recently, published data suggest that six weeks of antibiotics equals 12 weeks in culture-positive cases.

Espondilodiscitis: análisis de 19 casos internados en un hospital de tercer nivel / Spondylodiscitis: analiysis of 19 inpatients at a referral hospital in Rosario, Argentina

Introducción: la espondilitis representa un desafío diagnóstico, ya que el dolor lumbar, su principal manifestación clínica, constituyeun motivo de consulta muy frecuente en la práctica cotidiana y carece de especificidad. Por lo tanto, resulta indispensablemantener una elevada sospecha clínica. Objetivo: Analizar las características clínicas, analíticas, microbiológicas e imagenológicas,el tratamiento, la evolución y los factores pronósticos de pacientes internados por espondilodiscitis en el Hospital Provincial delCentenario, desde enero de 2011 a marzo de 2015, excluyéndose los casos postquirúrquicos. Resultados: Se analizaron 19 pacientescon una edad media 48±11 años, 63% varones. Se identificaron como comorbilidades: diabetes (37%), obesidad (16%), etilismo(21%), insuficiencia renal crónica en hemodiálisis (16%), HIV (11%), adicción EV (11%). Los gérmenes más frecuentes fueron losestafilococos (52%). Al ingreso el 94% presentó dolor, 73% fiebre y 36% foco neurológico. La media de tiempo de evolución desíntomas hasta ingreso fue 62±80 días (rango 4-360 días). La velocidad de eritrosedimentación fue elevada en todos los pacientes,y sólo 37% presentaban leucocitosis. La vancomicina fue el antibiótico más utilizado. El 37% de los pacientes presentaba infeccióndiseminada. La mortalidad fue del 26%. Los pacientes que tuvieron un tiempo de evolución al ingreso mayor a 25 días presentaronpeor evolución (colecciones, foco neurológico o muerte) (p<0,05). Conclusiones: en esta serie, la asociación de la consulta tardíacon la mala evolución destaca la importancia de considerar las pautas de alarma en centros de atención primaria para posibilitar undiagnóstico más temprano.

Introduction: Spondylodiscitis represents a diagnostic challenge since the main clinical manifestation, low back pain, is very frequent andnonspecific, and often impedes a timely diagnosis. Clinical suspicion is essential. Objective: to analyze the clinical, analytical, microbiological,and radiological features, as well as outcome and prognostics factors, in patients with spondylodiscitis admitted to the Hospital Provincialdel Centenario (Rosario, Argentina), from January 2011 to March 2015. Postsurgical cases were excluded. Results: Nineteen patients wereincluded. Mean age was 48±11 years, 63% were males. We identified the following comorbid diseases: diabetes (37%), obesity (16%),alcoholism (21%), hemodialysis-dependent chronic kidney disease (16%), HIV (11%), intravenous drug abuse (11%). The most frequentcausative organism was Staphylococcus sp. (52%). Upon admission 94% of patients presented pain, 73% fever, and 36% neurologicalinvolvement. The average time from the onset of symptoms to diagnosis was 62±80 days (range 4-360). The erythrocyte sedimentation ratewas raised in all the patients, and only 37% had leukocytosis. Vancomycin was the most frequently prescribed antibiotic. Disseminatedinfection was present in 37% of patients. The mortality rate was 26%. Patients with a time lag to diagnosis higher than 25 days had worseoutcome (suppurative collections, neurological involvement, or death) compared to those with earlier diagnosis (p <0.05). Conclusions:The association of late consultation with poor outcome in this study emphasizes the importance of educating the general population toencourage attendance to medical centers. Physicians in primary care settings must be trained to identify pain pattern, and incorporateclinical perspectives capable of recognizing a defined syndrome at first contact, in other to achieve a better outcome.Key words: Spondylodiscitis, comorbid conditions, diagnostic delay, outcome.

Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management.

BACKGROUND: We report, for the first time, a case of pyogenic spondylodiscitis combined with vertebral osteomyelitis and bilateral psoas abscesses after acupuncture. CASE HISTORY: A 60-year-old man was diagnosed with rectal cancer, and radical rectectomy and permanent colostomy were carried out. However, 3 years after the surgery the patient complained of pain in the lower back, and the symptoms worsened after seven sessions of acupuncture. Technetium 99m-labelled methylene diphosphonate ((99m)Tc-MDP) bone scintigraphy (BS) revealed abnormal uptake of (99m)Tc-MDP in the L4 and L5 vertebrae. He was admitted to our hospital because of suspected bone metastases from rectal cancer. He was diagnosed with infection based on a history of acupuncture and the findings of enhanced MRI and CT. Percutaneous lumbar discectomy (PLD), external drainage and irrigation using antibiotics were carried out to treat the L4-5 disc. Pathological analyses and bacterial culture of the resected disc confirmed infection with group C streptococcus. Postoperative antibiotic treatment resulted in significant pain relief on the third day and gradual complete relief. Considerable improvement was seen on CT and MRI at follow-up. CONCLUSIONS: We consider it highly likely that this patient's infection was caused by acupuncture. In patients with malignancy, abnormal uptake of (99m)Tc-MDP in BS may signify bone metastasis but can also be observed in bone infections. PLD can be used to resect diseased discs to relieve pain quickly and to prevent herniation of lumbar discs. After PLD, external drainage can be employed for abscess drainage, decompression and perfusion of antibiotics. PLD may serve as an alternative to open surgery for pyogenic spondylodiscitis.

Endovascular treatment of an iliac artery rupture caused by invasive Salmonella spondylodiscitis.

The rate of non-typhoid Salmonella infections has increased remarkably in recent years. Endovascular system infection is one of the most serious forms of extraintestinal Salmonella infection. The abdominal aorta is frequently involved, while bone and joint involvement are rarely seen. We present a rare case of successful endovascular treatment of a left iliac artery rupture and pseudoaneurysm both occurring due to the direct invasion of lumbar spondylodiscitis caused by Salmonella typhimurium.

Postoperative spondylodiscitis. A review of 24 consecutive patients.

BACKGROUND: Postoperative discitis is a rare complication of spine surgery that creates a significant patient suffering and requires long-term treatment. The aim of this study was to compare the empirical antibiotic treatment with the treatment according antibiotics to susceptibility of isolates germs in curing this complication. MATERIAL AND METHOD: In the period January 2002 - December 2012, 4698 patients were operated for lumbar spine disorders:lumbar disc herniation, spinal canal stenosis. Of these patients, 47 (1%) were diagnosed with postoperative discitis. In December 2012 there were 24 cases of spondylodiscitis after lumbar disc herniation operated by inter-lamar approach and foraminotomy. The A group of 13 patients received antistaphylococcalempirical antibiotic treatment. The B group consisting of 11 patients received antibiotic therapy after germ isolation by open biopsy from discal intervertebral space (n=8)and from surgical wound secretion (n=3) and antibiotic susceptibility testing. RESULTS: After 4 to 6 months of antibiotic treatment associated with immobilization in Boston corset the symptoms gradually improved in parallel with normalization of biological constants, ESR, CRP. Five patients of Group A did not respond to the given antibiotic treatment and required further debridement and germ isolation. CONCLUSIONS: Spondylodiscitis is a complication of spine surgery that is treated with antibiotics given for a long time of 4-6 months. Germ isolation by needle biopsy or open biopsy allows proper antibiotic treatment and faster healing.

L5-S1 Achromobacter xylosoxidans infection secondary to oxygen-ozone therapy for the treatment of lumbosacral disc herniation: a case report and review of the literature.

STUDY DESIGN: Case report and literature review. OBJECTIVE: To present a unique case of Achromobacter xylosoxidans infection secondary to oxygen-ozone therapy for the treatment of L5-S1 disc herniation. SUMMARY OF BACKGROUND DATA: Oxygen-ozone therapy is a minimally invasive technique for the treatment of lumbar disc herniations, with unproven efficacy and few reported complications. Achromobacter xylosoxidans is an opportunistic pathogen that inhabits aquatic environments and is a rare cause of osteomyelitis. To the best of our knowledge, this is the first report of A. xylosoxidans spondylodiscitis in the lumbar spine and the third report of spinal infection after intradiscal oxygen-ozone chemonucleolysis in the English literature. METHODS: The medical records, operative reports, and radiographical imaging studies of a single patient were retrospectively reviewed. RESULTS: A 29-year-old female patient who previously underwent oxygen-ozone therapy for L5-S1 disc herniation presented to our institution with a 5-month history of intractable back and leg pain. The patient's laboratory studies were within normal limits and did not indicate signs of an active infection. Her physical examination revealed globally decreased muscle strength (4/5) and hyperesthesia in the lower extremities. Magnetic resonance imaging and computed tomography revealed severe disc degeneration and vertebral body endplate changes at L5-S1, in addition to paravertebral soft tissue swelling consistent with a previous infection. Given the severity of symptoms, the patient underwent anterior lumbar interbody fusion and posterior segmental instrumentation at L5-S1. Histopathological evaluation of the disc material confirmed the diagnosis of chronic osteomyelitis and septic discitis at L5-S1. Intraoperative cultures grew A. xylosoxidans and Propionibacterium acnes. The patient had prompt improvement in her level of pain and was discharged on a 6-week course of piperacillin-tazobactam without complication. CONCLUSION: This first report of A. xylosoxidans vertebral infection secondary to oxygen-ozone therapy illustrates the wide variety of environmental pathogens that can complicate the percutaneous treatment of degenerative vertebral disease.

Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis.

BACKGROUND CONTEXT: Currently, treatment for patients diagnosed with noncomplicated (ie, known infectious agent, no neurologic compromise, and preserved spinal stability) pyogenic spondylodiscitis (PS) is based on intravenous antibiotics and rigid brace immobilization. Since January 2010, we started offering our patients percutaneous posterior screw-rod instrumentation as an alternative approach to rigid bracing. Supposed benefits of posterior percutaneous instrumentation over rigid bracing are earlier free mobilization, increased comfort, and faster recovery. PURPOSE: To evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single-level PS and compare clinical and quality-of-life outcomes with standard thoracolumbosacral orthosis (TLSO) rigid bracing. STUDY DESIGN/SETTING: Retrospective observational cohort study. PATIENT SAMPLE: Twenty-seven patients consecutively diagnosed with single-level noncomplicated lower thoracic or lumbar PS from January 2010 to December 2011. OUTCOME MEASURES: Healing rate, healing time, and changes in segmental kyphosis Cobb angle were compared in the two treatment groups. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count at regular time points until complete healing were also obtained. Self-report measures included Visual Analog Scale (VAS), Short-Form 12 (SF-12), and EuroQol five-dimension (EQ-5D) questionnaires. METHODS: At enrollment, patients were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and bridging posterior percutaneous screw-rod instrumentation followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy accordingly to isolated infectious agents. Patients were seen in the clinic at 1, 3, 6, and 9 months, and ESR, CRP, complete blood count, VAS, SF-12, and EQ-5D questionnaires were obtained. Segmental kyphosis was measured at diagnosis and at 9 months follow-up. Two-way repeated-measures analysis of variance was used to assess group and time differences across time points. RESULTS: Fifteen patients chose conservative treatment, whereas 12 patients chose surgical treatment. Complete infection healing was achieved in all patients with no significant differences in healing time (p<.366). C-reactive protein and ESR levels decreased in both groups accordingly with positive response to therapy with no significant differences. Surgically treated patients had significantly lower VAS scores at 1 month (2.76±0.80 vs. 5.20±1.21, p<.001) and 3 months (2.31±0.54 vs. 2.85±0.54, p<.016) post-diagnosis over TLSO patients. Moreover, surgery patients also showed steeper and statistically significant improvements in SF-12 scores over TLSO patients at 1, 3, and 6 months post-diagnosis (p<.012); no significant differences were detected at the other time points. EuroQol five-dimension index was significantly higher in surgery patients at 1 month (0.764±0.043 vs. 0.458±0.197, p<.001) and 3 months (0.890±0.116 vs. 0.688±0.142, p<.001); no significant changes were observed in segmental pre- and posttreatment kyphosis between the two groups. No instrumentation-related complications were observed in any patient. CONCLUSIONS: Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity, and neurologic compromise in patients affected by noncomplicated lower thoracic (T9-T12) or lumbar PS. Posterior instrumentation did not offer any advantage in healing time over TLSO rigid bracing because infection clearance is strongly dependent on proper antibiotic therapy. Nevertheless, surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1, 3, and 6 months after treatment.