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.

Modic changes and spondylodiscitis at multiple levels of the thoracolumbar spine in a patient with ankylosing spondylitis.

BACKGROUND AND OBJECTIVE: Modic changes (MC) on magnetic resonance imaging (MRI) were described in 1988 by Modic et al. in a study among patients with chronic low back pain. Type 1 changes were shown to represent an acute inflammatory process while type 2 changes were found in chronic lesions. Since mechanical back pain is very common, it is often difficult to differentiate precisely the origin of the back pain in patients with ankylosing spondylitis (AS) based only on clinical assessment, laboratory findings and/or plain imaging. CASE REPORT: We report a male patient with AS who presented with low back pain. MRI revealed MCs and spondylodiscitis, an uncommon manifestation of AS, at multiple levels of the thoracolumbar spine. CONCLUSION: We believe that MRI may provide key information in addition to the clinical, laboratory and plain radiological assessments and can help to guide physicians in decision-making when treating patients with AS.

Repeat upright positional magnetic resonance imaging for diagnosis of disorders underlying chronic noncancer lumbar pain.

OBJECTIVE: Cases of chronic noncancer pain are both the most frequent and the most difficult that the spine care professional is called upon to treat. We use this case to illustrate the potential effectiveness of repeat positional upright, weight-bearing magnetic resonance (MR) imaging to diagnose disorders and to detect changes in disorders. CLINICAL FEATURES: We present the case of a 35-year-old man referred to our neurosurgical clinic with complaints of chronic, noncancer lower back pain and right-greater-than-left sciatica. Traditional recumbent MR imaging had revealed degenerative disk disease at L5-S1 and a 2.2-mm (grade 1) degenerative spondylolisthesis. The patient had not improved after more than a year of conservative treatments and, moreover, had been prescribed opiates for pain management that were potentially masking changes in his condition. INTERVENTION AND OUTCOMES: After referral to our clinic, we ordered repeat lumbar MR imaging in an upright weight-bearing position (sitting) 14 months after the patient's recumbent MR imaging. The weight-bearing MR imaging revealed a 9.13-mm (grade 1) degenerative spondylolisthesis at L5-S1. The patient underwent arthrodesis. His leg pain and back were significantly and clinically improved. CONCLUSION: When patients with noncancer, lower back pain worsen, fail to improve, or require opiates to manage their pain, updated clinical diagnosis including repeat positional imaging may be an effective diagnostic strategy.

Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain.

Low back pain affects a minority of individuals over 65 years of age. Four years after the onset of sciatica, the number of individuals working is independent of their workers' compensation status. A complex interaction of metalloproteinases, cytokines, chondrocytes, and macrophages are necessary for the resorption of herniated intervertebral discs. Positional magnetic resonance imaging in the seated extended posture identifies foraminal narrowing that is not visualized with conventional magnetic resonance studies. Compression associated with cauda equina syndrome must be reversed within 48 hours to preserve neurologic function. The gene for transforming growth factor can be transferred to intervertebral discs, resulting in increased proteogylcan production in a rabbit animal model. An aerobic exercise program is as effective as more expensive exercise programs in the treatment of chronic low back pain. Complementary therapies, willow bark and magnets, have marginal benefit for low back pain. Surgical intervention results in improved function for spinal stenosis patients.

A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain.

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)