Imaging in the Diagnosis of Nonspecific Pyogenic Spondylodiskitis.

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach.

Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study.

BACKGROUND: Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction. METHODS: Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated. RESULTS: Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up. CONCLUSIONS: Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.

Sacroiliac innervation.

PURPOSE: To investigate the innervation pattern of the sacroiliac region, especially with regard to the sacroiliac joint (SIJ). Dorsal SIJ innervation was analyzed and described. Our main hypothesis was that nerves reach the SIJ dorsally, passing ligamental compartments, as this would explain dorsal SIJ pain. METHODS: To examine sacroiliac innervation, we followed the nerves in over 50 specimens over several years. Plastinated slices were evaluated, nerves in the region were stained histologically, and the data were summarized as 3D models. RESULTS: The Rami communicans and posterior branches of the spinal nerves and their branches that form a dorsal sacral plexus and communicating branches, together with corresponding vessels, were observed to form neurovascular bundles embedded by tiny fatty connectives in gaps and tunnels. Branches of L5-S1 pass the inner sacroiliac ligaments (the interosseous sacroiliac ligament and axial interosseous ligament). The outer sacroiliac ligaments (posterior sacroiliac ligaments, long posterior sacroiliac ligament, sacrotuberal ligament, thoracolumbar fascia) are passed by the S1-S4 branches. However, although the paths of these nerves are in the direction of the SIJ, they do not reach it. It is possible that impingement of the neurovascular bundles may result in pain. Moreover, the gaps and tunnels connect to the open dorsal SIJ. CONCLUSION: Our findings suggest that Bogduk's term "sacroiliac pain" correlates to "sacroiliac innervation", which consists of "inner-" and "outer sacroiliac ligament innervation", and to ventral "SIJ pain". The watery gaps and tunnels observed could play a significant role in innervation and thus in the origins of SIJ pain. LEVEL OF EVIDENCE: Individual cross-sectional studies with consistently applied reference standard and blinding.

Convolutional Neural Networks in Spinal Magnetic Resonance Imaging: A Systematic Review.

OBJECTIVE: Convolutional neural networks (CNNs) are being increasingly used in the medical field, especially for image recognition in high-resolution, large-volume data sets. The study represents the current state of research on the application of CNNs in image segmentation and pathology detection in spine magnetic resonance imaging. METHODS: For this systematic literature review, the authors performed a systematic initial search of the PubMed/Medline and Web of Science (Core collection) databases for eligible investigations. The authors limited the search to observational studies. Outcome parameters were analyzed according to the inclusion criteria and assigned to 3 groups: 1) segmentation of anatomical structures, 2) segmentation and evaluation of pathologic structures, and 3) specific implementation of CNNs. RESULTS: Twenty-four retrospectively designed articles met the inclusion criteria. Publication dates ranged from 2017 to 2021. In total, 14,065 patients with 113,110 analyzed images were included. Most authors trained their network with a training-to-testing ratio of 80/20, while all but 2 articles used 5- to 10-fold cross-validation. Nine articles compared their performance results with other neural networks and algorithms, and all 24 articles described outcomes as positive. CONCLUSIONS: State-of-the-art CNNs can detect and segment-specific anatomical landmarks and pathologies across a wide range, comparable to the skills of radiologists and experienced clinicians. With rapidly evolving network architectures and growing medical image databases, the future is likely to show growth in the development and refinement of these capable networks. However, the aid of automated segmentation and classification by neural networks cannot and should not be expected to replace clinical experts.

Degeneration of the lumbar spine and its relation to the expression of collagen and elastin in facet joint capsules and ligament flavum.

OBJECTIVE: The aim of the study was to assess the relationship between the expression of elastin, collagen type I, II,III and the degenera- tion of the facet joint capsule and the ligamentum flavum. METHODS: 10 patients (4 male, 6 female) (mean age 61 ± 14,9) undergoing surgery for degenerative lumbar spine syndrome and 5 cadav- ers (3 male, 2 female) (age of death 87 ± 8,6 years) were included in this study. One set of tissue samples was taken from each patient in the patient group intraoperatively and two sets of samples were taken from each cadaver in the cadaver group posthumosly from the ligamentum flavum (medial and lateral) and from the facet joint capsules (superior and inferior articular process) at the L4/5 segment. Western blot analysis was performed for collagen types I, II, III and for elastin. Disc degeneration was scored according to the Pfirmann Classification, facet joint arthrosis was scored according to the Fujiwara Classification and their relationship with protein expression was investigated. RESULTS: There was a strong expression of Collagen type I in the patient group (PG) compared to the body donor group (BDG) in the facet joint capsule (FJC) and in the lateral samples of the ligamentum flavum. Samples of the FJC showed lower expression of elastin in the PG compared with the BDG, but without statistical significance. An increased expression of collagen type I compared to elastin in the PG could be shown. In contrast, elastin predominated in the samples of the BDG group compared to collagen type I (collagen type I/ elastin PG: PAsup 2,78; PAinf 2,61; LFmed 2,23; 225 LFlat 1,83; BDG: PAsup 0,15; PAinf 0,2; LFmed 0,2; LFlat 0,27). Rank correlation coefficient according to Spearman showed low to moderate correlations for collagen type I, III and elastin for the degree of disc degeneration accord- ing to Pfirrmann and the degree of facet joint osteoarthritis according to Fujiwara, all of them without statistical significance. CONCLUSION: This study has shown us that in the context of degenerative changes of the lumbar spine, there is an increased expression of collagen type I and a dominance over elastin. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Does the anatomical region predict blood loss or neurological deficits in embolized renal cancer spine metastases? A single-center experience with 31 patients.

BACKGROUND: No comparison of a single hypervascular tumor entity in terms of major complications in different spinal regions has been performed. We aimed to evaluate post-embolic and post-operative outcomes in anatomic regions with renal cell carcinoma (RCC) metastases to the spine. METHODS: We retrospectively evaluated data from patients with confirmed, embolized, and surgically treated RCC spine metastases at a single-spine center between 2010 and 2020. Patients were divided into thoracic (TSM) and lumbar (LSM) spine metastasis groups. RESULTS: Seventeen patients had TSM and 14 had LSM. In all cases, embolization was performed preoperatively. The ΔHb value did not differ between the two groups pre- and postoperatively (p=0.3934). There was no significant difference in intraoperative blood loss between both groups either within 1 day or 2 days after embolization. Neurological deficits occurred in eight patients after embolization or surgery, with no significant difference between TSM (n=5) and LSM (n=3). CONCLUSIONS: Embolization is the standard procedure for the preoperative treatment of hypervascular spinal metastases, possible up to 48 h before surgery, without the risk of higher intraoperative blood loss. Regardless of intraoperative complications, major complications can occur up to several hours after embolization. We recommend surgery the day after embolization to reliably detect neurologic complications from this procedure.

In vivo detection of the lumbar intraforaminal ligaments by MRI.

PURPOSE: Intraforaminal ligaments (IFL) are of great interest to anatomists and clinicians to fully understand the detailed anatomy of the neuroforamina and to diagnose unclear radicular symptoms. Studies published until now have described radiological imaging of the IFLs using magnetic resonance imaging (MRI) on donor bodies. In the present study, we investigated the detectability of lumbar IFLs in vivo in adults using the high spatial resolution of the constructive interference in steady state (CISS) sequence. METHODS: A total of 14 patients were studied using a 1.5 T MRI scanner. The lumbar spine was imaged using the parasagittal CISS sequence, and the detectability of the IFLs was assessed for each lumbar level. All image datasets were analyzed by a radiologist, an orthopedic surgeon, and an anatomist. Interrater reliability was expressed as Fleiss' Kappa. Using a single data set, a three-dimensional (3D) model was created to map the location of the IFLs within the intervertebral foramen (IF) and the immediate surrounding vessels. RESULTS: Overall, the radiologist was able to detect IFLs in 60% of all imaged IFs, the orthopedic surgeon in 62%, and the anatomist in 66%. Fleiss' Kappa for the various segments varies from 0.71 for L4/5 up to 0.90 for L3/4. CONCLUSION: Lumbar IFLs were successfully detected in vivo in every patient. The detection frequency varied from 42-86% per IF. We demonstrated reproducible imaging of the IFLs on MRI, with good interrater reliability. The present study was a launching point for further clinical studies investigating the potential impact of altered IFLs on radicular pain.

Analysis of the paraspinal muscle morphology of the lumbar spine using a convolutional neural network (CNN).

PURPOSE: This single-center study aimed to develop a convolutional neural network to segment multiple consecutive axial magnetic resonance imaging (MRI) slices of the lumbar spinal muscles of patients with lower back pain and automatically classify fatty muscle degeneration. METHODS: We developed a fully connected deep convolutional neural network (CNN) with a pre-trained U-Net model trained on a dataset of 3,650 axial T2-weighted MRI images from 100 patients with lower back pain. We included all qualities of MRI; the exclusion criteria were fractures, tumors, infection, or spine implants. The training was performed using k-fold cross-validation (k = 10), and performance was evaluated using the dice similarity coefficient (DSC) and cross-sectional area error (CSA error). For clinical correlation, we used a simplified Goutallier classification (SGC) system with three classes. RESULTS: The mean DSC was high for overall muscle (0.91) and muscle tissue segmentation (0.83) but showed deficiencies in fatty tissue segmentation (0.51). The CSA error was small for the overall muscle area of 8.42%, and fatty tissue segmentation showed a high mean CSA error of 40.74%. The SGC classification was correctly predicted in 75% of the patients. CONCLUSION: Our fully connected CNN segmented overall muscle and muscle tissue with high precision and recall, as well as good DSC values. The mean predicted SGC values of all available patient axial slices showed promising results. With an overall Error of 25%, further development is needed for clinical implementation. Larger datasets and training of other model architectures are required to segment fatty tissue more accurately.

Total spine magnetic resonance imaging for detection of multifocal infection in pyogenic spondylodiscitis: a retrospective observational study.

BACKGROUND: Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for magnetic resonance imaging of the entire spine to exclude multisegmental infections and to determine the required surgical interventions. The aims of this study were to assess the incidence of multilevel non-contiguous pyogenic SpD and compare comorbidities, pain symptoms, and subsequent surgical strategies between unifocal (uSpD) and multifocal (mSpD) SpD. METHODS: We retrospectively evaluated the data of patients with confirmed, surgically treated, pyogenic SpD who had received a total spine MRI in a single spine center between 2016 and 2018. MRI findings were classified according to Pola-classification and demographics, duration of clinical symptoms (pain and neurology) and Charlson Comorbidity-Index (CCI) results were compared between uSpD und mSpD groups. Surgical therapy was evaluated in patients with mSpD. RESULTS: uSpD was detected by MRI in 69 of 79 patients (87%). Of these, mSpD was detected in 10 patients (13%) with 21 infected segments (cervical and/ or thoracic and/ or lumbar region). Age and CCI were similar between uSpD and mSpD and 24 of all SpD regions were clinically unapparent. All patients with uSpD were treated operatively. In seven patients with mSpD, all infected levels of the spine were treated surgically in a one-stage procedure; one patient had a two-stage procedure and one patient had surgery at the lumbar spine, and an additional infected segment of the upper thoracic spine was treated conservatively. One patient died before a planned two-stage procedure was performed. CONCLUSIONS: Due to mSpD being found in approximately 13% of SpD cases, and considering the risk of overlooking an mSpD case, MRI imaging of the total spine is recommended. The detection of multiple infection levels can have an impact on the therapeutic strategy chosen.

Magnetic resonance tomography for the early detection of occult fractures of the spinal column in patients with ankylosing spondylitis.

PURPOSE: The purpose of this study was to determine the extent to which magnetic resonance imaging (MRI) performed in patients with ankylosing spondylitis (AS) after low- and no-energy trauma leads to an improved diagnosis and, as a result, to a change in the therapeutic strategy. METHODS: All patients with AS, who underwent surgery after minor traumas (low-energy traumas, LETs) and patients without trauma history (NET: no-energy trauma), were retrospectively analysed. The diagnostic and planned surgical procedure was examined initially and again after total spine MRI in patients with persistent and/or new complaints. RESULTS: One hundred and thirty-six patients with AS after trauma were surgically treated. A total of 92 patients with LETs and 12 patients with NETs were included. After initial diagnostics (CT and X-ray) were performed in 15.4% of the patients with LET or NET (n = 16), we found occult fractures on MRI scans. In ten of these patients (6 LET, 4 NET) in which a previous decision was made to follow conservative therapy, no fracture indication was found on CT or X-ray. Two fracture heights were observed in six patients who experienced LET. However, on X-ray and CT, the fractures were only visible at one height. All fractures were treated surgically with stabilization and decompression if indicated. CONCLUSION: Considering the high percentage of our patient population with occult fractures, we recommend supplementing the basic diagnostic procedures with an MRI of the entire spinal column in patients with painful spinal column findings after minor trauma and for those with persistent pain without trauma. These slides can be retrieved under Electronic Supplementary Material.

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis. METHODS: A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time. RESULTS: One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups. CONCLUSIONS: Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Balloon kyphoplasty and additional anterior odontoid screw fixation for treatment of unstable osteolytic lesions of the vertebral body C2: a case series.

BACKGROUND: Unstable osteolytic lesions of the occipitocervical junction are rare and may occur in hematological malignancy or vertebral hemangioma, among others. Different case reports have been published about vertebroplasty for treatment of spinal metastases of the upper cervical spine. Only few cases concern balloon kyphoplasty of C2. We present a consecutive case series including four patients with an osteolytic lesion of the dens axis and describe a technical note for balloon kyphoplasty of C2 and an additional anterior odontoid screw fixation. METHODS: Four consecutive patients with an osteolytic lesion of the vertebral body of C2 were treated by anterior balloon kyphoplasty and additional anterior odontoid screw fixation of the dens axis. The radiological imaging showed a lytic process of the vertebral body C2 with no vertebral collapse but involvement of more than 50% of the vertebral body in all patients. RESULTS: Two cases of potentially unstable osteolytic lesions of C2 by myeloma, one case with metastatic osteolytic lesion of C2 by adenocarcinoma of the colon and one patient with vertebral hemangioma located in C2 were presented to our clinic. In all cases, surgical treatment with an anterior balloon kyphoplasty of C2 and an additional anterior, bicortical odontoid screw placement was performed. Control x-rays showed sufficient osteosynthesis and cement placement in the vertebral body C2. DISCUSSION: Anterior balloon kyphoplasty and anterior odontoid screw placement is a safe treatment option for large osteolytic lesions of C2. The additional odontoid screw placement has the advantage of providing more stabilization and may prevent late complications, like odontoid fractures. For patients with potentially unstable or large osteolytic lesions of the dens without spinal cord compression or neurological symptoms we recommend the placement of an anterior odontoid screw when performing a balloon kyphoplasty. LEVEL OF EVIDENCE: - IV: retrospective or historical series.

Analysis of a Unilateral Bridging Cage for Lumbar Interbody Fusion: 2-Year Clinical Results and Fusion Rate with a Focus on Subsidence.

PURPOSE: The aim of this study was to evaluate the biomechanical stability and the clinical and radiographic outcomes in patients undergoing transforaminal lumbar interbody fusion (TLIF) using an oblique bridging cage with a particular focus on subsidence. METHODS: Finite element models were developed to compare the biomechanics of the oblique cage with conventional posterior lumbar interbody fusion and banana-shaped cages with TLIF. Additionally, a retrospective review of a prospective collected database was performed to investigate the clinical and radiologic results with a focus on the subsidence rate using an oblique polyetheretherketone (PEEK) cage with a bicortical load-bearing design. We included 87 patients with degenerative pathologic conditions of the lumbar spine who underwent TLIF. The clinical outcome was assessed using the Oswestry Low Back Pain Disability Questionnaire and the visual analogue scale. Fusion and subsidence rates were assessed radiographically. RESULTS: The finite element models showed no differences in stability on compression or extension/flexion. The oblique cage differed in terms of the location of the maximal stresses. A total of 105 levels were fused. The level at which fusion was most frequently performed was L4-L5 (59%). The fusion rate was 93.2% after 24 months. Subsidence was found at 4 levels after the last follow-up visit (3.9%). Overall clinical outcome improvement was achieved after 24 months. CONCLUSION: Regarding fusion, the use of an oblique PEEK cage with a cortical load-bearing design provided highly satisfactory clinical and radiologic results after 2 years. A review of the literature suggests a lower rate of cage subsidence after lumbar interbody fusion using bridging cages rather than single cages.

Results of lumbar spondylodeses using different bone grafting materials after transforaminal lumbar interbody fusion (TLIF).

PURPOSE: Can a mixture of hydroxyapatite (HA) and autologous bone from decompression sites produce similar results when used for transforaminal lumbar interbody fusion (TLIF)? In the current literature, autologous iliac crest bone grafts (ICBGs) have been reported the gold standard for this procedure. Indeed, to date, no clinical data have confirmed that a mixture of equal volumes of HA and local autologous bone produce similar results in term of fusion as the same volume of autologous ICBG alone. METHODS: Study design/setting This study was approved by the local ethics committee and completed in a prospective, randomized, single-blinded manner. The results of lumbar fusion using TLIF and different bone grafting materials were compared. Patient sample The patient sample included patients with spinal lumbar degenerative disease. Outcome measures The clinical outcome was determined using the Oswestry Low Back Pain Disability Questionnaire (ODI) and Visual Analog Scale (VAS). The radiological outcomes and fusion rates were determined with radiographs evaluated using the McAfee criteria and computed tomography (CT) data evaluated by the Williams criteria. Three blinded investigators (one radiologist and two orthopedic surgeons) assessed the data. The secondary variables included donor site morbidity. Methods The patients were admitted to our department for orthopedic surgery with degenerative lumbar pathologies (L2-S1) that required stabilization in one or two segments using a TLIF procedure. The patients were 18-80 years old. Only those patients who had degenerative lumbar pathologies and agreed to be educated about the study were included. The patients were divided into the following two randomized groups: group A: TLIF procedure using autologous ICBGs alone; and group B: TLIF procedure using local bone from decompression site mixed with hydroxyapatite. Each group received equal graft volumes. The mixture in group B consisted of equal volumes of local autograft (5 cc) and synthetic bone (5 cc). A graft volume of 10 cc was used at each fusion level. The patients were followed up at three appointments at 1.5, 6 and 12 months postoperatively. Every patient received detailed education about the course of the study. RESULTS: Forty-eight patients finished the study (2 patients dropped out). The radiographic fusion rate did not significantly differ between the two groups. Based on the CT criteria, 83.3% of the patients showed fusion in both groups after 12 months. Furthermore, 95.3% of the patients in group A and 91.7% of the patients in group B showed bony spondylodeses according to the radiographic criteria at the 12-month follow-up. The donor site morbidity consisted of one patient with a wound infection and one with a hematoma in group A and two patients with persistent pain in group B. Group A also included one patient with cage subsidence of 4 mm and archived fusion after 12 months. In group B, one patient had a pedicle screw breakage and achieved fusion after 6 months. The clinical outcomes were similar between the two groups. In both groups, the VAS and ODI data improved during the follow-up period (p < 0.05). No patients required additional surgeries. CONCLUSIONS: Both groups demonstrated equivalent clinical outcomes. HA and autologous bone from decompression sites can achieve similar fusion rates to those achieved with identical volumes of the gold standard autologous graft. The graft mixture can be used for one- or two-level lumbar spondylodeses to avoid donor site morbidity.

Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report.

INTRODUCTION: Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. MATERIALS AND METHODS: Case report and review of the literature. RESULTS: A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. CONCLUSION: Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner.

Results after the surgical treatment of anterior cervical hyperostosis causing dysphagia.

PURPOSE: The objective of this study was to investigate the outcome of a case series of patients with dysphagia resulting from diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine who were treated surgically with resection and fusion. METHODS: A retrospective study was performed on all patients who presented (2005-2013) with complaints of dysphagia or respiratory compromise and who underwent anterior cervical osteophyte resection with fusion (polyether ether ketone cage and/or plate system) using an anterior approach. All patients were diagnosed with DISH and underwent preoperative esophageal and laryngoscopic examinations and a fluoroscopic swallowing study. Initial non-operative strategies were performed, including diet, change in head position during swallowing, non-steroidal anti-inflammatory drugs and pantoprazole. RESULTS: A total of six patients with DISH were included. The mean age was 67 ± 5 years. All patients were male and had symptoms of dysphagia and neck pain, one had simultaneous airway complaints, and another had regurgitation with a sleep disorder. All patients had significant improvements in dysphagia, respiratory complaints and regurgitation 6 weeks after surgery. The postoperative radiographs showed complete removal of the compressive structures. There were no postoperative complications. At the final follow-up (23 ± 8 months), the radiographic examinations showed no pathological regrowth, and the patients reported no recurrence of dysphagia. CONCLUSION: Diffuse idiopathic skeletal hyperostosis may lead to osteophyte-associated pathologies of the aerodigestive tract. Preoperative investigations with esophageal and laryngoscopic examinations combined with fluoroscopic swallowing tests are essential. Surgical decompression through osteophytectomy and fusion is an effective management strategy in selected patients and should be considered when non-operative strategies have failed.

Impact of a multidisciplinary pain program for the management of chronic low back pain in patients undergoing spine surgery and primary total hip replacement: a retrospective cohort study.

BACKGROUND: Low back pain is a very common disorder. In this field chronic low back pain represents a special challenge. The management of chronic low back pain consists of a range of different intervention strategies. Usually operative intervention should be avoided if possible. However, there are constellations were surgical therapy in patients with chronic low back pain seems to be meaningful. The aim of this study was to investigate the clinical outcomes after spine surgery and hip replacement in patients with chronic low back pain after undergoing a structured rehabilitation program including cognitive - behavioral therapy. METHODS: From January 1, 2007 to January 1, 2010 patients were indicated for total hip replacement (THA) or spine surgery after receiving inpatient multidisciplinary pain programs including cognitive - behavioral therapy at our orthopedic institute with a specialized unit for the rehabilitation of chronic pain patients. Indications for surgery were based on the synopsis of clinical and imaging findings and on positive effects after local injections during the multidisciplinary pain program. The tools for assessment included follow-up at 6 and 12 months and analyses of pain, chronicity, physical functioning and depression. RESULTS: Of the 256 patients admitted for multidisciplinary pain program, fifteen were indicated to benefit from a surgical intervention during multidisciplinary pain program. Ten patients received spine surgery. THA was indicated in five patients. In all cases, the peri- and postoperative clinical courses were uneventful. Only two of the patients subjected to spine surgery and three patients who had THA were improved after 12 months. One patient reported a worsened condition. All patients presented with good functional outcomes and normal radiological findings. CONCLUSIONS: The indication for surgical intervention in patients with chronic low back pain and degenerative diseases must be critically assessed. THA in this cohort should focus on functional aspects, such as the improvement of range of motion, rather than the reduction of pain. Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive - behavioral therapy cannot be recommended due to its questionable success.

Is the radiographic subsidence of stand-alone cages associated with adverse clinical outcomes after cervical spine fusion? An observational cohort study with 2-year follow-up outcome scoring.

BACKGROUND: The stand-alone treatment of degenerative cervical spine pathologies is a proven method in clinical practice. However, its impact on subsidence, the resulting changes to the profile of the cervical spine and the possible influence of clinical results compared to treatment with additive plate osteosynthesis remain under discussion until present. METHODS: This study was designed as a retrospective observational cohort study to test the hypothesis that radiographic subsidence of cervical cages is not associated with adverse clinical outcomes. 33 cervical segments were treated surgically by ACDF with stand-alone cage in 17 patients (11 female, 6 male), mean age 56 years (33-82 years), and re-examined after eight and twenty-six months (mean) by means of radiology and score assessment (Medical Outcomes Study Short Form (MOS-SF 36), Oswestry Neck Disability Index (ONDI), painDETECT questionnaire and the visual analogue scale (VAS)). RESULTS: Subsidence was observed in 50.5% of segments (18/33) and 70.6% of patients (12/17). 36.3% of cases of subsidence (12/33) were observed after eight months during mean time of follow-up 1. After 26 months during mean time of follow-up 2, full radiographic fusion was seen in 100%. MOS-SF 36, ONDI and VAS did not show any significant difference between cases with and without subsidence in the two-sample t-test. Only in one type of scoring (painDETECT questionnaire) did a statistically significant difference in t-Test emerge between the two groups (p = 0.03; α = 0.05). However, preoperative painDETECT score differ significantly between patients with subsidence (13.3 falling to 12.6) and patients without subsidence (7.8 dropped to 6.3). CONCLUSIONS: The radiological findings indicated 100% healing after stand-alone treatment with ACDF. Subsidence occurred in 50% of the segments treated. No impact on the clinical results was detected in the medium-term study period.

Total spondylectomy for solitary bone plasmacytoma of the lumbar spine in a young woman: a case report and review of literature.

INTRODUCTION: Solitary bone plasmacytoma (SP) is a rare diagnosis for which the primary treatment is local radiotherapy. There is no established consensus suggesting a total spondylectomy in spinal SP. MATERIALS AND METHODS: We report the case of a 43-year-old woman with solitary plasmacytoma of the lumbar spine treated with complete vertebral resection. Radiographs, CT scan and MRI showed a single osteolytic lesion of the third lumbar vertebra. Further diagnostics following recommended algorithm for tumour screening were negative. Two times, biopsy showed no histological pathologies. Due to the instability of the spine with suspicious unknown lesion, we decided to perform a dorsal lumbar approach and instrumentation with complete resection of the posterior parts to prepare for a complete resection if mandatory. Resamples were taken and the bone surfaces sealed. Consecutive findings were positive for plasma cell infiltration of the respective vertebra, however not on the first pass, but after diagnostic pathological reference. Surgery was completed by total spondylectomy. Reference histological findings with restaging and cytogenetic risk analysis confirmed a non-high-risk solitary bone plasmacytoma, and the patient was scheduled for localized radiotherapy with 40 Gy. RESULTS: Follow-up examinations (53 months) showed no local recurrence or disease progression. DISCUSSION: There is no consensus in the literature regarding appropriate surgical approach and perioperative strategies in the treatment of solitary plasmacytoma. The finding of a solitary plasmacytoma of the spine was the determining factor for our decision to perform radical surgery with subsequent radiotherapy. The rationale for the chosen approach was to minimize the risk of local recurrence and to avoid conversion into multiple myeloma. The follow-up with 53 months is limited. However, discussion remains, if radical surgery in addition to local radiotherapy could be an alternative therapeutic approach depending on paraclinical parameters, age and cytogenetic risk analysis.

Multifocal infections of the musculoskeletal system: description of a safe one-step procedure for eradication of associated spinal infections.

BACKGROUND: The aim of this study was to evaluate the clinical outcome after radical surgical treatment of multifocal infections involving the spine. METHODS: The study demonstrates a retrospective chart review of seven patients who had more than three different abscesses in the musculoskeletal system and at least one of them in the area of the spinal column. All patients had a sepsis. RESULTS: Beside different musculoskeletal abscesses four patients had a spondylodiscitis in the cervical spine segments C4/5 or C5/6. Six patients had inflammatory processes in the lumbar spine with epidural abscesses, diffuse thoracolumbar paravertebral abscesses and a spondylodiscitis in different segments. In all cases we performed a radical surgical treatment of all related inflammatory focuses. Prompt radical surgical treatment of the spine included decompression, debridement and in the cases of spondylodiscitis a fusion of the involved segments. For more than one focus at the spine, a surgical one-step procedure was performed. An antibiotic therapy was administered for six to eight weeks. In follow up examinations no signs of ongoing inflammatory processes were seen in imaging studies or laboratory tests. CONCLUSIONS: In the event of multiple abscesses of the musculoskeletal system involving the spine an early correct diagnosis and radical surgical treatment is recommended. We strongly favor a surgical single-stage procedure for treatment of multiple infections of the spine. In addition to a radical debridement and a sufficient decompression, the segmental fusion of affected areas in spondylodiscitis is essential. At the same time a surgical therapy of all other infected sites should be performed.