Evolution and Progression of Spondylodiskitis: A Case Presentation.

Pyogenic infection of the spinal column is a relatively rare condition. Spondylodiskitis is characterized by infection of the intervertebral disk and the adjacent vertebrae. Diagnosis is often delayed because the symptoms are often nonspecific and also because of the high incidence of nonspecific low back pain in the general population. We report the case of a 42-year-old woman who developed low back pain secondary to spondylodiskitis. Her diagnosis was delayed because of a lack of supporting findings on initial magnetic resonance imaging. The case highlights the clinical scenario in which maintaining a high index of suspicion may lead to follow-up imaging and an accurate diagnosis. LEVEL OF EVIDENCE: V.

Espondilodiscitis lumbar: clínica y factores de riesgo en el diagnóstico precoz / Lumbar spondylodiscitis: Symptoms and risk factors in the early diagnosis

La espondilodiscitis lumbar (EDL) es una infección del cuerpo y el disco vertebral cuya clínica en fases iniciales se puede confundir fácilmente con otros cuadros de dolor lumbar de causa menor. Es necesario un elevado grado de sospecha clínica para evitar retrasar su diagnóstico, así como tener en cuenta la presencia de factores de riesgo que pudieran favorecer su desarrollo. La detección y el manejo precoces pueden evitar en gran parte la discapacidad que causa este cuadro. Se presentan dos casos clínicos de EDL asociados a estreptococos del grupo viridans y Enterobacter aerogenes, respectivamente, y se destacan, a propósito de éstos, los pasos clave necesarios para evitar un retraso diagnóstico (AU)

Lumbar spondylodiscitis is an infection of the low back vertebral body and the intervertebral disc space. In early stages it must be differenciated from other minor causes of low back pain. Its diagnosis demands a high level of clinical suspicion, as well as taking into account any risk factor which could favour its development. Early detection and treatment prevent future disability. Two cases, related to Viridians Streptococi and Enterobacter aerogenes, respectively, are described in order to review the key steps to avoid delayed diagnosis (AU)

A case of brucellar spondylodiscitis involving the cervical spine.

We have presented a patient of 71-year-age with brucellar spondylodiscitis, involving the cervical spine, especially the C3-C4 segment. The patient had painful percussion of the cervical spine and passive mobilization of the neck, decreased range of motion, and cervical paravertebral tenderness; but no abnormalities observed on neurological examination. Wright agglutination test for brucella was positive at 1/320. Cervical localization for brucellar spondylodiscitis is an unusual case and should be detected and treated as early as possible. In endemic regions, spinal involvement of brucellosis should be considered in cases with fever, neck and low back pain.

[Spondilodyscitis: five years of experience in a department of rehabilitation]. / Espondilodiscite: experiência de cinco anos de um serviço de reabilitação.

INTRODUCTION: Spondylodiscitis is a rare cause of spinal cord lesion. Although this kind of infection is known to have a low incidence; it reflects cases of major clinical interest, since early diagnosis and treatment are determinant reducing morbi-mortality and in improving functional prognosis. OBJECTIVES: To analyse demographic and clinical data; the diagnostic investigations, the rehabilitation programme and the outcome in hospitalised patients. METHODS: The authors performed a retrospective, descriptive study. They reviewed the medical records of all hospitalised patients in Centro Hospitalar de Coimbra (CHC), between January 2002 and April 2007, with the diagnosis of spondylodiscitis and for which the cooperation of Physical Medicine and Rehabilitation was required. RESULTS: Of the 28 hospitalised patients found, the mean age was 63.5 years (DP +/-15,6); 71% come from a rural environment. The average days of hospitalisation time was 76.6 days (DP +/- 34,2). The most frequent involved agents were Mycobacterium tuberculosis (21%), Staphylococcus aureus (14%) and Brucella mellitensis (14%). In 39% of the cases no agent was identified. The most common clinical manifestations were pain (92%) and neurological sings/symptoms (35%). Of the diagnostic investigations undertaken, MRI (85%), CT scan (67%), increased ESR (60%) and CRP (71%) were the most used. The lumbar spine was the region most frequently involved (67%). In 42% of the cases para-spinal soft-tissue and/or spinal canal were affected. The preferable treatment was the conservative one; there was a need for surgical approach only in two patients. The rising up of the patients constituted the main reason, why the cooperation of Physical Medicine and Rehabilitation was required. In 67% of de cases, the patients were advised to use orthosis and 64% started a rehabilitation programme. Of the 21 patients with a known outcome, 62% recovered completely. DISCUSSION: The most frequent causative agent was Mycobacterium tuberculosis, having a significant role in spondylodiscitis in our country, attending to its high prevalence. As there is almost always a late diagnosis, a long pharmacological treatment and a slow rehabilitation, there has to be a high rate of suspicion and an early rehabilitation in order to diminish mortality and its economic costs. Physical Medicine and Rehabilitation has a prevailing role in the improvement of the functional prognosis in this disease.

A randomized clinical trial of treatment for lumbar segmental rigidity.

STUDY DESIGN: A randomized single-blind clinical trial of facet injections plus exercise, versus exercise alone, in chronic disabling work-related lumbar spinal disorders (CDWRLSD), accompanied by pilot interrater reliability and facet syndrome prevalence studies. OBJECTIVES: To systematically investigate the use of facet injections as an adjunct to supervised lumbar stretching exercises in regaining lumbar range of motion (ROM) following prolonged deconditioning after work-related lumbar injuries. To assess interrater reliability of visual assessment of segmental rigidity (SR), and to evaluate the prevalence of facet syndrome in cases of lumbar SR. SUMMARY OF BACKGROUND DATA: Corticosteroid joint injections have often been used to reduce musculoskeletal inflammation to facilitate joint mobilization in the presence of degenerative arthritis. Lumbar segmental rigidity is a recently described entity usually associated with painful chronic spinal disorders and postoperative spine surgery. Previous work has shown that SR and lumbar ROM improves with a brief intervention consisting of facet injections followed by specific stretching exercises. No systematic study has investigated the potential benefits of a combination of facet injections and exercise over supervised exercises alone to treat lumbar SR. Similarly, no study has assessed the association between SR and the facet syndrome. METHODS: From a group of consecutive patients (n = 421) with CDWRLSD referred for tertiary rehabilitation between November 1999 and January 2001, 70 were noted to have SR on intake physical examination. The first part of this study assessed interrater reliability for detecting SR, and intrarater reliability for 3-segment true lumbar ROM measurements. Patients randomly assigned to participate in supervised stretching exercises with the addition of fluoroscopically guided bilateral facet injections at the involved levels (Group A, n = 36) also underwent facet syndrome prevalence assessment at the time of injection. They were compared to a randomly allocated comparison group (Group B, n = 34) undergoing exercises alone in a single-blind design. Physical therapists saw patients an average of twice per week, providing supervision of a progressive home stretching program. Inclinometric joint ROM was measured at the time of group allocation, and again 5 to 7 weeks later. Validated questionnaires of pain (intensity VAS) and disability (Million VAS) related to the CDWRLSD were provided before and after the interventions. RESULTS: Part 1 reliability and facet syndrome prevalence work revealed that interrater reliability for experienced examiners to detect rigid segments was excellent (Pearson's r = 0.97, P < 0.01). Intrarater 3-joint motion measurement reliability was also good for all sagittal/coronal ROM (Pearson's r = 0.95-0.99, P < 0.01). Only 5 of 29 subjects with SR met criteria for facet syndrome (17%), consistent with prior prevalence studies of unselected patients with low back pain. In Part 2, a large majority of patients in both groups improved from the initial to the post-treatment ROM measurements (the primary outcome criterion of the study). However, a higher proportion of Group A (injection) patients (87%-95%) showed ROM improvement, compared to Group B (exercise only) patients (64%-79%). Group A patients showed a significantly greater ROM improvement in all sagittal and coronal movements, both in absolute terms and percent of initial measurement. No significant differences in pain or disability self-report were found between groups, pre- or postintervention, but both groups showed significant improvement from pre- to postintervention in pain and disability assessments. CONCLUSIONS: The detection of SR and measurement of 3-segment true lumbar ROM by experienced examiners is highly reliable. Only 17% of CDWRLSD patients with lumbar SR met criteria for the facet syndrome, a rate approximately equal to that of unselected low back pain cohorts. This indicates that lumbar SR may be found whether or not pain of facet joint origin is present. In the randomized trial, facet injections significantly increased the percentage of patients with SR showing ROM improvement, as well as the degree of improvement in lumbar mobility after treatment. There is no evidence that facet injections increase the improvements in pain/disability report noted in both groups.

Espondilodiscitis cervical / Cervical spondylodiscitis

La discitis séptica es un proceso inflamatorio del disco intervertebral que suele extenderse a los cuerpos vertebrales afectando, en ocasiones, al espacio epidural y tejidos blandos paraespinales. Presentamos el caso de un paciente de 57 años que acudió a urgencias por presentar un cuadro de fiebre, odinofagia con dolor y limitación cervical. Se diagnosticó inicialmente de absceso retrofaríngeo, que fue tratado mediante antibióticos y, posteriormente, drenaje quirúrgico. Tras la mejoría clínica inicial, el paciente fue remitido a rehabilitación por persistir el dolor cervical irradiado a la extremidad superior izquierda. En la exploración destacaba la existencia de una movilidad cervical limitada, con dolor a la palpación de C6-C7, así como un balance muscular en bíceps y tríceps de 4-/5. Ante la sospecha de una patología no mecánica se solicitó una resonancia magnética que confirmó la existencia de una espondilodiscitis C5-C6 y C6-C7. Tras descartar un proceso activo mediante analítica y gammagrafía ósea con galio, se indicó tratamiento conservador mediante collar tipo Philadelphia durante 3 meses. La evolución fue satisfactoria y a los 4 meses sólo presentaba discretas molestias a la movilización cervical (AU)