An unusual case of infective spondylodiscitis caused by Campylobacter fetus subsp. fetus: molecular characterization by whole-genome sequencing.

Spondylodiscitis is an infectious inflammation that affects the intervertebral disc and adjacent structures. Treating infective spondylodiscitis is often challenging due to the lack of specific symptoms. Here we present an unusual case of infective spondylodiscitis caused by Campylobacter fetus subsp. fetus.

Role of Biochemical Nutritional Parameters as Predictors of Postoperative Morbidity in Major Spine Surgeries.

STUDY DESIGN: Prospective cohort study. PURPOSE: To evaluate the association between nutritional parameters related to postoperative surgical site infections and duration of hospital stay and intensive care unit (ICU) stay in patients undergoing major spine surgery. OVERVIEW OF LITERATURE: Malnutrition is highly prevalent in surgical patients. Malnourished patients are considered to be at higher risk for postoperative morbidity and mortality due to impaired wound healing, delayed inflammation, impaired fibroblast proliferation, and collagen synthesis. Decreased lymphocyte count also impairs the ability of the immune system to eradicate or prevent infection, which predisposes these patients to infections. However, this association between malnutrition and postoperative morbidity is not consistent across studies, thus necessitating further investigation. METHODS: The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients' surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined. RESULTS: Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery. CONCLUSIONS: The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p<0.05) predictor of wound-related complications, rather than a single nutritional parameter evaluated at a point of time.

Does the Surgical Reduction of High Grade Spondylolisthesis Restore Spino-Pelvic Alignment? An Analysis of 35 Patients.

STUDY DESIGN: Retrospective case series. PURPOSE: This study aimed to analyze how the sagittal spinopelvic alignment is influenced by an attempted surgical reduction of the L5-S1 segment in patients with high-grade spondylolisthesis (HGS). OVERVIEW OF LITERATURE: Conventional treatment strategies stress the importance of achieving fusion across the lumbosacral junction in patients with HGS. The role of reduction in this subset of patients is controversial. METHODS: This is a retrospective case series of 35 patients with Meyerding grades III, IV, or V spondylolisthesis who underwent surgical treatment in our institution. Before and after surgery, we took standing lateral radiographs from L1 vertebra to pelvis, including the femoral heads, and measured the slip grade, pelvic incidence, sacral slope, pelvic tilt, lumbosacral angle, and lumbar lordosis. Patients were subdivided into "balanced" and "unbalanced" pelvis groups. To determine the effect and correlation of reduction on these spinopelvic parameters, we statistically compared the pre- and postoperative measurements. RESULTS: The average follow-up was 9 months (range, 3-169 months). Slip grade improved from an average 74.0%±13.2% to 30.0%±14.0% (p<0.001), and lumbosacral angle reduced from an average 32.0°±11.6° to 6.0°±0.6° (p<0.001). Although the pelvic tilt was reduced, this was not significant. There was a modest negative correlation between the reduction in slip grade and the increase in sacral slope (r=-0.3, p=0.06). At follow-up, five patients improved, from an unbalanced pelvis to a balanced pelvis. Fusion occurred in 33 patients (95%). CONCLUSIONS: Surgical reduction of HGS restores the lumbosacral alignment. However, a similar trend is not noted with the pelvic parameters.

'Munchausen syndrome': a forgotten diagnosis in the spine.

PURPOSE: To present the case of a patient with Munchausen's syndrome who underwent multiple surgeries in the spine before the diagnosis was made and, therefore, to highlight the importance of this obscure condition that can result in unnecessary surgical treatment. METHODS: A 44-year-old businesswoman presented with multiple episodes of low back pain and weakness in both lower limbs over past 11 years. Past history consisted of multiple hospitalizations, and three surgeries on her lumbar spine at different hospitals, with dramatic improvement in symptoms being reported each time after surgery. Clinical examination showed inconsistent and nonspecific neurological findings. Imaging studies like X-rays, magnetic resonance imaging, and all neurophysiological studies were within normal limits. RESULTS: Multi-disciplinary evaluation by a team of orthopedicians, neurologist and psychiatrist and rehabilitation specialists diagnosed it as 'Munchausen syndrome'. Only one report of this fictitious disease in spine was found in review of literature (Association AP, Diagnostic and statistical manual of mental disorders: DSM-IV-TR(®), 2003). CONCLUSIONS: A history of multiple surgical interventions at multiple hospitals, often followed by dramatic improvement and then relapse, should trigger a suspicion of Munchausen syndrome, particularly in the scenario of normal imaging studies. Diagnosing this rare condition in spine is key to avoid unnecessary surgery.

Lumbar plexopathy following instrumented posterior lumbar interbody fusion: a complication with use of Hohmann's retractor.

INTRODUCTION: A series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4-L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions. STUDY DESIGN: Retrospective observational study. OBJECTIVE: To find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre. MATERIAL AND METHODS: We analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication. RESULTS: We found injury to lumbar plexus that probably occurred intraoperatively with Hohmann's retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections. CONCLUSION: We conclude that surgical technique with improper use of Hohmann's retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann's retractor and also recommend use of modified Hohmann's retractor with shorter tips for spinal procedures to prevent such complication.

Decision making in the surgical treatment of cervical spine metastases.

STUDY DESIGN: Qualitative systematic review of the literature. OBJECTIVE: To determine whether surgical indications and techniques are influenced by the region of the cervical spine (occipitocervical, midcervical, and cervicothoracic junctions). SUMMARY OF BACKGROUND DATA: There are distinct differences in the anatomic as well as biomechanical characteristics at the occipitocervical junction (C0-C2), subaxial spine (C3-C6), and the cervicothoracic junction (C7-T2), and there is no information on whether these differences influence the decision to intervene surgically or influence the choice of surgical approach. METHODS: A systematic review was designed to answer 2 primary research questions that were determined through consensus among a panel of experts drawn from the Spine Oncology Study Group: 1. Is the decision to operate influenced by the anatomic region of the cervical spine? 2. Is the operative approach influenced by the anatomic region of the cervical spine? RESULTS: For C0-C2 disease, posterior approaches are favored in the majority of cases. In the subaxial cervical spine (C3-C6), anterior approaches were preferred in the majority of cases. A combined anterior/posterior approach was favored for multilevel disease, circumferential tumor involvement, and poor bone quality. At the cervicothoracic junction (C7-T1), anterior or posterior approach was used for decompression. Three column reconstruction from a single posterior approach was an increasingly commonly performed procedure. CONCLUSION: Although there are no level-1 studies to guide decision-making in this area, a literature review does provide some general guidelines for clinical management. Metastatic involvement of junctional regions of the cervical spine (Occ-C2 and C7-T1) and/or kyphosis and collapse involving any region of the cervical spine are key determinants influencing the decision to stabilize the spine.Posterior techniques are favored at the occipitocervical junction, anterior techniques are generally recommended to in the subaxial cervical spine, and either anterior or posterior approaches can be used at the cervicothoracic junction.

Bilateral C5 motor paralysis following anterior cervical surgery--a case report.

Numerous authors have reported C5 root palsies following posterior cervical surgery, and several mechanisms of injury have been proposed. Similar deficits after anterior cervical procedures are considered to occur less commonly. We report on a 48-year-old male who underwent multi-level anterior discectomy and fusion for cervical spondylotic myelopathy. Bilateral C5 nerve root deficits were noticed in the immediate postoperative period, and treated non-operatively. A postoperative magnetic resonance imaging (MRI) scan showed an increase in cervical lordosis accompanied by a posterior shifting of the spinal cord. Potential mechanisms of nerve root injury in this situation are discussed, and the literature on postoperative C5 root deficits is reviewed. The patient returned to his preoperative occupation as an operating room nurse 6 months following surgery, with complete neurologic recovery occurring over an 11-month period. C5 deficits following anterior cervical surgery occur more frequently than generally assumed. Improved lordosis and longitudinal lengthening of the cervical spinal column in multilevel anterior decompression and interbody fusion can paradoxically result in a traction injury to the spinal cord and C5 nerve roots.

Biomechanical changes at adjacent segments following anterior lumbar interbody fusion using tapered cages.

STUDY DESIGN: A biomechanical evaluation of anterior cages in a calf lumbar spine model. OBJECTIVES: To determine changes in spinal motion and intradiscal pressures at immediately adjacent lumbar motion segments following anterior insertion of tapered cages. SUMMARY OF BACKGROUND DATA: Stand-alone anterior lumbar interbody fusion (ALIF) is an effective approach in the treatment of discogenic low back pain. A tapered lumbar (LT) cage design attempts to restore physiologic lordosis and sagittal balance. We are not aware of any previous biomechanical evaluation of the effects of LT cages on adjacent motion segments. METHODS: Nine fresh calf spines (L2-L5) were procured for the study. Pure moments (up to 8.5 Nm) in flexion, extension, and lateral bending were applied to the L2 vertebra in five steps through a nonconstrained loading system. With each step of loading, three-dimensional rotation at three intervertebral disc levels was obtained through a three-camera motion analysis system, and intradiscal pressures within the nucleus pulposus of the two nonoperated discs were measured with miniature transducers. The spines were tested initially intact and following paired anterior LT cage insertion. RESULTS: Following ALIF, small to moderate increase in motion was found at both adjacent segments in flexion (superior: 12.5%, P < 0.05; inferior: 11.3%, P < 0.02) and lateral bending (superior: 7.8%, P < 0.02; inferior: 6.6%, P < 0.02). An increase in intradiscal pressure was noted at the superior adjacent segment under flexion (21%, P < 0.01) and lateral bending (16%, P < 0.03). Intradiscal pressure changes at the inferior adjacent level were not significant. CONCLUSIONS: Statistically significant changes in intradiscal pressures and motion were found at the adjacent levels following a single-level stand-alone ALIF procedure using paired LT cages.

Does anterior plating of the cervical spine predispose to adjacent segment changes?

STUDY DESIGN: In a human cadaveric model, the effects of plate supplementation on the mechanical behaviors of adjacent segments were investigated. OBJECTIVES: The objective was to determine the effects of anterior cervical fusion and plating on the adjacent segments. SUMMARY OF BACKGROUND DATA: Increases in intradiscal pressure and intervertebral motion at adjacent segments have been reported in the lumbar spine following an instrumented fusion. It is unclear if the same phenomenon presents in the cervical spine. METHODS: Seven human cadaveric cervical spines (C2-T1) were used, and fusion of the C5-C6 segment was chosen for the purpose of this study. Two miniature pressure transducers were implanted within each adjacent disc. Flexion, extension, lateral bending, and torsion loads up to 2.5 Nm were applied to the intact spine, and following each of the two procedures, anterior discectomy and grafted fusion, and anterior plating of the C5-C6 motion segment. RESULTS: At the surgical level, a significant increase in segmental stiffness was observed after plating in all directions. Following the grafted fusion, there were no statistically significant changes at the superior adjacent segment, and there was a 13.7% increase in axial rotation in the inferior adjacent segment. Once anterior plating was applied, slight increase (<12%) over the intact spines was noted in lateral bending in both adjacent segments. However, there was no significant difference between the grafted fusion and anterior plated fusion at either adjacent segment. At both adjacent disc levels, the differences in intradiscal pressures between grafted fusion and plated fusion were less than 30% in all directions, and none of these differences was statistically significant. CONCLUSIONS: Intradiscal pressures and intervertebral motion at the adjacent levels are not significantly affected by the instrumented anterior fusion. The clinically observed degenerative change at adjacent segments in the cervical spine is more likely to be attributed to natural progression of the spondylotic process as opposed to biomechanical effect of the instrumentation or fusion.

Idiopathic chondrolysis of the hip: medium- to long-term results.

BACKGROUND: Chondrolysis of the hip secondary to severe trauma, prolonged immobilization and slipped capital femoral epiphysis have been well documented. There have not been many reports, however, of idiopathic chondrolysis of the hip. We here present our experience with 21 hips with an average follow-up of 23.4 months. METHODS: Twenty patients (21 hips), with gross deformities of the hip who presented with fibrous ankylosis were treated over a 23-year period. Average age at presentation was 13 years. None of the patients responded to a trial of conservative treatment (non-steroidal anti-inflammatory medications, traction and physiotherapy.) RESULTS: Most of the preoperative deformities were corrected following arthrotomy, capsulectomy and skeletal traction. However, return of normal hip motion was not seen in any of the patients. Fibrous ankylosis in a functional position was seen to develop in two patients; one patient underwent hip arthrodesis, while another with bilateral involvement underwent excision arthroplasties. CONCLUSIONS: Circumferential capsulectomy with aggressive mobilization of the hip can correct the deformities associated with this condition, although long-term results are uniformly disappointing with regard to return of hip joint motion in cases of late presentation.

Intra-articular ganglion cyst of the knee.

Ganglion cysts of the knee are extremely uncommon. They usually cause non-specific symptoms and do not produce classical signs. Advances in imaging techniques as well as widespread use of arthroscopy have made detection of these cysts easier, and most can be treated arthroscopically. Ganglion cysts arising within the infrapatellar fat pad are even more uncommon. We report a case of a young lady with a giant intra-articular ganglion within the infrapatellar fat pad that was treated by open excision.