Antibiotic-Resistant Spondylodiscitis With Canal Invasion and Aggressive Evolution to Epidural Abscess: A Case Series of Spontaneous Occurrence in 16 Patients.

BACKGROUND: The study aimed to assess the effectiveness of antibiotic treatment for spondylodiscitis, its failure rates, and the need for surgical intervention. METHODS: This is a retrospective study of patients who presented with spontaneous deep spinal infections and spondylodiscitis between 2011 and 2013. Clinical, bacteriologic, and radiographic data during hospitalization were analyzed. RESULTS: A total of 16 patients presented with deep spinal infections during the study period; 15 of them presented with spontaneous pyogenic spondylodiscitis, and 1 presented with epidural abscess. Median age was 68 years (range, 50-80 years), and 6 (38%) were healthy young laborers. None of the patients were immunocompromised. On admission all patients presented with pain, there was fever in 3 patients (19%), and there was elevated blood C-reactive protein, white blood cell count and erythrocyte sedimentation rate, with a mean of 147 ± 83.1 mg/L, 11.65 ± 5.6 × 103/µL, 93.6 ± 35.1 mm/h, respectively. A total of 15 patients (94%) developed infections that were refractory to appropriate culture-specific intravenous antibiotic treatment (mean, 10.2 days); 8 patients (50%) deteriorated neurologically and required wide surgical decompression. Complications included widespread epidural free gas in 2 patients (12%), multiple bilateral psoas abscesses in 2 patients (12%), kyphotic segmental instability in 4 patients (25%), and inferior vena cava septic thrombi in 1 patient (6%). A total of 3 patients (19%) died within 6 months; 7 of 13 surviving patients still had residual neurologic deficits at the 6-month follow-up. CONCLUSIONS: Spondylodiscitis may be resistant to antibiotic treatment and may evolve into epidural abscess via extension of the infection and pus into the spinal canal, necessitating repetitive surgical treatment due to neurologic and clinical deterioration, and expansion of the persistent infection with a mass effect. Increased vigilance for this condition and its misleading initial presentations is warranted.

Cervical spine injuries in civilian victims of explosions: Should cervical collars be used?

BACKGROUND: Semirigid cervical collars (SRCCs) are routinely applied to victims of explosions as part of the prehospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified because of the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force, and burns. The purpose of the study was to determine the occurrence of cervical spine instability without irreversible neurologic deficit and other potentially life-threatening nonskeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion-related injuries were evaluated. METHODS: This is a retrospective cohort study of all explosion civilian victims admitted to Israeli hospitals during the years 1998 to 2010. Data collection was based on the Israeli national trauma registry and the hospital records and included demographic, clinical, and radiologic details of all patients with documented cervical spine injuries. RESULTS: The cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurologic deficit on admission. A total of 151 patients (6.6%) had potentially life-threatening penetrating nonskeletal neck injuries. CONCLUSION: Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurologic deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the prehospital management of victims of explosions. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Extra-peritoneal pressure packing without external pelvic fixation: A life-saving stand-alone surgical treatment.

PURPOSE: Traditional maneuvers aim to decrease retroperitoneal bleeding in hemodynamically unstable multi-trauma patients with unstable pelvic fractures, are reportedly successful in approximately only 50%. The life-saving effect of extra-peritoneal pressure packing (EPPP) is based on direct compression and control of both venous and arterial retroperitoneal bleeders. This study describes the safety and efficacy of emergent EPPP employment, as a stand-alone surgical treatment, that is, carried out without external pelvic fixation or emergent angiography. MATERIALS AND METHODS: A retrospective chart review of all hemodynamic unstable, multi-trauma patients with mechanically unstable pelvic fractures treated by the EPPP technique at our medical center between the years 2005 and 2011. Survival rates, clinical, and physiological outcomes were followed prospectively. RESULTS: Twenty-five of the 181 pelvic fracture patients had biomechanically unstable fractures that required surgical fixation. Fourteen of those 25 patients had deteriorating hemodynamic instability from massive pelvic bleeding which was resistant to resuscitation, and they underwent EPPP, as a stand-alone treatment. The procedure successfully achieved hemodynamic stability in all 14 patients and obviated the early mortality associated with massive pelvic bleeding. Three of these patients eventually succumbed to their multiple injuries. CONCLUSION: Implementation of EPPP improved all measured physiological outcome parameters and survival rates of hemodynamically unstable multi-trauma patients with unstable pelvic fractures in our trauma center. It provided the unique advantage of directly compressing the life-threatening retroperitoneal bleeders by applying direct pressure and causing a tamponade effect to stanch venous and arterial pelvic blood flow and obviate the early mortality associated with massive pelvic bleeding.

Differential impact of some risk factors on trochanteric and cervical hip fractures.

AIM: To investigate the potential distinct risk factors associated with trochanteric and cervical hip fractures. METHODS: Elderly patients aged 65 years and older (n = 1161) were admitted to the orthopedic department with hip fractures during the years 2006-2011. Demographic and clinical data, as well as routine blood tests, were retrieved from the patient electronic medical records. RESULTS: Approximately 58% of patients had trochanteric fractures and 42% had cervical fractures. Women were more likely to have trochanteric fractures than men (P = 0.002). Female sex, frailty, falls, diabetes and subnormal calcium, as well as subnormal hemoglobin levels, were significant risk factors for trochanteric fractures (OR 1.39, P = 0.0202, OR 1.36, P = 0.0166, OR 1.49, P = 0.0015, OR 1.33, P = 0.0343, OR 0.68, P = 0.0054, OR 0.70, P = 0.0036, respectively). Patients with Parkinson's disease were at a lower risk for trochanteric fractures (OR 0.6, P = 0.007). CONCLUSION: As there are some differences between risk factors for trochanteric and cervical hip fractures, there is a need for further studies in order to understand the etiology of fractures and to be able to carry out effective preventive efforts.

Intradural Extension of a Pyogenic Epidural Abscess: A Case Report.

CASE: Few cases of spinal epidural abscess involving an extradural abscess with an intradural extension have been reported. A unique complication with extension of pus from the epidural space through multiple perforations into the dura is described. Due to a proximal meningeal inflammatory reaction, which served as a proximal plug, no cerebrospinal fluid leak was encountered. CONCLUSION: Intradural extension of pus through multiple dural perforations is a rare complication of spinal epidural abscess and a treatment challenge. Early diagnosis enabling prompt surgical decompression, along with subsequent aggressive debridements and prolonged intravenous antibiotic treatment, can lead to a favorable outcome.