Meningitis and spondylodiscitis due to Nocardia nova in an immunocompetent patient.

BACKGROUND: Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova. CASE PRESENTATION: We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years. CONCLUSIONS: Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR.

eCross-cultural adaptation of the spine oncology-specific SOSGOQ2.0 questionnaire to German language and the assessment of its validity and reliability in the clinical setting.

BACKGROUND: The recently developed Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) was proven a valid and reliable instrument measuring health-related quality of life (HRQOL) for patients with spinal malignancies. A German version was not available. OBJECTIVE: A cross-cultural adaptation of the SOSGOQ2.0 to the German language and its multicenter evaluation. METHODS: In a multistep process, a cross-cultural adaptation of the SOSGOQ2.0 was conducted. Subsequently, a multicenter, prospective observational cohort study was initiated to assess the reliability and validity of the German adaptation. To assess external construct validity of the cross-cultural adapted questionnaire, a comparison to the established questionnaire QLQ-C30 from the European Organisation for Research and Treatment of Cancer was conducted. Mean-difference plots were used to measure the agreement between the questionnaires in total score and by domain (deviation from mean up to 10% allowed). Further reliability and validity tests were carried out. Change to baseline was analysed 3-16 weeks later after different interventions occurred. Clinically relevant thresholds in comparison to the EORTC QLQ-C30 questionnaire were evaluated by ROC curve analysis. RESULTS: We could enroll 113 patients from four different university hospitals (58 females, 55 males). Mean age was 64.11 years (sd 11.9). 80 patients had an ECOG performance status of 2 or higher at baseline. External construct validity in comparison to the EORTC QLQ-C30 questionnaire in total score and by domain was confirmed (range of deviation 4.4 to 9.0%). Good responsiveness for the domains Physical Functioning (P < .001) and Pain (P < .001) could be shown. The group mean values also displayed a difference in the domains of Social Functioning (P = .331) and Mental Health (P = .130), but not significant. The minimum clinically relevant threshold values for the questionnaire ranged from 4.0 to 7.5 points. CONCLUSIONS: According to our results, the cross-cultural adapted questionnaire is a reliable and valid tool to measure HRQOL in German speaking patients with spinal malignancies. Especially the domains Physical Functioning and Pain showed overall good psychometric characteristics. In this way, a generic questionnaire, such as the EORTC QLQ-C30, can be usefully supplemented by spine-specific questions to increase the overall accuracy measuring HRQOL in patients with spinal malignancies.

[Minimally invasive posterior and anterior stabilization of the thoracolumbar spine after traumatic injuries]. / Minimal-invasive dorsale und ventrale Stabilisierung der thorakolumbalen Wirbelsäule bei traumatischen Verletzungen.

Injuries of the thoracolumbar junction are the most common fractures of the spine due to their anatomical position and load. Common classification systems differentiate between stable and unstable injuries and thus also between operative and conservative therapy. The majority of injuries can be treated conservatively; however, unstable injuries require surgical treatment for a variety of reasons. In the grey area between stable and unstable injuries, a clinical decision based on clinical experience is necessary in order to select the best treatment. A wide variety of parameters must be included and a change in strategy from conservative to operative may also be necessary. Posterior instrumentation is the most common procedure; purely anterior stabilization is rarely used. The length of the instrumentation/spondylodesis depends on bone quality, age of the patient, and fracture. The decision as to whether anterior operative treatment should be performed depends on fracture morphology, success of reduction, and the resulting stability. The open surgical procedure is increasingly being replaced by minimally invasive procedures in posterior and anterior techniques but can be an advantage in complex injuries (B and C injuries according to AO). Hybrid procedures are also possible. This also applies to the treatment of osteoporotic fractures, since a clear assignment between traumatic and osteoporotic cause is not always easy and possible. This article describes the principles, the possible indications, and limitations of minimally invasive posterior and anterior stabilization.

Rescue Nuss procedure for inferior vena cava compression syndrome following posterior scoliosis surgery in Marfan syndrome.

PURPOSE: Scoliosis surgery in Marfan syndrome is common, even in the presence of a funnel chest. However, to date, no case has been reported with acute intra-/postoperative decompensation caused by vena cava compression following posterior spinal derotation and fusion. METHODS: A 15-year-old male patient with Marfan syndrome, a funnel chest and severe scoliosis was treated with surgery for the spinal deformity. Intraoperatively, the patient developed a clinically relevant compression of the inferior vena cava with severe circular depression. Postoperatively, a cava compression syndrome with severe pleural effusion, ascites and enormous swelling of the lower limbs was developed. A conservative treatment of the symptoms, consisting of thoracic drainage and negative fluid balance, failed. Subsequently, the patient was transferred to pediatric intensive care unit for further treatment. Echocardiography and a CT scan demonstrated cava compression syndrome. A rescue Nuss procedure of the funnel chest deformity was performed since conservative treatment failed. The clinical course proceeded without complications and with a decrease in clinical symptoms of inferior inflow congestion. The patient was discharged after almost 3 weeks. CONCLUSION: The problem of congenital stenosis of the inferior vena cava in Marfan syndrome has not yet been investigated. In the case of simultaneously existing funnel chest and scoliosis in Marfan syndrome, an interdisciplinary discussion is required to decide whether a repair of the funnel chest should be performed first in order to prevent a clinically relevant compression syndrome. For the detection of a preoperatively relevant stenosis of the inferior vena cava, an MRI or thoracic/abdominal CT should be used preoperatively.

Traumatic lumbar disc herniation: A systemic case review and meta-analysis.

Introduction: Traumatic lumbar disc herniation (TLDH) without fracture in the in-situ motion segment is a rare occurrence compared with degenerative herniation. Research question: This study provides a systematic discussion of various aspects related to the diagnosis of TLDH. Material and methods: This review includes 12 cases of TLDH with MR-images since 2009 published in the PubMed and one adjunct illustration. The cases were categorized into two groups for a comprehensive analysis, TLDH with or without in-situ segment fracture. Additionally, we reported a case of a 43-year-old female patient with a recent stenosing TLDH at L5/S1, accompanied by a large sequestration (disc herniation stage-4, and Michigan State University Classification: MSU 3-AB) and an endplate compression fracture at L2 (AO A1). Results: Isolated traumatic lumbar disc herniation is possible, but it is required exclude cases with fractures in the in-situ motion segment. Discussion and conclusion: Trauma with related injury mechanisms is the highest priority for the diagnosis of TLDH. Low-grade disc degeneration without significant instability could be accepted for diagnosing TLDH. A TLDH on MR images might show a slightly lower T2-signal compared to the CSF and a homogeneous T1-signal like the spinal cord, as well as a similar STIR-signal of the sequestration and CSF. If necessary, a histological examination could be performed to evaluate the degenerative changes in the injured disc, especially to assist the evaluation due to legal reasons.

[Odontoid fracture after high impact trauma : Assess instability correctly]. / Densfraktur nach Hochrasanztrauma : Instabilität richtig einschätzen.

Odontoid process fractures are frequent injuries of the cervical spine and usually occur at an advanced age and often due to minor trauma. In younger patients they are mainly observed in the context of high impact trauma. Odontoid fractures are classified according to Anderson and D'Alonzo. In rare cases the fracture results in cervical myelopathy, which can be life-threatening.In this article, two cases of patients with odontoid fractures and traumatic myelopathy are presented. The first case concerns a type III fracture, the second a type II fracture. In both cases the instability present was incorrectly assessed on the basis of the anatomical position in the initial computed tomography (CT). In the further course both cases showed considerable instability, which led to fatal spinal cord injuries.The purpose of this case report is to draw attention to the possible presence of spinal cord injuries in supposedly trivial odontoid fractures when high speed trauma has occurred. In particular, spinal cord compression should be considered in patients requiring resuscitation without having an internal medical cause. If the patient with a bone injury on CT, e.g. cannot be adequately assessed clinically by intubation, the indications for magnetic resonance imaging must be generously considered. This is the only way to ensure early detection of a myelopathy and timely treatment.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis.

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003-2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013-2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

[Posterior vertebral column resection for correction of kyphotic deformity due to osteoporotic fractures of the thoracic spine]. / Posterior vertebral column resection (PVCR) zur Korrektur von Hyperkyphosen bei osteoporotischen Frakturen der Brustwirbelsäule.

OBJECTIVE: The posterior vertebral column resection (PVCR) comprises a one-step resection of the vertebral body by a costotransversectomy together with a 360° spondylodesis. After removing the vertebral body, straightening of the existing kyphotic malposition is possible. INDICATIONS: Pronounced thoracic kyphosis after osteoporotic sintering fractures in one or more vertebral bodies. CONTRAINDICATIONS: General contraindications for surgical procedures, ASA >3 (American Society of Anesthesiologists). SURGICAL TECHNIQUE: First, dorsal stabilization of the vertebral column on at least two levels cranial and caudal of the VCR. Next, in a one-step procedure the laminectomy with costotransversectomy and the resection of the vertebral body is done. The ventral defect gap is filled by a mesh cage to provide ventral support. By compression the malposition is reduced and the mesh cage is fixed into position. Finally the vertebrae joints are opened up using a chisel and bone or bone substitute is placed to complete the 360° spondylodesis. POSTOPERATIVE MANAGEMENT: Functional treatment without peak load exercises as well as appropriate osteoporosis treatment. RESULTS: In a retrospective study 10 patients treated with this surgical technique were investigated. The results show a very good correction of the kyphotic maldeformity while the complications remain moderate.

Cement augmentation versus extended dorsal instrumentation in the treatment of osteoporotic vertebral fractures: a biomechanical comparison.

AIMS: Loosening of pedicle screws is a major complication of posterior spinal stabilisation, especially in the osteoporotic spine. Our aim was to evaluate the effect of cement augmentation compared with extended dorsal instrumentation on the stability of posterior spinal fixation. MATERIALS AND METHODS: A total of 12 osteoporotic human cadaveric spines (T11-L3) were randomised by bone mineral density into two groups and instrumented with pedicle screws: group I (SHORT) separated T12 or L2 and group II (EXTENDED) specimen consisting of T11/12 to L2/3. Screws were augmented with cement unilaterally in each vertebra. Fatigue testing was performed using a cranial-caudal sinusoidal, cyclic (1.0 Hz) load with stepwise increasing peak force. RESULTS: Augmentation showed no significant increase in the mean cycles to failure and fatigue force (SHORT p = 0.067; EXTENDED p = 0.239). Extending the instrumentation resulted in a significantly increased number of cycles to failure and a significantly higher fatigue force compared with the SHORT instrumentation (EXTENDED non-augmented + 76%, p < 0.001; EXTENDED augmented + 87%, p < 0.001). CONCLUSION: The stabilising effect of cement augmentation of pedicle screws might not be as beneficial as expected from biomechanical pull-out tests. Lengthening the dorsal instrumentation results in a much higher increase of stability during fatigue testing in the osteoporotic spine compared with cement augmentation. Cite this article: Bone Joint J 2016;98-B:1099-1105.

Effect of drugs used for neuropathic pain management on tetrodotoxin-resistant Na(+) currents in rat sensory neurons.

BACKGROUND: Tetrodotoxin-resistant Na(+) channels play an important role in generation and conduction of nociceptive discharges in peripheral endings of small-diameter axons of the peripheral nervous system. Pathophysiologically, these channels may produce ectopic discharges in damaged nociceptive fibers, leading to neuropathic pain syndromes. Systemically applied Na(+) channel--blocking drugs can alleviate pain, the mechanism of which is rather unresolved. The authors investigated the effects of some commonly used drugs, i.e., lidocaine, mexiletine, carbamazepine, amitriptyline, memantine, and gabapentin, on tetrodotoxin-resistant Na+ channels in rat dorsal root ganglia. METHODS: Tetrodotoxin-resistant Na(+) currents were recorded in the whole-cell configuration of the patch-clamp method in enzymatically dissociated dorsal root ganglion neurons of adult rats. Half-maximal blocking concentrations were derived from concentration-inhibition curves at different holding potentials (-90, -70, and -60 mV). RESULTS: Lidocaine, mexiletine, and amitriptyline reversibly blocked tetrodotoxin-resistant Na(+) currents in a concentration- and use-dependent manner. Block by carbamazepine and memantine was not use-dependent at 2 Hz. Gabapentin had no effect at concentrations of up to 3 mm. Depolarizing the membrane potential from -90 mV to -60 mV reduced the available Na(+) current only by 23% but increased the sensitivity of the channels to the use-dependent blockers approximately fivefold. The availability curve of the current was shifted by 5.3 mV to the left in 300 microm lidocaine. CONCLUSIONS: Less negative membrane potential and repetitive firing have little effect on tetrodotoxin-resistant Na(+) current amplitude but increase their sensitivity to lidocaine, mexiletine, and amitriptyline so that concentrations after intravenous administration of these drugs can impair channel function. This may explain alleviation from pain by reducing firing frequency in ectopic sites without depressing central nervous or cardiac excitability.