Zeitschrift für Wirbelsäule

The term spondylodiscitis is an entity that refers to an infection that affects the vertebral body and intervertebral disks. These are commonly caused by pyogenic infections, particularly by Staphylococcus aureus, which responsible for 60% of them. Fungal spinal infections remain a rare pathology, although an increased incidence has been reported due to a progressively more susceptible population (immuno-deficient patient). Fungal spondylodiscitis diagnosis currently relies on the presence of risk factors, microbiology, serological tests (Antigen detection and antibody testing) and imaging such as magnetic resonance with contrast, being the most useful study. The gold standard for establishing a diagnosis of fungal infection is to obtain tissue for histological confirmation or culture; endoscopy is currently the ideal method for sampling. Medical management is the initial approach for most fungal infections of the spine. This usually involves a multidisciplinary approach with anti-fungal therapy under the supervision of infectious disease specialists and bracing with early mobilization, but there are clear indications for surgical treatment where mechanical stabilization by posterior approach and drainage and placement of structured autologous grafts anterior approach, in the same act or a second surgical stage.

Spinal trauma is a very common disease, associated with spinal cord injury in 15-30% of cases. The treatment is affected both from non-modifiable variables (fracture’s morphology and biomechanics of the trauma, fracture site, neurological status, primary or secondary comorbidities) both from modifiable variables (first aid and hospital transportation, supportive therapy, surgical timing etc.). The role of the surgical timing after acute thoraco-lumbar spinal cord injury is still one of the most controversial points actually debated in literature. Surgical treatment is conditioned both by the general conditions of the patient both by the extent of the neurological deficit. In literature are described three possible windows for surgical timing: early surgery , performed in the first 48 hours; intermediate surgery, performed between 48 hours - 7 days; late surgery, performed after 7 days from the injury. In the light of the debatment actually under discussion in literature, the real question is: The implementations of the early surgery have effectively a role in the management of thoraco-lumbar spine injury and, if so, when is mandatory? Actually, based on the literature evidence, is extremely difficult to find a clear indication.

Purpose: It has been observed to biopsy directed by computerized axial tomography as axis for the diagnosis of vertebral destruction syndrome VDS. Evaluate the usefulness of CT-guided biopsy to determine the etiology of VDS.

Method: Cross-sectional, analytical study of diagnostic tests, which took place in individuals of any age who were admitted with a diagnosis of syndrome of vertebral destruction, attended for the first time. The sample size consisted of 91 patients; computerized axial tomography-guided biopsy was performed. We compared the results of the biopsy between two pathologists from different institution.

Results: Definitive histological findings were grouped into 7 categories: osteomyelitis (15.3%), tumors (38.46%), metastasis (37.36%), normal tissue (3.29%), inflammation (2.19%), and showing inadequate 0%, Pott’s disease (3.29%). According to the values of Z obtained by test of 2 proportions, with a n = 91, p = 0.05, the critical value of Z, two-tailed, was from 1.966 (±); they found no significant difference between the results reported by 2 different pathology services in vertebral biopsy guided by CT in Vertebral destruction syndrome; determining that this part of the process is a counselor on a 96.7% and final by 79%.

Conclusion: Percutaneous biopsy guided by tomography is an essential tool for the diagnosis of the syndrome of vertebral destruction approach and the ability to get diagnostics in the 96.7% indicates that it is a fundamental in the study of this syndrome.

Object: Neuroforaminal stenosis has been documented frequently in patients with degenerative lumbar scoliosis. Pedicle screw fixation with posterior lumbar interbody fusion is usually performed although a debate has been started on the need for unilateral or bilateral screws, or interbody fusion only. Trabecular Metal is a porous tantalum biomaterial with good osteoconductive properties, which may be suitable for unilateral interbody fusion aiming at enlargement of neuroforamen.

Methods: From July 2011 until January 2013, 20 consecutive patients with degenerative scoliosis-related foraminal stenosis were treated with unilateral stand-alone Trabecular Metal cages (Zimmer TM 500) without additional pedicle screw fixation. All patients presented with leg pain, with or without low back pain. Patients underwent CT and MRI to confirm neuroforaminal stenosis on the concave side of the degenerative scoliosis. All patients were followed-up and examined at 2 months after surgery (follow-up moment 1). Long-term follow-up (moment 2; mean 36 months) was available of 17 patients; 2 patients died of unrelated disease and 1 patient was lost to follow-up. On both follow-up moments, neutral and dynamic flexion-extension images were documented. Based on these images, the position of the cage was determined and the Cobb’s angle of the segmental scoliosis (angle between the cranial endplate of the upper vertebral body and the caudal endplate of the lower vertebral body) was measured. The clinical outcome was measured by the patients’ global perceived recovery according to the 7-point Likert scale; “complete recovery” and “almost complete recovery” were determined as good results.

Results: Most of the patients were operated on L3L4 and L4L5 (70%). The mean duration of surgery was 56 ± 15 minutes. Surgical complications occurred in 5 patients, namely cerebrospinal fluid leakage (4 patients) and nerve root injury (1 patient) with sensory deficit. Good outcome (Likert 1 or 2) was reported by 14 patients (70%) on the shortterm follow-up (moment 1), and by 9 patients (53%) on the long-term follow-up (moment 2). Whenever Likert 1-3 was dichotomized, 95% of the patients on the short-term and 83% of the patients on the long-term reported at least some benefit from the operation. The mean Cobb’s angle improved significantly from 13.4 ± 5.1º pre-operatively, to 6.1 ± 3.5º at moment 1, and 7.1 ± 3.6º at moment 2 (P < 0.001). On follow-up moment 1 and 2, radiographic examination showed subsidence in 3 and 9 patients, respectively. Pseudarthrosis around the stand-alone cage was only seen at follow-up moment 2 in 3 patients.

Conclusions: Instrumented fusion with bilateral pedicle screw fixation and interbody fusion may not always be necessary in patients with scoliosis-related foraminal stenosis. Unilateral stand-alone TM cages could be an alternative strategy in a subgroup of patients leading to correction of Cobb’s angle and improvement of symptoms in most cases. However, the long-term result is moderately satisfying and could be explained by the development of cage subsidence over time.

Human diseases sometimes represented across phylogenetic lines. Their recognition is at times compromised by differential (between human and veterinary medicine) use of diagnostic terms. A major impetus to such change is recognition of additional treatment options that would not be considered for the replaced diagnosis/category. Canine syndesmophytes are recognized as identifier for spondyloarthropathy. This study examines the breed-specificity of those changes.
The axial skeletons and peripheral joints (when available) of 1323 dogs, identified to breed, were examined for evidence of syndesmophytes and sacroiliac joint disease.
Syndesmophytes were found in 315 of 1323 axial skeletons examined, extremely common in Boxer and German Shephard; rare, in Beagle, Chihauahua, Dachshund, Maltese and Pug. First noted at 2 years of age, its prevalence increased geometrically over the next 13 years. All affected individuals weighed more than 2 kilograms and prevalence increased geometrically through 39.9 kilograms. Spondyloarthropathy was present in 17.3% of brachycephalic, contrasted with 35.0% of mesticephalic dogs [Chi square = 16.972, p < 0.0001].
Presence of syndesmophytes identified the underlying arthritis as spondyloarthropathy, not osteoarthritis. Recognition of the vertebral findings as characteristic of this inflammatory arthritis affords an opportunity for controlling the disease process and improving quality of life of the afflicted dog.

Introduction: In many cases, cervical arthroplasty can avoid adjacent segment degeneration, by preserving the mobility of the operated level. In this paper, we present and analyze the radiological results of a cohort of patients who underwent cervical disc arthroplasty, with the Baguera®C cervical disc prosthesis.

Material and methods: 99 patients and a total of 123 prostheses were included in a retrospective analysis of radiographic images, based on a registry type data collection, with a two-year follow-up (FU). The radiological data was independently assessed for the range of motion, disc angle, disc height at the operated level and at the adjacent level, and for heterotopic ossifications (HO).

Results: At the operated level, the range of motion (ROM) decreased from 10.2° preoperatively to 8.7° (nonsignificant) after two years in the one level total disc replacement (TDR) group, from 9.8° to 9.1° (non-significant) in the two levels TDR group. The motion of the upper FSU changed from 10.6° preoperatively to 13.5° after two years in the one level TDR group, from 11.6° to 10.9° in the two levels group. The disc height at the level of the operated FSU changed from 4 mm preoperatively to 7.1 mm after six weeks and 6.5 mm after two years for the one level TDR.

The disc height at the level above the highest operated FSU changed from 4.24 mm preoperatively to 4 mm after six weeks and 4.2 mm after two years for the one level TDR, from 4.5 mm to 5.4 mm (6W) and 5.3 mm (2Y) for the two levels TDR.

No heterotopic ossification was observed in 46% of the patients. HO was observed, respectively 20.1% grade I, 14.5% grade II, 13.7% grade III and 5.6% grade IV. HO restricting mobility (grades III and IV) were seen in 19.3%. The prostheses were mobile in 80.6% after two years.

Conclusion: Cervical arthroplasty using the Baguera®C prosthesis, demonstrated cervical mobility preservation in 80.6% of the patients, an HO rate of 54%, mostly grade I and II, no signs of subsidence and no signs of degeneration or kyphosis of the adjacent disc. This motion preserving surgical treatment, either used alone or in combination with segmental fusion, shows encouraging results in term of adjacent level disease protection and appears, therefore, as safe and effective.

Introduction: Herniated nucleus pulposus (HNP) can be best diagnosed clinically by history followed by physical examinations suggested by Mckenzie and Cyriax as well as radiologically by MRI. Sacralization, which is mostly congenital in origin in later life, gives rise to altered biomechanics. It is thought to be a leading cause of low back pain and HNP. There is controversy in the literature whether sacralization is associated with HNP or not. So the present study intended to find out whether sacralization is associated with HNP.

Methodology: A total no of 150 subjects with LBP with or without radiation to lower limb were taken in the study. MRI report from each subject was studied. Subjects were diagnosed as HNP when they fulfill the clinical criteria as well as the MRI suggesting HNP. Sacralization was diagnosed by using lumbo-sacral A-P radiograph and various types of sacralization were noted. Pain was measured by using VAS, A-P diameter of spinal canal is noted from MRI and disability status was measured using ODI and WHODAS-2 (12 items).

Results: Result of the study showed that 71.42% sacralized subjects have HNP and sacralized subjects are 5.92 times risk for HNP, the relative risk factor for HNP in type 2 a and 1b is highest i.e., 9.44 each , next to it is type – 4 i.e., 7.08. The prevalence of LSTV was found to be 44% which includes sacralization (42%) and lumbarisation (2%). It has been found that incidence of sacralization in HNP group also found to be more i.e., 64.28 %. Besides this, it has also been found that sacralized subjects suffer from more disability and there is a weak correlation between SLR and disability. However, sacralization doesn’t give rise to significant reduction of A-P diameter of spinal canal and more pain.

Conclusion: Sacralization is a risk factor for HNP and out of all sacralization type – 1B and 2A risk factor is highest. It has also been found that prevalence of sacralization in the low back pain population is more, sacralized individual suffered from more disability but not more pain or any changes in A-P diameter of spinal canal. SLR is weakly correlated with disability, A-P diameter of spinal canal and pain are not correlated.

Intradural Lumbar disc herniation (IDLDH) is a known rare subgroup, accounting for 0.3% of all disc herniation. The incidence of IDDHs in 50-60 year olds is 2.2%, while that of 40-50 is only 0.2%. Most cases of reported intradural disc herniation (IDDH) are in the lumbar spine (92%), especially at L4-5 level (55%) with some reports in the cervical (5%) and thoracic (3%) spine. Chronic disease process is postulated as a possible etiology of the condition in most of the cases. We present a case of IDLDH in a patient with HIV infection as a possible etiological factor.