Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Aims

CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

Spondylodiscitis is an uncommon condition with an incidence of 1:100,000 to 1:250,000 in developed countries. Diagnosis and treatment can be delayed resulting in poor outcomes. A high index of suspicion is necessary considering the associated mortality, reported at 2–17%. Establishing a diagnosis can be challenging as features are non-specific and onset may be insidious. While treatment is usually conservative, certain situations require surgery. All patients however require careful assessment and monitoring for complications that may require further intervention. A review of our practice in Wexham Park and Heatherwood Hospital NHS Trust from 2009 to 2013 produced a guideline suggesting the need for blood cultures, imaging with MRI and involvement of the infectious diseases and spinal teams. We re-audited (20 cases) to assess compliance with the guidelines, which were in place to reduce the delay in diagnosis. Recurrent presentation, infections of unknown origin and deterioration after a short course of antibiotics were indicators for triggering imaging of the spine for discitis. Delays in diagnosis were more marked in bacterial cases rather than tuberculosis. It was impossible to predetermine patients that would require surgical intervention. Our compliance with the guideline had improved from 70 to over 90% and there were no relapses or mortality

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW). Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61. Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure.

A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks.

A ‘terminal event’ or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation.

Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Cite this article: Bone Joint J 2013;95-B:1121–6.

This prospective study of 136 children with progressive infantile scoliosis treated under the age of four years, and followed up for nine years, shows that the scoliosis can be reversed by harnessing the vigorous growth of the infant to early treatment by serial corrective plaster jackets.

In 94 children (group 1), who were referred and treated in the early stages of progression, at a mean age of one year seven months (6 to 48 months) and with a mean Cobb angle of 32° (11° to 65°), the scoliosis resolved by a mean age of three years and six months. They needed no further treatment and went on to lead a normal life. At the last follow-up, their mean age was 11 years and two months (1 year 10 months to 25 years 2 months), 23 (24.5%) were at Risser stages 4 and 5 and 13 girls were post-menarchal.

In 42 children (group 2), who were referred late at a mean age of two years and six months (11 to 48 months) and with a mean Cobb angle of 52° (23° to 92°), treatment could only reduce but not reverse the deformity. At the last follow-up, at a mean age of ten years and four months (1 year 9 months to 22 years 1 month), eight children (19%) were at Risser stages 4 and 5 and five girls were post-menarchal. Fifteen children (35.7%) had undergone spinal fusion, as may all the rest eventually.