Survival of sepsis has been documented worldwide, but little is documented about the long-term health outcomes of multifocal sepsis from acute musculoskeletal infection - the first study of its kind in New Zealand. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1. st. January 2002 to 31. st. December 2017 with a musculoskeletal focus of infection were identified from hospital coding data. Notes review from discharge to present day determined survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. Seventy patients were studied. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Long-term survival was favourable with no recorded deaths after discharge. Recurrence/chronic infection occurred in 23%, a mean of 1.1 year after discharge. Growth disturbance occurred in 18%, a mean of 3 years after discharge. The hip joint and proximal femur have the worst complications. Children under 2 years are most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years after discharge. Health-related quality of life scores were on par with normative data. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with long hospital stay and multi-organ complications. Māori and Pasifika children, those under two and those involving the proximal femur/or hip are most at risk. Other outcomes are favourable with no evidence of chronic lung disease or poor quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

This study aimed to identify long-term physical and psychosocial health outcomes in children with overwhelming musculoskeletal sepsis. Children admitted to the Paediatric Intensive Care Unit (PICU) from 1st January 2002 to 31st December 2017 with a musculoskeletal focus of infection were identified. A medical notes review was completed to determine survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed. 70 patients were identified over 15 years. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Recurrence/chronic infection affected 23%. Growth disturbance affected 18%. The hip joint and proximal femur suffered the worst long-term complications. Children under 2 years most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent acquired brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years (SD 4.5, range 2– 18 years) after discharge. Health-related quality of life scores were on par with normative data. All patients who underwent pulmonary function tests had normal results. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder. Paediatric multifocal musculoskeletal sepsis can result in complex illness with multi-organ complications for some children. Māori and Pasifika children are most at risk. Children under 2 years and those with proximal femur and/or hip involvement are most likely to have chronic musculoskeletal sequelae and permanent disability. Other outcomes are favourable with no evidence of chronic lung disease or mean reduced quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning

Aim. Spinal implant-associated infections (SIAI) require combined surgical and antimicrobial treatment and prolonged hospital stay. We evaluated the clinical, laboratory, microbiological and radiological characteristics and treatment approaches in patients with SIAI. Method. Consecutive adult patients with SIAI treated between 2015 and 2017 were prosepctively included. SIAI was defined by: (i) significant microbial growth from intraoperative tissue or sonication fluid, (ii) intraoperative purulence, secondary wound dehiscence or implant on view, (iii) radiographic evidence of infection and fever (>38°C) without other recognized cause, increasing back pain or neurologic impairment, (iv) peri-implant tissue inflammation in histopathology. Results. A total of 60 patients were included, median age was 66 years (range, 28–91 years), 29 (48%) were males. The most common reason for spinal stabilization was spinal canal stenosis in 20 patients (33%) followed by vertebral degenerative disease in 14 (23%). 31 patients (52%) had one or more previous spine surgeries (range, 1–4 interventions). The anatomic site of spinal instrumentation was lumbar/sacral in 26 (43%), cervical in 23 patients (38%), thoracic in 11 (18%). The median number of fused segments was 5 (range, 1–14). Clinical manifestations included wound healing disturbance in 41 patients (68%), increasing back pain in 15 (25%), neurologic impairment in 12 patients (20%) and fever in 14 (23%). Serum CRP was abnormal (>10mg/l) in 46/59 patients (78%). Most (n=54) infections were postsurgical, 5 were hematogenous and 1 was contiguous. Imaging showed epidural, intraspinal or paravertebral abscess in 21/42 patients (50%), implant failure in 9 (21%) and implant loosening in 3 cases (7%). Monomicrobial infection was observed in 41 (68%), polymicrobial in 16 (27%) patients and culture-negative infection in 3 episodes (5%). Predominant causative pathogens were S. aureus (n=19), coagulase-negative staphylococci (n=18) and gram-negative rods (n=16). Surgery was performed in all patients including debridement and implant retention in 39 patients (65%), partial implant exchange in 10 (17%) and complete exchange in 11 (18%). Antimicrobial treatment included biofilm-active substances in 52 patients (87%). The median duration of antimicrobial therapy was 11,7 weeks (range, 6–12 weeks). 14 patients (23%) recieved suppressive therapy for a median duration of 9 months (range 3–12 months). Conclusions. Most SIAI were seen in lumbar/sacral segments and wound healing disturbance and increasing back pain were the most common manifestations. In 95% the causative pathogen was isolated, predominantly staphylococci. In half of the episodes, abscesses were present. All patients underwent surgery and biofilm-active antibiotics were administered in 87%

The spine is a common site of metastasis. Complications include pathologic fracture, spinal cord compression, and neurological deficits. Vertebroplasty (VP) and Balloon Kyphoplasty (KP) are minimally invasive stabilization procedures used as a palliative treatment to improve mechanical stability, quality of life, and reduce pain. Photodynamic therapy (PDT) is a tumour-ablative modality that may complement mechanical stability afforded by VP/KP. This first-in-human study evaluates PDT safety when applied in conjunction with VP/KP. This dose escalation trial involved one light only control group and four light-drug doses (50,100,150,200J;n=6) delivered at 150mW from a 690nm diode laser by 800-micron optical fibers prior to KP/VP. Patients eligible for VP/KP in treating pathologic fracture or at-risk lesions at a single level were recruited. Exclusion criteria included spinal canal compromise or neurologic impairment. PDT is a two-step binary therapy of systemic drug followed by intravertebral light activation. Light was applied via bone trochar prior to cementation. This study used a benzoporphyrin derivative monoacid (BPD-MA), Verteporfin (VisudyneTm), as the photosensitizer drug in the therapy. Drug/light safety, neurologic safety, generic (SF-36), and disease-specific outcomes (VAS, EORTC-QLQ-BM22, EORTC-QLQ-C15-PAL) were recorded through six weeks. Phototoxicity and the side effects of the BPD-MA were also examined following PDT use. Thirty (10 male, 20 female) patients were treated (13 KP, 17 VP). The average age was 61 and significantly different between genders (Male 70yrs vs. Female 57yrs: p 0.05), and tumour status (lytic vs. mixed blastic/lytic: p>0.05). In most cases, fluence rates were similar throughout PDT treatment time, indicating a relatively stable treatment. Twelve (40%) of patients experienced complications during the study, none of which were attributed to PDT therapy. This included two kyphoplasty failures due to progression of disease, one case of shingles, one ankle fracture, one prominent suture, one case of constipation due to a lung lesion, one case of fatigue, and five patients experienced pain that was surgically related or preceded therapy. Vertebral PDT appears safe from pharmaceutical and neurologic perspectives. KP/VP failure rate is broadly in line with reported values and PDT did not compromise efficacy. The 50J group demonstrated an improved response. Ongoing study determining safe dose range and subsequent efficacy studies are necessary

Background. There is minimal published data regarding the long-term functional outcome in pyogenic spinal infection. Previous studies have used heterogeneous, unreliable and non-validated measure instruments, or neurological outcome alone, yielding data that is difficult to interpret. We aim to assess long-term adverse outcome using standardised measures, Oswestry disability index (ODI) and MOS short form-36 (SF-36). Methods. All cases of pyogenic spinal infection presenting to a single institution managed operatively and non-operatively from 1994-2004 were retrospectively identified. Follow-up was by clinical review and standardised questionnaires. Inclusion in each case was on the basis of consistent clinical, imaging and microbiology criteria. Results. Twenty-nine cases of pyogenic spinal infection were identified. Twenty-eight percent were managed operatively and 72% with antibiotic therapy alone. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) having persistent neurological deficit. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and patients who recovered (p=0.003). SF-36 scores of all patients, regardless of management or outcome, failed to reach those of a normative population. A strong correlation was observed between ODI and SF-36 PF scores (rho=0.61, p<0.05). Seventeen percent (n=5) of admissions resulted in acute sepsis-related death. Subgroup analysis revealed delay in diagnosis of spinal infection (p=0.025) and neurological impairment at diagnosis (p<0.001) to be significant predictors of neurological deficit at follow-up. Previous spinal surgery was associated with adverse outcome in patients requiring readmission within 1 year of hospital discharge following first spinal infection (p=0.018). No independent predictors of adverse outcome, persistent neurological impairment, readmission within 1 year or acute death were identified by logistical regression analysis. Conclusions. High rates of adverse outcome detected using SF-36 and ODI suggest under-reporting of poor outcome when ASIA score alone is used to qualify outcome

We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy. Retrospective data analysis. A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor. During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac. The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery. Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment

Purpose of the study. To review the primary bone tumours of the spine treated at our unit. Description of methods. Retrospective review of folders and x-rays of all the patients with primary bone tumours of the spine treated at our unit between 2005 and 2012. All haematological tumours were excluded. Summary of results. We treated 15 cases during this period. The median age at presentation was 36 years (8–65). There was a significant delay from onset of symptoms to diagnosis in most cases (median 7 months). Histological diagnoses included:. -Benign tumours.  Active. Hemangioma. 3. Osteoid osteoma. 1. Eosinophilic granuloma. 1.  Aggressive. Osteoblastoma. 1. Giant cell tumours. 2. Aneurysmal bone cysts. 4. -Malignant tumours.  Osteosarcomas. 2.  Leiomyosarcoma of bone. 1. A variety of definitive surgical methods were utilised. Seven patients had a debulking or intralesional resection of the tumour. Eight patients had an attempted marginal excision. This was achieved through anterior surgery only in 1 case, posterior only surgery in 6 cases and combination anterior and posterior surgery in 8 cases. The anterior and posterior surgery was performed in a single sitting in 5 cases and in a staged fashion in 3 cases. Adjuvant radiotherapy and chemotherapy were used where indicated. Three cases presented with significant neurological impairment. Of these 2 made a significant recovery. There were no cases of neurological deterioration following surgery. All 3 patients with malignant tumours died in the follow up period. We had 1 case of hardware failure due to chronic sepsis. Conclusion. Primary bone tumours of the spine are associated with a significant delay in diagnosis. Surgical treatment options and adjuvant therapy should be tailor made for each case depending on the diagnosis. Acceptable results with minimal complications can be achieved with this approach

Introduction:. Trauma is endemic in South Africa. The upper thoracic spine is extremely difficult to image and assess clearly with frontline x-rays resulting in up to 22% of proximal fractures being missed. Aim:. To review a series of patients with proximal thoracic fractures. Methods:. Thirty-three patients with proximal thoracic fractures in the T1–T4 area managed in a spinal unit were identified. A retrospective review of medical records and radiology was undertaken. Demographic data, mechanism of injury, diagnostic modalities, level and type of fracture, neurological status, associated injuries, hospital stay, management, complications and outcome was recorded. Results:. There were 21 males and 12 females, with a median age of 31.8 years. Aetiology was 21 MVA passengers, 8 drivers, 1 pedestrian, 1 assault, 1 bicycle and 1 hanglider accident. Delay in diagnosis was 1 day in 8, 2–5 days in 2 and greater than 2 weeks in 5. The fractures were A1 in 7, A3 in 14, B1 in 7, C1 in 2 and C2 in 2. Twenty three patients had neurological compromise, 13 being complete. Twenty-three had associated chest and head injuries. Hospital stay was a mean of 27 days (maximum 246) and ICU stay median 14 (maximum 115) days. Twenty-six patients underwent surgery, posterior instrumented fusion being the commonest procedure. Although the surgery did not change the median kyphosis (25° preop to 20°at 1 year and 21°at 2 years), the most kyphotic patients were improved (55°to 45°). Conclusion:. A high index of suspicion for proximal thoracic fractures needs to be maintained in high energy injuries, especially MVA passengers, where there is chest injury. Prompt exclusion by appropriate special investigations is mandatory. Once recognized, they can be adequately managed with posterior instrumented fusion, although these patients are resource intensive due to the associated neurological impairment and chest injuries

Introduction. We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm. Materials and methods. A retrospective study of 19 patients who presented with dual pathology was performed and the patients were assessed with regards to pre and post-operative symptoms, walking distance, and neurological status. Results. There were 17 patients with improvement in the spinal stenotic symptoms following hip replacement to an extent that none required spinal surgery. There were two patients who had spinal surgery after THR, at varying lengths following hip replacements as their spinal stenotic symptoms worsened over time, and had lateral spinal stenosis on MRI. Discussion. In advanced hip osteoarthritis, a fixed flexion deformity may develop at the hip leading to an exaggerated lumbar lordosis in erect posture. In the presence of co-existing spinal stenosis, the exaggerated lumbar lordosis may worsen the spinal stenotic symptoms while standing and walking. Cadaveric & Radiological studies have shown that canal narrowing occurs with increased lordosis/ extension in the lumbar spine. Our findings suggest that when central lumbar spinal stenosis coexists with bilateral hip arthritis and FFD at the hip, THR should be offered first. Successful hip surgery for arthritis correcting significant fixed flexion deformity would lessen the lumbar lordosis, thus correcting the excessive pathological narrowing. If a patient is fit enough, simultaneous bilateral THR via an anterior type of approach makes surgical correction of FFD easier. Although it has been suggested in the literature that patients with spinal stenosis have a increased risk of neurological impairment following THR, we did not find any clear association