A paradigm for the evaluation and management of spinal coccidioidomycosis

Background: Coccidioidomycosis is a fungal infection that is endemic to parts of the Southwestern United States. When infection involves the spine, the treatment strategies can be challenging. We have devised a management protocol for spinal coccidioidomycosis based on a review of the literature and our experience. Methods: The electronic literature search of National Library of Medicine for publications from 1964 to 2014 was performed using the following keywords: Coccidioidomycosis and spine. The search yielded 24 papers. Treatment strategies were summarized into a treatment protocol. Results: A total of 164 cases of spinal coccidioidomycosis were identified, ranging in age from <10 to >80 years. Males (n = 131) and African-Americans (n = 79) were strikingly over-represented. Medical therapy: Once a diagnosis of spinal coccidioidomycosis is established, antifungal therapy should always be started. Antifungal therapy with amphotericin B or azoles like fluconazole. Medical therapy needs to be continued for many years and sometimes indefinitely to reduce disease recurrence or progression. Surgical management is indicated in cases with mechanical instability, neurologic deficit, medically intractable pain, or progression of infection despite antifungal therapy. Conclusions: This work provides a working protocol involving assessment and reassessment for the management of spinal coccidioidomycosis. Medical management with antifungal agents in some cases can provide satisfactory disease control. However, in patients with mechanical instability, neurologic deficit, medically intractable pain or disease progression disease control may only be achieved with surgical debridement and stabilization

Surgical anatomy of the minimally invasive lateral lumbar approach

The lateral lumbar interbody fusion approach (LLIF), which encompasses the extreme lateral interbody fusion or direct lateral interbody fusion techniques, has gained popularity as an alternative to traditional posterior approaches. With rapidly expanding applications, this minimally invasive surgery (MIS) approach is now utilized in basic degenerative pathologies as well as complex lumbar degenerative deformities and tumors. Given the intimate relationship of the psoas muscle, and hence the lumbar plexus, to this MIS approach, several authors have examined the surgical anatomy of this approach. Understanding this regional neural anatomy is imperative given the potential for serious injuries to both the motor and sensory nerves of the lumbar plexus. In this review, we critically and comprehensively discuss all published studies detailing the surgical anatomy of the lateral lumbar approach with respect to the MIS LLIF techniques. This is a timely review given the rapidly growing number of surgeons utilizing this technique

Salvage revision surgery after inappropriate approach for primary spine tumors: long term follow-up in 56 cases

Background: The mainstay treatment of primary malignant bone tumors is wide surgery in the spine. Unfortunately, most cases undergo the first approach in a nonspecialized center; this often means adopting an inappropriate approach with contamination, which consistently decreases the effectiveness of a second surgery. The aim of the present paper is to evaluate recurrence and survival rates after en-bloc resection. Methods: All patients underwent wide resection by the senior author from January 1997 to December 2013 after the first inappropriate approach was reviewed. Fifty-six patients were included in the present evaluation. Epidemiologic and clinical characteristics, surgeries, early and late complications, and survival rate were reported. Results: The margin obtained was wide, marginal, and intralesional in 9, 28, and 19 cases, respectively. The complication rates were 55.4% and 44.6% for early and late complications, respectively. Most (73.2%) of the patients had complications. The survival rate is 82.1% at 1 year and then decreases 10% each year until 42.1% at 5 years from surgeries. No statistically significant correlation was found between margin and local recurrence and survival. Conclusion: In our series, the first inappropriate approach had already compromised patient prognosis, so in case of suspicious primary spine tumor, the patient had to be referred to a specialized center. The margin obtained during salvage surgery does not appear to influence recurrence and survival, probably because it is already compromised by the first surgery. More prospective studies are necessary to confirm our data and verify the impact of the margin obtained during salvage surgery on patients' survival