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Isolated multiple lumbar transverse process fractures with spinal instability: an uncommon yet serious association
Isolated vertebral transverse process fractures of thoracolumbar spine without other vertebral injuries and neurological deficit are generally considered as minor injuries with no concern for associated spinal instability. This report describes a case of multiple lumbar transverse fractures associated with an unexpected yet clinically significant spinal instability.
A young male presented with right flank pain following being pushed and trapped against the ground by a reversing truck. The neurological examination was normal, and computed tomography (CT) imaging revealed multiple fractures at right transverse processes from L1 to L5, a single left-sided transverse process fracture at L2 and subtle facet joint distraction without other spinal lesions or visceral injuries. The injury was initially deemed as stable requiring symptomatic treatment and in-patient observation. However, discharge upright X-rays taken in a brace showed marked subluxation of L2/L3 and L3/L4 levels.
Magnetic resonance imaging revealed significant discoligamentous injuries involving anterior and posterior longitudinal ligaments, annulus fibrosus as well as posterior ligamentous complex. The patient underwent posterior spinal instrumentation and fusion of L1 to L5.
This is the first case description of association of multisegmental lumbar transverse process fractures with notoriously unstable injuries of the major soft-tissue stabilizers of the spine presenting subtle changes on CT images. When a seemingly benign spinal injury is caused by high-energy trauma, careful scrutiny for associated instability is needed. In this case, the standing in-brace X-ray was able to avoid a misdiagnosis and potentially unfavourable outcome
C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections
BACKGROUND: Periprosthetic tissue cultures, sonication and synovial fluid cultures remain the gold standard for prosthetic joint infection (PJI) diagnosis. However, some 15-20% culture-negative PJI are still reported. Therefore, there is the need for other diagnostic criteria. One point of concern relative to the different definitions of PJI is as to the inclusion of the c-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) as diagnostic criteria for PJI despite them being non-specific inflammatory blood tests. PURPOSE: The purpose of the present study was to determine the relevance of CRP and the ESR in the diagnosis of PJI. METHODS: All PJI with positive cultures over a two-year period in two hospitals were reviewed. The main variables of the present study were the type of prosthesis and the CRP level. More information was recorded in those patients with normal CRP: radiographs, physical examination records and the ESR. RESULTS: Seventy-three patients were included in study. Pre-operative CRP levels were normal (lower than 0.8 mg/dl) in 23 patients, representing 32% of all PJI with positive cultures. Low virulence micro-organisms, 12 coagulase-negative staphylococci and four P. acnes, grew in most of them. They represented 70% of all PJI with normal CRP levels. In addition, 17 patients (23% of all PJI with positive cultures) had a normal ESR, a normal physical examination (they only presented with pain) and no clear loosening was observed in the radiographs. CONCLUSIONS: Per the American Association of Orthopaedic Surgeons (AAOS) guidelines or the Musculoskeletal Infection Society (MSIS), 23% of the patients in the present study with PJI would never have been identified. Blood inflammatory markers such as the CRP level and ESR may not be accurate as diagnostic tools in PJI, particularly to identify low-grade and chronic PJI