Correlation of histopathological findings and magnetic resonance imaging in the spine of patients with ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease which affects primarily the sacroiliac joints and the spine. In patients with active disease, magnetic resonance imaging (MRI) of the spine shows areas of bone marrow edema, the histopathological equivalent of which is unknown. In this study we correlate inflammation in the spine of patients with AS as revealed by histological examination with bone marrow edema as detected by MRI. We have compared the histopathological findings of zygapophyseal joints from 8 patients with AS (age: 30 to 64, disease duration 7 to 33 years) undergoing spinal surgery with findings in MRI. For histopathological analysis, we quantified infiltrates of CD3+, CD4+ and CD8+ T cells as well as CD20+ B cells immunohistochemically. Bone marrow edema was evaluated in hematoxylin and eosin stained sections and quantified as the percentage of the bone marrow area involved. All patients with AS showed interstitial mononuclear cell infiltrates and various degrees of bone marrow edema (range from 10% to 60%) in histopathological analysis. However, in only three of eight patients histopathological inflammation and edema in the zygapophyseal joints correlated with bone marrow edema in zygapophyseal joints of the lumbar spine as detected by MRI. Interestingly, two of these patients showed the highest histological score for bone marrow edema (60%). This first study correlating histopathological changes in the spine of patients with AS with findings in MRI scans suggests that a substantial degree of bone marrow inflammation and edema is necessary to be detected by MRI

Congenital deformation of the posterior arch of the atlas: Subluxation of the atlanto-axial joint with temporary quadriplegia

Instabilities of the craniocervical junction can be of rheumatic, traumatic, or congenital origin. The reported patient has a congenital malformation of the cervical spine, which is frequently observed in patients with Klippel–Feil syndrome. Her posterior arch of the atlas (C1) is hypoplastic and a chronic subluxation of the atlanto-axial joint would be possible. Although most common fusions in Klippel–Feil syndrome patients exist at C2/3, the majority of studies about Klippel–Feil syndrome deal with pediatric or adolescent individuals. Through extreme flexion of her neck, there was a compression of the spinal cord by the odontoid process. This led to a quadriplegia lasting about 10 min. Over the following weeks, all of her symptoms started to diminish. This situation turned out to be the third episode involving temporary neurological disorders in this 60-year-old female’s life

The Hamburg Spondylodiscitis Assessment Score (HSAS) for Immediate Evaluation of Mortality Risk on Hospital Admission

(1) Background: Patients with spondylodiscitis often present with unspecific and heterogeneous symptoms that delay diagnosis and inevitable therapeutic steps leading to increased mortality rates of up to 27%. A rapid initial triage is essential to identify patients at risk for a complicative disease course. We therefore aimed to develop a risk assessment score using fast available parameters to predict in-hospital mortality of patients admitted with spondylodiscitis. (2) Methods: A retrospective data analysis of 307 patients with spondylodiscitis recruited from 2013 to 2020 was carried out. Patients were grouped according to all-cause mortality. Via logistic regression, individual patient and clinical characteristics predictive of mortality were identified. A weighted sum score to estimate a patient’s risk of mortality was developed and validated in a randomly selected subgroup of spondylodiscitis patients. (3) Results: 14% of patients with spondylodiscitis died during their in-hospital stay at a tertiary center for spinal surgery. Univariate and logistic regression analyses of parameters recorded at hospital admission showed that age older than 72.5 years, rheumatoid arthritis, creatinine > 1.29 mg/dL and CRP > 140.5 mg/L increased the risk of mortality 3.9-fold, 9.4-fold, 4.3-fold and 4.1-fold, respectively. S. aureus detection increased the risk of mortality by 2.3-fold. (4) Conclusions: The novel Hamburg Spondylodiscitis Assessment Score (HSAS) shows a good fit identifying patients at low-, moderate-, high- and very high risk for in hospital mortality on admission (AUC: 0.795; p < 0.001). The implementation of the HSAS into clinical practice could ease identification of high-risk patients using readily available parameters alone, improving the patient’s safety and outcome

To fuse or not to fuse: a survey among members of the German Spine Society (DWG) regarding lumbar degenerative spondylolisthesis and spinal stenosis

Introduction Surgical treatment methods for degenerative spondylolisthesis (decompression versus decompression and fusion) have been critically debated. The medical care situation is almost unknown for either treatment. Therefore, the aim of the present study was to provide information regarding the use of parameters for decision-making and the employment of surgical techniques. Materials and methods A web-based survey was performed among members of the German-Spine-Society (DWG). Information regarding participant characteristics (specialty, age, DWG certification status, number of spine surgeries performed at the participant's institution each year, institutional status), estimates of the use of both treatment options, clinical and morphological decision-making criteria for additive fusion, and the surgical technique used was queried. Results 305 members (45% neurosurgeons/ 55% orthopedic or trauma surgeons) participated in the present study. The participants estimated that in 41.7% of the cases, decompression only was required, while 55.6% would benefit from additional fusion. Among the participants, 74% reported that low back pain was an important indicator of the need for fusion if the numerical rating scale for back pain was at least 6/10. The most commonly used decompression technique was minimally invasive unilateral laminotomy, whereas open approach-based interbody fusion with transpedicular fixation and laminotomy was the most frequently used fusion technique. Specialty, age, certification status, and institutional status had a partial effect on the responses regarding indications, treatment and surgical technique. Conclusions The present survey depicts the diversity of approaches to surgery for degenerative spondylolistheses in Germany. Considerable differences in treatment selection were observed in relation to the participants' educational level and specialty

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures&mdash;A Retrospective Analysis from Two Centers

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012&ndash;2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 &plusmn; 10.2 y. The mean VAS decreased significantly from 7.7 &plusmn; 2.8 preoperatively to 3.0 &plusmn; 1.6 at last follow-up (p &lt; 0.001) and the segmental kyphosis decreased from 29.4 &plusmn; 14.1&deg; to 7.9 &plusmn; 8.0&deg; (p &lt; 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up &gt;120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients&rsquo; segmental kyphosis and VAS improved significantly, while the KPS remained stable

Destructive per continuitatem spondylodiscitis after endovascular abdominal or thoracic aneurysm repair (EVAR/TEVAR): rare and untreatable?

Introduction!#!Very few publications have previously described spondylodiscitis as a potential complication of endovascular aortic procedures (EVAR/TEVAR). We present to our knowledge the first case series of spondylodiscitis following EVAR/TEVAR based on our data base. Particular focus was laid on the complexity of disease treatment and grave outcome perspectives from a spine surgeon's point of view in this seriously affected patient group.!##!Materials and methods!#!A retrospective analysis and chart review was performed for 11 out of 284 consecutive spondylodiscitis patients who underwent EVAR/TEVAR procedure and developed destructive per continuitatem spondylodiscitis.!##!Results!#!All 11 patients had single or more level destructive spondylodiscitis adjacent to the thoracic/lumbar stent graft. In mean, four surgeries were performed per patient to treat this rare complication. Six out of eleven patients (55%) died within 6 months of first identification of per continuitatem spondylodiscitis. In four patients due to persisting infection of the graft and recurrence of the abscess formation, a persisting fistula from anterior approach to the skin was applied.!##!Conclusions!#!Destructive per continuitatem spondylodiscitis is a rare and severe complication post-EVAR/TEVAR. Clinical and imaging features of anterior paravertebral disease and anterior vertebral body involvement suggest direct continuous spread of the graft infection to the adjacent vertebral column. The mortality rate of these severe infections is extremely high and treatment with a permanent fistula may be one salvage procedure

Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3-30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p &amp;lt; 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p &amp;lt; 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p &amp;lt; 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p &amp;lt; 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome

Influence of microbiological diagnosis on the clinical course of spondylodiscitis

Purpose!#!This study sought to recognize differences in clinical disease manifestations of spondylodiscitis depending on the causative bacterial species.!##!Methods!#!We performed an evaluation of all spondylodiscitis cases in our clinic from 2013-2018. 211 patients were included, in whom a causative bacterial pathogen was identified in 80.6% (170/211). We collected the following data; disease complications, comorbidities, laboratory parameters, abscess occurrence, localization of the infection (cervical, thoracic, lumbar, disseminated), length of hospital stay and 30-day mortality rates depending on the causative bacterial species. Differences between bacterial detection in blood culture and intraoperative samples were also recorded.!##!Results!#!The detection rate of bacterial pathogens through intraoperative sampling was 66.3% and could be increased by the results of the blood cultures to a total of 80.6% (n = 170/211). S. aureus was the most frequently detected pathogen in blood culture and intraoperative specimens and and was isolated in a higher percentage cervically than in other locations of the spine. Bacteremic S. aureus infections were associated with an increased mortality (31.4% vs. overall mortality of 13.7%, p = 0.001), more frequently developing complications, such as shock, pneumonia, and myocardial infarction. Comorbidities, abscesses, length of stay, sex, and laboratory parameters all showed no differences depending on the bacterial species.!##!Conclusion!#!Blood culture significantly improved the diagnostic yield, thus underscoring the need for a structured diagnostic approach. MSSA spondylodiscitis was associated with increased mortality and a higher incidence of complications