Category Archives: Spine

Theatre Practitioners Spine & Neurosurgery Update

Theatre Practitioners Spine & Neurosurgery Update

September 11 — September 12

Coventry, UK

Website: www.neurosurgeryupdate.com / Click HERE for the flyer.

Course Features

  • 2 day Course with Lectures & Hands on
  • Video sessions of operative procedures
  • Hands on & Products Demonstration
  • Gala Dinner with DJ music
  • Sponsors Exhibition

 

Key Topics

  • Anatomy revision for common condition for Spine & Brain
  • Wrong level/site surgery & reading Scans & X ray
  • Theatre set up for spine surgery & Brain surgery
  • Patient positioning for Brain & Spine Surgery
  • Anaesthesia and surgical emergencies
  • WHO checklist & Safe Surgery
  • Infection prevention & control
  • Dressing & Drains
  • DVT prophylaxis
  • Consent 

Hand On & Products Demonstration

  • Clamps, Mayfield & Retractors
  • Drills & Craniotomies
  • Diathermy & electrosurgery
  • Ultrasonic Preparation & Use
  • Microscope preparation & drapes
  • Cranial & Spinal Navigation
  • Cranial defects & implants
  • Haemostatic agents & preparation
  • Dural Sealants & preparation
  • Spinal instrumentation & implants 

Course is designed for: Theatre Practitioners practicing in the field of Neurosurgery & Spine Surgery.

Accreditation: 12 hours towards Revalidation Portfolio (CPD)

In conjunction with Theatre Managers, Sisters & Charge Nurses from University Hospitals Coventry & Warwickshire NHS Trust; BMI, The Meriden Hospital, Coventry; BMI Three Shires Hospital, Northampton; The Woodland Hospital, Ramsay Health, Kettering.

Fees:

Course fee: £200 / for EANS Individual Members: £150

Registration / Sponsorship Contact:

Mrs Anita Vicars, Senior Course Administrator, anita@neurosurgeryupdate.com

Update: Double level isthmic spondylolisthesis

Double level isthmic spondylolisthesis

Isthmic spondylolisthesis, which is demonstrated in 4%-6% of the general population, is one of the most common types of spondylolisthesis. However, double-level isthmic spondylolisthesis is extremely rare. Only a few reports have examined the outcomes of surgical treatment of double-level spondylolisthesis.

Reviews

Between 2004 and 2014, thirty-two patients with double-level isthmic spondylolisthesis who underwent posterior lumbar interbody fusion (PLIF) with autogenous bone chips were reviewed retrospectively. The clinical outcomes were measured by VAS (Visual analog scale) and JOA(Japanese Orthopaedic Association) score.

At an average follow-up of 2.8 years, the mean score on the VAS of back pain and sciatica decreased from 6.48 and 4.26 points preoperatively to 1.82 and 1.10 points at final follow-up, respectively. The average JOA score improved from 13.8±3.1 preoperative to 25.6±1.3 (range, 17-28) points postoperative. The average recovery rate was 77.6%. The good and excellent rate was 84.3% (27/32). The fusion rate was 87.5% (28/32). Changes in disc height, degree of listhesis, whole lumbar lordosis, and sacral inclination between the pre- and postoperative periods were significant.

The findings suggest that PLIF with autogenous bone chips for double-level isthmic spondylolisthesis could yield good functional short-term results. It seems to be a viable approach in the treatment of double-level isthmic spondylolisthesis 1).

Case series

Fifty-four patients who were managed surgically for treatment of double-level symptomatic isthmic spondylolisthesis were included in this study. Between May 2004 and September 2012, 29 consecutive patients underwent posterior lumbar interbody fusion (PLIF) with autogenous bone chips (group I) at Foshan Hospital of Traditional Chinese Medicine, Guangdong, China. Between March 2005 and December 2013, 25 consecutive patients underwent PLIF with cage (group II) at Zhujiang Hospital of Southern Medical University, Guangdong, China. The mean follow-up periods were 27.2 and 26.8 months, respectively.

The mean VAS scores of back and leg pain significantly decreased from 7.2 to 2.2 and 5.8 to 2.1 in the group I and from 7.0 to 1.9 and 6.1 to 1.8 in the group II, respectively. In the group I, mean ODI scores improved significantly from 54% to 14.2% and, in the group II, from 60% to 12.6%. In both groups, VAS and ODI scores significantly changed from pre- to postoperatively (p<0.001), but postoperative outcome between groups was statistically not significant. Solid union was observed in 27 of 29 patients (89.6%) in the group I and in 22 of 25 patients (88%) in the group II, without statistically significant differences (p>0.05). In both groups, changes in disc height, degree of listhesis, and whole lumbar lordosis between the pre- and postoperative periods were significant.

Clinical and functional outcomes demonstrate no significant differences between groups in treating back and leg pain of adult patients with double-level isthmic spondylolisthesis 2).

Case reports

2017

To the best of Kim et al. knowledge, there has been no report regarding rheumatoid arthritis associated with spinal neuroarthropathy and combined double-level isthmic spondylolisthesis.

They report a rare case of spinal neuroarthropathy with double-level isthmic spondylolisthesis in a rheumatoid arthritis (RA) patient. A 56-year-old female patient under medical treatment for RA during the last 13 years presented aggravating radiating pain to her right lower extremity and a limping gait developed 4 months ago. The disease activity of RA had remained low for a long time. Serial radiographs during last 8-year follow-up showed progressive dislocation at L4-L5 and L5-S1 with double-level isthmic spondylolisthesis and severe destructive status at the last follow-up. The patient underwent decompression and circumferential fusion with sacropelvic fixation and acceptable reduction was obtained.

A RA patient with double-level isthmic spondylolisthesis showed a progressive destructive lesion. In addition to clinical presentations, the imaging findings were very similar to ones of spinal neuroarthropathy. The authors conclude that this Grand Round case probably had SNA secondary to RA and that this, combined with two-level isthmic spondylolisthesis, resulted in her rapidly progressing destructive lumbar lesion 3).

2014

Song et al. present an unusual case of double-level isthmic spondylolisthesis of the lumbar spine. The patient had low-back pain for 20 years and did not respond to conservative treatment. Radiographs revealed bilateral pars defects at L-4 and L-5. Grade 2 isthmic spondylolisthesis was present, both at L4-5 and at L5-S1. The patient underwent decompression, reduction, and posterior lumbar interbody fusion with autogenous bone chips from posterior decompression. At follow-up after 12 months, the patient was free of pain, slippage was corrected, and fusion was achieved. Posterior lumbar interbody fusion with posterior instrumentation and reduction may yield good functional short-term results for double-level spondylolisthesis 4).

2012

An unusual case of a double-level isthmic spondylolisthesis of the lumbar spine in a 38-year-old female was described. The patient had been suffering from low back pain for 8 years and did not respond to conservative treatment. Her medical examination revealed that grade II isthmic spondylolisthesis was present both at L-4 to L-5 and at L-5 to S-1. The patient was managed by surgical treatment. After the reduction of lysthesis with posterior instrumentation, posterior lumbar interbody fusion (PLIF) technique was performed for double level. At a recent follow-up, 1 year after the surgery, the symptoms of the patient were completely resolved, reduction was preserved, and fusion was achieved. PLIF with posterior instrumentation and reduction seems to be a convenient treatment option in the treatment for double-level spondylolisthesis 5).

1)

Song D, Song D, Zhang K, Chen Z, Wang F, Xuan T. Double-level isthmic spondylolisthesis treated with posterior lumbar interbody fusion: A review of 32 cases. Clin Neurol Neurosurg. 2017 Aug 19;161:35-40. doi: 10.1016/j.clineuro.2017.08.007. [Epub ahead of print] PubMed PMID: 28843115.
2)

Song D, Chen Z, Song D, Li Z. Comparison of posterior lumbar interbody fusion (PLIF) with autogenous bone chips and PLIF with cage for treatment of double-level isthmic spondylolisthesis. Clin Neurol Neurosurg. 2015 Nov;138:111-6. doi: 10.1016/j.clineuro.2015.08.012. Epub 2015 Aug 20. PubMed PMID: 26318362.
3)

Kim SI, Kim YH, Lee JW, Kang WW, Ha KY. Rheumatoid arthritis-associated spinal neuroarthropathy with double-level isthmic spondylolisthesis. Eur Spine J. 2017 Jul 28. doi: 10.1007/s00586-017-5220-6. [Epub ahead of print] PubMed PMID: 28755075.
4)

Song D, Chen Z, Song D. Surgical treatment of double-level isthmic spondylolisthesis. J Neurosurg Spine. 2014 Apr;20(4):396-9. doi: 10.3171/2013.12.SPINE13521. Epub 2014 Jan 31. PubMed PMID: 24484307.
5)

Uysal M, Circi E, Ozalay M, Derincek A, Cinar M. The surgical treatment for a rare case of double-level isthmic spondylolisthesis in L4 and L5 lumbar spine: decompression, reduction and fusion. Eur J Orthop Surg Traumatol. 2012 Nov;22 Suppl 1:21-4. doi: 10.1007/s00590-012-0993-0. Epub 2012 Apr 19. PubMed PMID: 26662742.

Update: Rehabilitation after lumbar disc surgery

Rehabilitation after lumbar disc surgery

Studies have shown late post-operative physical disability and residual pain in patients following lumbar disc surgery despite growing evidence of its beneficial effects. Therefore, rehabilitation is required to minimise the late postoperative complications.

Several rehabilitation programmes are available for individuals after lumbar disc surgery.

Cochrane review in 2009 showed that exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery 1) 2).


metaanalysis in 2014 showed considerable variation in the content, duration and intensity of the rehabilitation programmes, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed 3).


A Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis in adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level.

Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge.

In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery.

There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year.

Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral 4).

Case series

2017

Twenty-one patients aged 25-65 years undergoing lumbar microdiscectomy were randomly assigned to the rehabilitation group (n = 14) or active control group (n = 7) by simple randomisation. Eight rehabilitation sessions were initiated 2-3 weeks after surgery. Thirty-minute sessions were conducted twice weekly for four weeks. Post-operative physical disability and pain were assessed at baseline and at the two-year follow-up.

Post-operative physical disability improved more in patients who had undergone rehabilitation than in those who had received control care (63% vs. -23%, P< 0.05). Post-operative residual low back and leg pain were alleviated in the treatment group (26% and 57%, respectively), but intensified in the control group (-5% and -8%, respectively).

This study demonstrated the potential of manipulative rehabilitation and importance of post-operative management after lumbar disc surgery. Definitive trials with larger sample sizes are required to confirm the feasibility and potential therapeutic effectiveness of this approach 5).


A study aimeds to investigate (1) motives, motivations and expectations regarding the choice for a specific rehabilitation setting after herniated disc surgery and (2) how rehabilitation-related motivations and expectations are associated with rehabilitation outcome (ability to work, health-related quality of life and satisfaction with rehabilitation) three months after disc surgery.

The longitudinal cohort study refers to 452 disc surgery patients participating in a subsequent rehabilitation. Baseline interviews took part during acute hospital stay (pre-rehabilitation), follow-up interviews three months later (post-rehabilitation). Binary logistic regression and multiple linear regression analyses were applied.

(1) Motives, motivations and expectations: Inpatient rehabilitation (IPR) patients stated “less effort/stress” (40.9%), more “relaxation and recreation” (39.1%) and greater “intensity of care and treatment” (37.0%) regarding their setting preference, whereas outpatient rehabilitation (OPR) patients indicated “family reasons” (45.3%), the wish for “staying in familiar environment” (35.9%) as well as “job-related reasons” (11.7%) as most relevant. IPR patients showed significantly higher motivation/expectation scores regarding regeneration (p < .001), health (p < .05), coping (p < .001), retirement/job (p < .01), psychological burden (p < .05) and physical burden (p < .001) compared to OPR patients. (2) Associations with rehabilitation outcome: Besides other factors (e.g. age, gender and educational level) rehabilitation-related motivations/expectations were significantly associated with rehabilitation outcome measures. For example, patients with less motivations/expectations to achieve improvements regarding “physical burden” showed a better health-related quality of life (p < .01) three months after disc surgery. Less motivations/expectations to achieve improvements regarding “psychological burden” was linked to a better mental health status (p < .001) and a greater satisfaction with rehabilitation (OR = .806; p < .05).

Rehabilitation-related motivations and expectations differed substantially between IPR and OPR patients before rehabilitation and were significantly associated with rehabilitation outcome. Taking motivational and expectation-related aspects into account may help to improve allocation procedures for different rehabilitation settings and may improve rehabilitation success 6).

2016

Twenty-one patients aged 25-69 years who underwent lumbar microdiscectomy were randomised to either the manipulative rehabilitation treatment group or the active control group. Rehabilitation was initiated 2-3 weeks after surgery, twice a week for 4 weeks. Each session was for 30 minutes. Primary outcomes were the Roland-Morris disability questionnaire and the visual analogue pain scale. Outcome measures were assessed at baseline and post-intervention.

Early post-operative physical disability was improved with a 55% reduction by early individualised manipulative rehabilitation, compared to that of control care with a 5% increase. Early post-operative residual leg pain decreased with rehabilitation (55%) and control care (9%).

This pilot study supports the feasibility of a future definitive randomised control trial and indicates this type of rehabilitation may be an important option for post-operative management after spinal surgery 7).

References

1)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD003007. doi: 10.1002/14651858.CD003007.pub2. Review. Update in: Cochrane Database Syst Rev. 2014;3:CD003007. PubMed PMID: 18843637.
2)

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery: an update Cochrane review. Spine (Phila Pa 1976). 2009 Aug 1;34(17):1839-48. doi: 10.1097/BRS.0b013e3181abbfdf. Review. PubMed PMID: 19602996.
3)

Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014 Mar 14;(3):CD003007. doi: 10.1002/14651858.CD003007.pub3. Review. PubMed PMID: 24627325.
4)

Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW. Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. J Physiother. 2017 Jul;63(3):144-153. doi: 10.1016/j.jphys.2017.05.016. Epub 2017 Jun 28. PubMed PMID: 28668558.
5)

Kim BJ, Kim T, Ahn J, Cho H, Kim D, Yoon B. Manipulative rehabilitation applied soon after lumbar disc surgery improves late post-operative functional disability: A preliminary 2-year follow-up study. J Back Musculoskelet Rehabil. 2017 May 5. doi: 10.3233/BMR-169546. [Epub ahead of print] PubMed PMID: 28505954.
6)

Löbner M, Stein J, Luppa M, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, Angermeyer MC, König HH, Riedel-Heller SG. Choosing the right rehabilitation setting after herniated disc surgery: Motives, motivations and expectations from the patients’ perspective. PLoS One. 2017 Aug 22;12(8):e0183698. doi: 10.1371/journal.pone.0183698. eCollection 2017. PubMed PMID: 28829828.
7)

Kim BJ, Ahn J, Cho H, Kim D, Kim T, Yoon B. Early individualised manipulative rehabilitation following lumbar open laser microdiscectomy improves early post-operative functional disability: A randomized, controlled pilot study. J Back Musculoskelet Rehabil. 2016;29(1):23-9. doi: 10.3233/BMR-150591. PubMed PMID: 25792303.

Update: Spinal instrumentation infection

Spinal instrumentation infection

Instrumentation has become an integral component in the management of various spinal disorders. The rate of infection varies from 2% to 20% of all instrumented spinal procedures.

Surgical site infection (SSI) in the spine is a serious postoperative complication. Factors such as posterior surgical approach, arthrodesis, use of spinal instrumentation, age, obesity, diabetes, tobacco use, operating-room environment and estimated blood loss are well established in the literature to affect the risk of infection 1).

Diagnosis

There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. 2).


Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42.

Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups 3).


MRI is a useful tool for the early diagnosis of a deep SSI. However, the diagnosis is frequently difficult with feverish patients with clear wounds after posterior spinal instrumentation (PSI) because of artifacts from the metallic implants. There are no reports on MRI findings that are specific to a deep SSI after PSI.

Kimura et al. found that fluid collection outside the head of the PS on an axial MRI scan (PS fluid sign) strongly suggested the possibility of an abscess.

The SSI group comprised 17 patients with a deep SSI after posterior lumbar spinal instrumentation who had undergone an MRI examination at the onset of the SSI. The non-SSI group comprised 64 patients who had undergone posterior lumbar spinal instrumentation who did not develop an SSI and had an MRI examination within 4 weeks after surgery. The frequency of a positive PS fluid sign was compared between both groups.

The PS fluid sign had a sensitivity of 88.2%, specificity of 89.1%, positive predictive value of 68.1%, and negative predictive value of 96.6%. The 2 patients with a false-negative PS fluid sign in the SSI group had an infection at the disk into which the interbody cage had been inserted. Three of the 7 patients with a false-positive PS fluid sign in the non-SSI group had a dural tear during surgery.

The PS fluid sign is a valuable tool for the early diagnosis of a deep SSI. The PS fluid sign is especially useful for diagnosing a deep SSI in difficult cases, such as feverish patients without wound discharge 4).

Treatment

Optimal results are obtained with surgical debridement followed by parenteral antibiotics.

Until today the role of spinal instrumentation in the presence of a wound infection has been widely discussed and recently many authors leave the hardware in place with appropriate antibiotic therapy 5).

Removal or replacement of hardware should be considered in delayed infections.

An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged 6).

Evidence based medicine

In a study, from the Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, USA evidence based medicine was used to assess optimal surgical and medical management of patients with post-operative deep wound infection following spinal instrumentation. A computerized literature search of the PubMed database was performed. Twenty pertinent studies were identified. Studies were separated into publications addressing instrumentation retention versus removal and publications addressing antibiotic therapy regimen. The findings were classified based on level of evidence (I-III) and findings were summarized into evidentiary tables.

No level of evidence 1 or level of evidence 2 was identified. With regards to surgical management, five studies support instrumentation retention in the setting of early deep infection. In contrast, for delayed infection, the evidence favors removal of instrumentation at the time of initial debridement. Surgeons should be aware that for deformity patients, even if solid fusion is observed, removal of instrumentation may be associated with significant loss of correction. A course of intravenous antibiotics followed by long-term oral suppressive therapy should be pursued if instrumentation is retained. A shorter treatment course may be appropriate if hardware is removed 7).


The objective of a study was to investigate the morbidity and mortality associated with instrumented fusion in the setting of primary spinal infection.

A search was performed in the PubMed and Medline databases for clinical case series describing instrumented fusion in the setting of primary spinal infection between 2003 and 2013. The search was limited to the English language and case series including at least 20 patients. The primary outcome measure was postoperative infection (recurrent local infection) + surgical site infection (SSI); secondary outcome measures included reoperation rates, development of other complications, and perioperative mortality.

There were 26 publications that met the inclusion criteria, representing 931 patients with spondylodiscitis who underwent decompression, debridement, and instrumented fusion. Spinal infections occurred most commonly in the lumbosacral spine (39.1%) followed by the thoracic spine (27.1%). The most common microorganisms were Staphylococcus spp. After decompression, debridement, and instrumented fusion, the overall rate of postoperative infection was 6.3% (1.6% recurrent infection rate + 4.7% SSI rate). The perioperative complication rate was 15.4%, and the mortality rate was estimated at 2.3%. Reoperation for wound debridement, instrumentation removal, pseudoarthrosis, and/or progressive neurological deficit was performed in 4.5% of patients.

The findings in this literature review suggest that the addition of instrumentation in the setting of a primary spinal infection has a low local recurrent infection rate (1.6%). However, the combined risk of postoperative infection is 6.3% (recurrent infection + SSI), more than three-fold the current infection rate following instrumentation procedures for degenerative spine disease. Moreover, the addition of hardware does usher in complications such as instrumentation failure and pseudoarthrosis requiring reoperation 8).

Case series

2017

A retrospective, cohort study of 84 patients with deep spine infection managed at a major tertiary hospital over 14 years with a minimum follow up of 2 years.

It is often believed that implants should not be inserted in patients with deep spine infection because of the risk of persistent or recurrent infection. However, there are often concerns about spinal stability and a paucity of evidence to guide clinical practice in this field.

Dennis et al. compared the mortality, reoperation, and reinfection rates in patients with spine infection treated with antibiotics alone, antibiotics with debridement, and antibiotics with debridement and instrumentation. Significant outcome predictors were determined using multivariable logistic regression model.

Forty-nine males and 35 females with a mean age was 62.0 years had spine infection affecting the lumbar spine predominantly. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%).There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude inhospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02).

Spinal instrumentation in an infected spine is safe and not associated with higher reoperation or relapse rates. Mortality is lower for patients treated with instrumentation 9).


A retrospective review of patients with MRSE-related SSIs from 665 consecutive cases of SI surgery performed between 2007 and 2014

During the study period, SSIs occurred in 21 patients. MRSE was isolated from cultures obtained from surgical wounds in nine of the 21 patients (43%). There were four males and five females with a mean age of 63.9 ± 15.1 years. Six patients presented with inflammatory signs, such as wound drainage, pyrexia, erythema, and elevated C-reactive protein. Three patients did not have signs of infection, but had early implant failure, and were diagnosed by positive cultures collected at the time of revision surgery. The mean time from index surgery to the diagnosis of infection was 23.6 days (range, 7-88 days). In one patient, the implant was removed before antibiotic treatment was administered because of implant failure. Eight patients were managed with antibiotics and implant retention. During the follow-up period, MRSE-related SSIs in seven of the eight patients were resolved with implant retention and antibiotics without the need for further surgical intervention. One patient did not complete the antibiotic course because of side effects, and implant removal was required to control the infection.

Early detection, surgical debridement, and administration of appropriate antibiotics for a suitable duration enabled infection control without the need for implant removal in the treatment of MRSE-related SSI after SI surgery 10).


Eleven patients with SSI after undergoing spinal surgery involving instrumentation were studied. All had been refractory to conventional treatments, including intravenous antibiotic administration and conventional debridement and irrigation. Antibiotic-loaded bone cement was placed on and around the instrumentation to cover them and to occupy the surrounding dead space. Two general types of antibiotics were loaded into the polymethylmethacrylate bone cement. The recipes for the mixture were changed depending on the bacterial cultures. Sensitive antibiotics were administered generally for 2-6 weeks until the C-reactive protein level was normalized.

All patients were treated successfully using antibiotic-loaded bone cement. Only 1 patient needed a repeat of this procedure to treat an infection. Antibiotic-loaded bone cement was placed in situ in all patients during the follow-up period and there were no significant adverse events.

Antibiotic-loaded bone cement treatment reduces the dead space and achieves the targeted drug delivery simultaneously. Treatment using antibiotic-loaded bone cement is an effective treatment option for complex spinal SSI 11).


Between 2010 and 2015, 12 out of 514 patients who developed a deep infection after spinal surgery, were selected and reviewed retrospectively at multiple centers (MGM Hospital, Kamothe and Center for Orthopaedic & Spine Surgery, New Panvel, Navi Mumbai, India). Out of 12 patients, one of the patients needed a partial implant exchange although none of the cases needed complete implant removal. All patients had achieved clean closed wounds along with a retention of the instrumentation. There was no need for flap surgery to cover wound defect in any case. However, antibiotic treatment was necessary in all cases. None of the patients showed a new infection after the treatment.

The study demonstrates the usefulness of VAC therapy as an alternative management for wound conditioning of a back wound with the high complexity in nature after instrumented spine surgeries as it eliminates complex secondary surgeries, prolong use of antibiotics and removal of the implants 12).

2015

A retrospective database review of consecutive patients with traditional open lumbar spinal surgery was performed. SSIs patients were identified and reviewed for clinically relevant details, and postoperative SSIs’ incidence was calculated for the entire cohort as well as for subgroups with or without spinal implants. In 15 years, 1,176 patients underwent open lumbar spinal surgery with spinal implants and 699 without. Thirty-eight developed postoperative SSIs. Total SSI rate for the entire group was 2.03%. The incidence of postoperative SSIs in the nonimplant group was relatively low. Patients received antibiotics, hyperbaric oxygen therapy, and wet dressing.

Liu et al. provided the precise rates of postoperative SSIs in traditional open spinal surgery obtained from a single-centre data. Patients with spinal implants had higher SSIs’ incidence than those without 13).

2014

Thirty-six patients underwent only decompression, and 82 underwent decompression and instrumented fusion. In the decompression-only group, 8.33% of patients had continued osteomyelitis/discitis compared with 9.76% of patients in the instrumented group (P = 0.807). Importantly, the reoperation rate was also similar between the decompression-only group (19.44%) and the instrumented group (17.07%; P = 0.756). Similarly, subanalyses based on infection location revealed no significant increase in rates of recurrent infection or reoperation in patients who underwent instrumentation 14).


Patients who received just decompression for spinal infection had similar reoperation and continued infection rates as patients who additionally underwent instrumentation, irrespective of infection location within the spine. These findings suggest that instrumentation of the infected spine may be a safe treatment modality and should be considered when the spinal integrity is compromised 15).

2008

A 10-year retrospective audit. (1) The incidence of infection; (2) causative organisms; (3) whether eradication of infection is achievable with spinal implant retention; (4) patient outcome. The reported incidence of infection following posterior spinal instrumentation is between 2.6 and 3.8%. Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants. There are no published data demonstrating that propionibacteria are associated with early postoperative infection. The management of infected cases at our institution includes eventual removal of their implants. Our population was identified by studying the case notes of all patients who had undergone removal of spinal implants and cross-referencing this population with positive microbiology or histology reports. The incidence of infection was 3.7%. Propionibacteria were isolated in 45% of cases. The diagnosis of infection was unexpected in 25% of patients, following removal of implants for prominence of implants or back pain. Sixty per cent of patients with acute postoperative deep wound infection had continuing active infection on subsequent removal of implants, despite long-term antibiotics and wound debridement. Fourty-six per cent of patients had a stable, pain-free spine at the end of their treatment. This is the largest reported series of infections following posterior spinal instrumented fusions of which we are aware. Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone 16).

1997

Twenty-three of 238 patients (9.7%) developed wound infections following segmental spinal instrumentation. When the infected group and a matched control group were compared, the infected group had a significantly higher number of patients with cerebral palsy and myelodysplasia (nonambulatory), patients with wound hematomas, patients with fusions that extended into the sacral region, and patients who were incontinent of urine. A high incidence of infections with gram-negative aerobic bacilli correlated with the extension of the surgery into the sacral region and bowel and/or bladder incontinence. Prophylactic antibiotics with broader coverage for gram-negative bacilli may be warranted for these procedures. Postoperative wound infections were managed by surgical drainage and debridement as well as antibiotics. Removal of the hardware was not necessary to control the infection in these patients who underwent segmental spinal instrumentation 17).

1)

Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. Int Orthop. 2012 Feb;36(2):457-64. doi: 10.1007/s00264-011-1426-0. Epub 2012 Jan 5. Review. PubMed PMID: 22218913; PubMed Central PMCID: PMC3282865.

2) , 6)

Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int. 2013 Oct 29;4(Suppl 5):S392-403. doi: 10.4103/2152-7806.120783. eCollection 2013. PubMed PMID: 24340238; PubMed Central PMCID: PMC3841941.

3)

Kunakornsawat S, Tungsiripat R, Putthiwara D, Piyakulkaew C, Pluemvitayaporn T, Pruttikul P, Kittithamvongs P. Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations. Global Spine J. 2017 Aug;7(5):448-451. doi: 10.1177/2192568217699389. Epub 2017 Apr 11. PubMed PMID: 28811989; PubMed Central PMCID: PMC5544159.

4)

Kimura H, Shikata J, Odate S, Soeda T. Pedicle Screw Fluid Sign: An Indication on Magnetic Resonance Imaging of a Deep Infection After Posterior Spinal Instrumentation. Clin Spine Surg. 2017 May;30(4):169-175. doi: 10.1097/BSD.0000000000000040. PubMed PMID: 28437330.

5)

Dobran M, Mancini F, Nasi D, Scerrati M. A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. BMJ Case Rep. 2017 Jul 28;2017. pii: bcr-2017-220792. doi: 10.1136/bcr-2017-220792. PubMed PMID: 28756380.

7)

Lall RR, Wong AP, Lall RR, Lawton CD, Smith ZA, Dahdaleh NS. Evidence-based management of deep wound infection after spinal instrumentation. J Clin Neurosci. 2015 Feb;22(2):238-42. doi: 10.1016/j.jocn.2014.07.010. Epub 2014 Oct 11. Review. PubMed PMID: 25308619.

8)

DE LA Garza-Ramos R, Bydon M, Macki M, Abt NB, Rhee J, Gokaslan ZL, Bydon A. Instrumented fusion in the setting of primary spinal infection. J Neurosurg Sci. 2017 Feb;61(1):64-76. Epub 2015 Apr 15. Review. PubMed PMID: 25875732.

9)

Dennis Hey HW, Nathaniel Ng LW, Tan CS, Fisher D, Vasudevan A, Liu KG, Thambiah JS, Kumar N, Lau LL, Wong HK, Tambyah PA. Spinal Implants Can Be Inserted in Patients With Deep Spine Infection: Results From a Large Cohort Study. Spine (Phila Pa 1976). 2017 Apr 15;42(8):E490-E495. doi: 10.1097/BRS.0000000000001747. PubMed PMID: 27333342.

10)

Takizawa T, Tsutsumimoto T, Yui M, Misawa H. Surgical Site Infections Caused by Methicillin-resistant Staphylococcus epidermidis After Spinal Instrumentation Surgery. Spine (Phila Pa 1976). 2017 Apr 1;42(7):525-530. doi: 10.1097/BRS.0000000000001792. PubMed PMID: 27428392.

11)

Masuda S, Fujibayashi S, Otsuki B, Kimura H, Matsuda S. Efficacy of Target Drug Delivery and Dead Space Reduction Using Antibiotic-loaded Bone Cement for the Treatment of Complex Spinal Infection. Clin Spine Surg. 2017 Jul 7. doi: 10.1097/BSD.0000000000000567. [Epub ahead of print] PubMed PMID: 28692571.

12)

Kale M, Padalkar P, Mehta V. Vacuum-Assisted Closure in Patients with Post-operative Infections after Instrumented Spine Surgery: A Series of 12 Cases. J Orthop Case Rep. 2017 Jan-Feb;7(1):95-100. doi: 10.13107/jocr.2250-0685.706. PubMed PMID: 28630851; PubMed Central PMCID: PMC5458710.

13)

Liu JT, Liao WJ, Chang CS, Chen YH. Management of Deep Infection after Instrumentation on Lumbar Spinal Surgery in a Single Institution. Biomed Res Int. 2015;2015:842010. doi: 10.1155/2015/842010. Epub 2015 Jul 26. PubMed PMID: 26273650; PubMed Central PMCID: PMC4529929.

14) , 15)

Bydon M, De la Garza-Ramos R, Macki M, Naumann M, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Spinal Instrumentation in Patients with Primary Spinal Infections Does Not Lead to Greater Recurrent Infection Rates: An Analysis of 118 Cases. World Neurosurg. 2014 Jun 14. pii: S1878-8750(14)00560-9. doi: 10.1016/j.wneu.2014.06.014. [Epub ahead of print] Review. PubMed PMID: 24937598.

16)

Collins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vineyakam P, Berendt T, Fairbank J. The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J. 2008 Mar;17(3):445-450. doi: 10.1007/s00586-007-0559-8. Epub 2007 Dec 13. Erratum in: Eur Spine J. 2017 Jul 20;:. PubMed PMID: 18075763; PubMed Central PMCID: PMC2270376.

17)

Perry JW, Montgomerie JZ, Swank S, Gilmore DS, Maeder K. Wound infections following spinal fusion with posterior segmental spinal instrumentation. Clin Infect Dis. 1997 Apr;24(4):558-61. PubMed PMID: 9145726.

Update: Spinal intramedullary tuberculosis

Spinal intramedullary tuberculosis

First reported by Cascino and Dibble 1).

Epidemiology

Intramedullary spinal tuberculosis is rare and constitute only 0.2-5% of all CNS tuberculoma2) 3). The combination of intramedullary and intracranial tuberculomas is extremely rare and only few cases have been reported in the literature so far 4) 5) 6) 7) 8).

Clinical features

Clinical presentation of spinal intramedullary tuberculosis (SIMT) is similar to intramedullary spinal cord tumor, with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction.

Diagnosis

Diagnosis is strongly suspected with a clinical history of known tuberculosis in conjunction with characteristic findings on magnetic resonance imaging.

The MRI is a sensitive and non-invasive tool for diagnosing and localizing intramedullary as well as brain tuberculomas. The lesion appears as an isointense or hyperintense ring on the T1-weighted images and as an isointense or hypointense lesion on the T2-weighted images. MRI will also delineate the extent of surrounding edema. MRI also helps in determining the stage of tuberculoma formation. Presence of a bright central spot in the granuloma (target sign) is indicative of central caseation (rich foci).

Gd-DTPA enhancement MRI is more sensitive than MRI without enhancement in demonstrating the lesions of tuberculoma and arachnoiditis. In early stages of brain tuberculoma contrast MRI will show homogeneous enhancement representing the early tuberculoma stage, which may later evolve to ring enhancement with hypointense center. 9) 10) 11).

Jaiswal et al. suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intracranial tuberculomas 12).

Treatment

Management involves multiagent antitubercular chemotherapy without or with operative intervention.

Conservative treatment with antituberculosis medications and a short course of injectable steroids offers an effective, inexpensive, safe, and feasible option for treating intra-medullary tuberculoma, especially in developing countries 13).

Role of steroid is largely unproven. However, in patients with peri-lesional edema short-term steroids may be helpful 14). Usually, the conservative treatment is successful in achieving complete clinical neurological recovery over a period of 1 year, which is also accompanied by resolution of the tuberculomas 15).

Surgery is reserved for the patients with large lesions causing significant compression, patients who do not respond to or deteriorates during conservative treatment 16) 17) 18) 19) 20) 21) 22) 23) 24).

Case series

2009

Fifteen patients were analyzed. Mean age of presentation was 31 years (range: 18-45 years), with average duration at presentation being 11 months (2-24 months). Common locations: dorsal region: 7 cases, cervical: 5 cases, cervicodorsal: 2 cases and dorsolumbar region: 1 case. Sensori-motor involvement was noted in fourteen patients. Bowel and bladder involvement was seen in ten patients while one patient had respiratory distress. Only 40% of patients had secondary involvement of spine while the rest of the cases were having primary spinal intramedullary tuberculosis. Three patients had previous history of tubercular meningitis, while one patient had old pulmonary tuberculosis. There were one case each of cervical node involvement and intracranial granuloma. Twelve patients underwent surgery while others were conservatively managed, all patients received antitubercular therapy for 18 months. Nine of the twelve operated patients showed improvement in motor power, while two of the conservatively managed patients improved. Patients presenting late had a poorer outcome.

Spinal intramedullary tuberculosis is a non-malignant, treatable lesion giving a good outcome on management. Surgically managed patients showed a better outcome 25).

2002

During a period of 16 years (1985-2000), ten cases of intramedullary tuberculomas were diagnosed in All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Of these, eight cases were histologically proven intramedullary tuberculomas. The clinical profile, radiological data and histological slides were reviewed.

Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (six men, four women). Duration of symptom varied from 3 to 20 months (mean 11.5 months). All of them presented with motor weakness and sensory impairment. Most common site of involvement was dorsal cord followed by cervical, cervicodorsal and dorsolumbar regions. Three patients had associated involvement of lungs, cervical lymphnodes, and brain, and one patient had past history of tuberculous meningitis. Two patients were treated conservatively but surgical excision was done in eight cases followed by medical treatment.

Radiologically, intramedullary tuberculomas should be differentiated from other space occupying lesions (SOL) to avoid unnecessary surgery especially in those patients with tuberculosis of the other organs. The incidence of intramedullary tuberculomas is likely to increase with a rise in the incidence of AIDS 26).

Case reports

2017

A case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention.

They suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intracranial tuberculomas 27).


A 9 month old boy with a retrospectively-recognized history of pulmonary TB presenting with fever and back tenderness found to have lower extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions 28).


Varghese et al. report the case of a 49-year-old female with dull aching pain of both upper limbs of 1-week duration. On examination, she had no motor deficits. All the deep tendon reflexes were normal. The plantar responses were flexor bilaterally. Cervical spine imaging favored intramedullary tumor. She had partial relief of symptoms with steroid treatment. Repeat imaging done 1 month later revealed mild interval enlargement of the intramedullary lesions and multiple enlarged mediastinal and hilar nodes. Endoscopic ultrasound-guided fine-needle aspiration cytology of mediastinal nodes was suggestive of granulomatous inflammation. Hence, SIMT was considered as the probable diagnosis. The patient was started on antituberculosis therapy 29).

2015

A 25-year-old male who presented with a history of progressive paraparesis. Initial diagnosis was made as an intramedullary tumor by magnetic resonance imaging (MRI). The treatment of the patient involved is complete surgical excision of intramedullary lesion followed by appropriate antituberculous therapy. Postoperatively, his neurological symptoms were dramatically improved. With combination of both surgical and medical treatments, excellent clinical outcome was obtained.

This case illustrates the risk of misdiagnosis and the importance of histological confirmation of a pathological lesion as spinal cord tuberculoma prior to surgical therapy, which should be kept in mind as a differential diagnosis of the intramedullary spinal cord tumors 30).

2012

A patient with dorsal intramedullary tuberculoma who improved clinically as well as radiologically with antituberculous treatment and steroids 31).

References

1)

Cascino J, Dibble JB. Tuberculoma of spinal cord. JAMA. 1956;162(5):461–462.
2) , 16)

Citow JS, Ammirati M. Intramedullary tuberculoma of the spinal cord: Case report. Neurosurgery. 1994;35:327–30.
3) , 17)

Süzer T, Coşkun E, Tahta K, Bayramoǧlu H, Düzcan E. Intramedullary spinal tuberculoma presenting as a conus tumor: A case report and review of the literature. Eur Spine J. 1998;7:168–71.
4) , 14)

Huang CR, Lui CC, Chang WN, Wu HS, Chen HJ. Neuroimages of disseminated neurotuberculosis: Report of one case. Clin Imaging. 1999;23:218–22.
5) , 9)

Lin SK, Wu T, Wai YY. Intramedullary spinal tuberculomas during treatment of tuberculous meningitis. Clin Neurol Neurosurg. 1994;96:71–8.
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Shen WC, Cheng TY, Lee SK, Ho YJ, Lee KR. Disseminated tuberculomas in spinal cord and brain demonstrated by MRI with gadolinium-DTPA. Neuroradiology. 1993;35:213–5.
7) , 10) , 13) , 15)

Thacker MM, Puri AI. Concurrent intra-medullary and intra-cranial tuberculomas. J Postgrad Med. 2004;50:107–9.
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Yen HL, Lee RJ, Lin JW, Chen HJ. Multiple tuberculomas in the brain and spinal cord: A case report. Spine (Phila Pa 1976) 2003;28:E499–502.
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Shaharao VB, Pawar M, Agarwal R, Bavdekar SB. Intra-medullary tuberculoma occurring during treatment of tuberculous meningitis. Indian J Pediatr. 2004;71:107–8.
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Jaiswal M, Gandhi A, Purohit D, Mittal RS. Concurrent multiple intracranial and intramedullary conus tuberculoma: A rare case report. Asian J Neurosurg. 2017 Apr-Jun;12(2):331-333. doi: 10.4103/1793-5482.143461. PubMed PMID: 28484568; PubMed Central PMCID: PMC5409404.
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Gupta VK, Sharma BS, Khosla VK. Intramedullary tuberculoma: Report of two cases with MRI findings. Surg Neurol. 1995;44:241–3.
22)

Kayaoglu CR, Tuzun Y, Boga Z, Erdogan F, Gorguner M, Aydin IH. Intramedullary spinal tuberculoma: A case report. Spine (Phila Pa 1976) 2000;25:2265–8.
23)

Kumar R, Jain R, Kaur A, Chhabra DK. Brain stem tuberculosis in children. Br J Neurosurg. 2000;14:356–61.
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Rhoton EL, Ballinger WE, Jr, Quisling R, Sypert GW. Intramedullary spinal tuberculoma. Neurosurgery. 1988;22:733–6
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Ramdurg SR, Gupta DK, Suri A, Sharma BS, Mahapatra AK. Spinal intramedullary tuberculosis: a series of 15 cases. Clin Neurol Neurosurg. 2009 Feb;111(2):115-8. doi: 10.1016/j.clineuro.2008.09.029. Epub 2008 Dec 5. PubMed PMID: 19058910.
26)

Sharma MC, Arora R, Deol PS, Mahapatra AK, Sinha AK, Sarkar C. Intramedullary tuberculoma of the spinal cord: a series of 10 cases. Clin Neurol Neurosurg. 2002 Sep;104(4):279-84. PubMed PMID: 12140088.
28)

Ghali MGZ, Srinivasan VM, Kim CJ, Malik A. Spinal intramedullary tuberculosis with concurrent supra- and infratentorial intracranial disease in a 9 month old boy: case report and review of the literature. World Neurosurg. 2017 May 19. pii: S1878-8750(17)30768-4. doi: 10.1016/j.wneu.2017.05.069. [Epub ahead of print] Review. PubMed PMID: 28532916.
29)

Varghese P, Abdul Jalal MJ, Kandathil JC, Mathew IL. Spinal Intramedullary Tuberculosis. Surg J (N Y). 2017 Mar 30;3(2):e53-e57. doi: 10.1055/s-0037-1599823. eCollection 2017 Apr. PubMed PMID: 28825021; PubMed Central PMCID: PMC5553513.
30)

Mishra SS, Das D, Das S, Mohanta I, Tripathy SR. Spinal cord compression due to primary intramedullary tuberculoma of the spinal cord presenting as paraplegia: A case report and literature review. Surg Neurol Int. 2015 Mar 23;6:42. doi: 10.4103/2152-7806.153844. eCollection 2015. PubMed PMID: 25883834; PubMed Central PMCID: PMC4392528.
31)

Thirunavukarasu SC, Ramachandrappa A. A rare case of intramedullary tuberculoma: Complete resolution after medical treatment and role of magnetic resonance imaging in diagnosis and follow-up. Asian J Neurosurg. 2012 Oct;7(4):223-6. doi: 10.4103/1793-5482.106661. PubMed PMID: 23559994; PubMed Central PMCID: PMC3613649.

Update: Thromboprophylaxis in Spinal Surgery

Thromboprophylaxis in Spinal Surgery

Published institutional practices for Venous thromboembolic prophylaxis are highly variable and there are no universally accepted guidelines.

While the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature.

Findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis 1)2).

Case series

2014

An institutional review board-approved retrospective review of outcomes in patients undergoing spine surgery 2 years before protocol implementation (representing the preprotocol group) and of outcomes in patients treated 2 years thereafter (the postprotocol group) was conducted. Inclusion criteria were that patients were 18 years or older and had been admitted for 1 or more days. Before 2008 (preprotocol), VTE prophylaxis was variable and provider dependent without any uniform protocol. Since 2008 (postprotocol), a new VTE-prophylaxis protocol was administered, starting either preoperatively or on the same day of surgery and continuing throughout hospitalization. The new protocol consisted of 5000 U heparin administered subcutaneously 3 times daily, except in patients older than 75 years or weighing less than 50 kg, who received this dose twice daily. All patients also received sequential compression device. The incidence of VTE in the 2 protocol phases was identified by codes of the International Classification of Diseases, Ninth Revision (ICD-9) codes for deep vein thrombosis (DVT) and pulmonary embolus (PE). Bleeding complications arising from anticoagulation treatments were evaluated by the Current Procedural Terminology (CPT) code for postoperative spinal epidural hematoma (EDH) requiring evacuation.

In total, 941 patients in the preprotocol group met the inclusion criteria: 25 had DVT (2.7%), 6 had PE (0.6%), and 6 had postoperative EDH (0.6%). In the postprotocol group, 992 patients met the criteria: 10 had DVT (1.0%), 5 had PE (0.5%), and 4 had postoperative EDH (0.4%). This reduction in DVT after the protocol’s implementation was statistically significant (p = 0.009). Despite early aggressive prophylaxis, the incidence of postoperative EDH did not increase and compared favorably to the published literature.

At a high-volume tertiary center, an aggressive protocol for early VTE prophylaxis after spine surgery decreases VTE incidence without increasing morbidity 3).


Between December 2006 and January 2011, 209 patients undergoing spinal surgery (121 males, 88 females; average age: 64 yr), who also had ultrasonographic assessments of both legs before and after surgery, were prospectively assessed. A pneumatic sequential compression device and standard compression stockings were used for primary VTE prophylaxis. In Mie University Hospital protocol, pharmacological agents were not used for VTE prophylaxis after surgery. However, when a distal type DVT was found preoperatively, an anticoagulant medication was administered until 6 hours prior to surgery. After detection of DVTs, weekly ultrasonography assessed the DVT.

Twenty-three patients (11.0%) showed VTE in the spinal surgery perioperative period. Nine patients (4.3%) had VTE (PE with proximal DVT, 1 [0.5%]; distal DVT, 8 [3.8%]) before surgery. In the one case of asymptomatic PE with proximal DVT, an inferior vena cava filter was placed before surgery. Fourteen patients (6.7%) developed new-onset VTE (PE with proximal DVT, 2 [1.0%]; distal DVT, 12 [5.9%]) after spinal surgery. New-onset PE with proximal DVT occurred in 2 patients after surgery. Follow-up ultrasonographic assessment showed that the DVT disappeared completely in 85% (17/20) of patients with a distal type DVT during the perioperative period.

DVT assessment using ultrasonography is important for proper management of VTE during the perioperative period of spinal surgery, especially for high-risk patients, such as those with advanced age or neurological deficit. The institutional protocol for VTE using pneumatic sequential compression device and compression stockings is effective, although the administration of chemoprophylaxis should be considered for high-risk patients, such as those with spinal tumors and spinal trauma 4).

2011

Yu et al., separated 298 spinal patients who had different VTE risk factors into low-, medium- and high-risk groups for 22 cases, 48 cases and 228 cases respectively. Physical prevention measures such as thigh-length thromboembolic deterrent stockings (TEDS) and pneumatic sequential compression device (PSCD) were used in low- and medium-risk groups. In high-risk groups, low molecular weight heparin(LMWH) was applied in addition to physical prevention measures. Lower limb vascular doppler ultrasonography was used to monitor thrombosis pre- and postoperatively. Simultaneously the occurrences of epidural or wound hematoma, mucosal bleeding, thrombocytopenia caused by low molecular heparin and nerve damage caused by extradural hemorrhage were monitored.

Among the 298 cases of patients with spinal surgery, DVT occurred in 23 cases, the incidence of DVT was 7.7%. There were 0, 2 and 21 patients with positive findings of deep vein thrombosis on duplex ultrasonograph respectively in low-, medium- and high-risk groups. There was no case of PE. All DVT was thrombosis in calf which was distal to the knee. There was no clinical symptom of VTE. The DVT needed no therapy. The vein with thrombosis was recanalized 3 months after operation. No case caught epidural or wound hematoma, mucosal bleeding, thrombocytopenia caused by low molecular heparin or nerve damage caused by extradural hemorrhage.

Individual VTE prophylaxis was taken according to risk stratifications. No VTE of clinical value or no complications from prophylaxis happened. So our prophylaxis is effective and safe. But more prospective, case-control studies are needed to assess the efficacy and safety of VTE prophylaxis5).

1)

Mosenthal WP, Landy DC, Boyajian HH, Idowu OA, Shi LL, Ramos E, Lee MJ. Thromboprophylaxis in Spinal Surgery. Spine (Phila Pa 1976). 2017 Aug 17. doi: 10.1097/BRS.0000000000002379. [Epub ahead of print] PubMed PMID: 28820759.
2)

Bryson DJ, Uzoigwe CE, Braybrooke J. Thromboprophylaxis in spinal surgery: a survey. J Orthop Surg Res. 2012 Mar 29;7:14. doi: 10.1186/1749-799X-7-14. PubMed PMID: 22458927; PubMed Central PMCID: PMC3349591.
3)

Cox JB, Weaver KJ, Neal DW, Jacob RP, Hoh DJ. Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis: Clinical article. J Neurosurg Spine. 2014 Oct;21(4):677-84. doi: 10.3171/2014.6.SPINE13447. PubMed PMID: 25105337.
4)

Akeda K, Matsunaga H, Imanishi T, Hasegawa M, Sakakibara T, Kasai Y, Sudo A. Prevalence and countermeasures for venous thromboembolic diseases associated with spinal surgery: a follow-up study of an institutional protocol in 209 patients. Spine (Phila Pa 1976). 2014 May 1;39(10):791-7. doi: 10.1097/BRS.0000000000000295. PubMed PMID: 24583727.
5)

Yu ZR, Li CD, Yi XD, Lin JR, Liu XY, Liu H, Lu HL. [Prevention for venous thromboembolism prophylaxis after spinal surgery]. Beijing Da Xue Xue Bao. 2011 Oct 18;43(5):661-5. Chinese. PubMed PMID: 22008671.

Update: Spine injury

Spine injury

Controversies

At this moment there is persistent controversy within the spinal trauma community, which can be grouped under 6 headings:

First of all there is still no unanimity on the role and timing of medical and surgical interventions for patients with associated neurologic injury.

Type and timing of surgical intervention in multiply injured patients.

In some common injury types like odontoid fractures and thoracolumbar burst fracture, there is wide variation in practice between operative versus nonoperative management without clear reasons.

The role of different surgical approaches and techniques in certain injury types are not clarified yet.

Methods of nonoperative management and care of elderly patients with concurrent complex disorders are also areas where there is no consensus1).

Types

Spinal cord injury

Whiplash-associated disorders

Pediatric spine injury

Cervical spine injury

Thoracolumbar spine fracture

Sacral fracture

Osteoporotic vertebral fracture

Spinal gunshot wound

Penetrating neck trauma


Traumatic spine injuries are often transferred to regional tertiary trauma centers from OSH and subsequently discharged from the trauma center’s emergency department (ED) suggesting secondary overtriage of such injuries.

A study to investigate interfacility transfers with spine injuries found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and spine specialist at the tertiary center, and utilization of teleradiology 2).

Complications

Hydrocephalus is a rare complication of traumatic spine injury. A literature review reflects the rare occurrence with cervical spine injury.

Dragojlovic et al present a case of traumatic injury to the lumbar spine from a gunshot wound, which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. The headaches worsened, so a computed tomography scan of the brain was obtained, which revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and subsequent computed tomography scan of the brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Intrathecal hemorrhage with subsequent obstruction or decreased absorption of cerebrospinal fluid at the distal spinal cord was thought to lead to communicating hydrocephalus in this case of lumbar penetrating trauma. In patients with a history of hemorrhagic, traumatic spinal injury who subsequently experience headaches or altered mental status, hydrocephalus should be included in the differential diagnosis and adequately investigated 3).

Assessment

ATLS® algorithm and spine trauma assessment. In Step „A“ cervical spine (C-Spine) protection is indispensable. Every unconscious patient is stabilized by stiff-neck. Patients with signs of chest injury in step „B” and abdominal injury in step „C“, especially retroperitoneal are highly suspicious for thoracic (T-) and/or (L-) lumbar spine injury. Normal motor exam and reflexes do not rule out significant spine injury in the comatose patient. Abnormal neurologic exam is a sign for substantial spinal column injury including spinal cord injury (SCI). Log roll in step „E” is important to assess the dorsum of the cervical to the sacral spine and to look out for any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and posterior processus in search for distraction injury. Spine precautions should only be discontinued when patients gain back consciousness and are alert to communicate sufficiently on spinal discomfort or neurologic sensations before the spine is cleared 4).

Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected:

There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1-2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females; low falls; one spine injury level; type 2 odontoid fractures; subaxial cervical spine distraction injuries; ASIA A, B, and C neurological grades; and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study’s unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma 5).

Outcome

There is no universally accepted outcome instrument available that is specifically designed or validated for spinal trauma patients, contributing to controversies related to the optimal treatment and evaluation of many types of spinal injuries. Therefore, the AOSpine Knowledge Forum Trauma aims to develop such an instrument using the International Classification of Functioning Disability and Health (ICF) as its basis.

Experts from the 5 AOSpine International world regions were asked to give their opinion on the relevance of a compilation of 143 ICF categories for spinal trauma patients on a 3-point scale: “not relevant,” “probably relevant,” or “definitely relevant.” The responses were analyzed using frequency analysis. Possible differences in responses between the 5 world regions were analyzed with the Fisher exact test and descriptive statistics.

Of the 895 invited AOSpine International members, 150 (16.8%) participated in this study. A total of 13 (9.1%) ICF categories were identified as definitely relevant by more than 80% of the participants. Most of these categories were related to the ICF component “activities and participation” (n = 8), followed by “body functions” (n = 4), and “body structures” (n = 1). Only some minor regional differences were observed in the pattern of answers.

More than 80% of an international group of health care professionals experienced in the clinical care of adult spinal trauma patients indicated 13 of 143 ICF categories as definitely relevant to measure outcomes after spinal trauma. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spinal trauma patients 6).

Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes 7).

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Tee JW, Chan CH, Gruen RL, Fitzgerald MC, Liew SM, Cameron PA, Rosenfeld JV.Early predictors of health-related quality of life outcomes in polytrauma patients with spine injuries: a level 1 trauma center study. Global Spine J. 2014 Feb;4(1):21-32. doi: 10.1055/s-0033-1358617. Epub 2013 Nov 6. PubMed PMID: 24494178.