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European Spine Journal : Official... Nov 2016Low back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic... (Review)
Review
PURPOSE
Low back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic changes on MRI have a high specificity for discogenic LBP. This review summarizes the pathobiology of Modic changes and suggests a disease model.
METHODS
Non-systematic literature review.
RESULTS
Chemical and mechanical stimulation of nociceptors adjacent to damaged endplates are likely a source of pain. Modic changes are adjacent to a degenerated intervertebral disc and have three generally interconvertible types suggesting that the different Modic change types represent different stages of the same pathological process, which is characterized by inflammation, high bone turnover, and fibrosis. A disease model is suggested where disc/endplate damage and the persistence of an inflammatory stimulus (i.e., occult discitis or autoimmune response against disc material) create predisposing conditions. The risk to develop Modic changes likely depends on the inflammatory potential of the disc and the capacity of the bone marrow to respond to it. Bone marrow lesions in osteoarthritic knee joints share many characteristics with Modic changes adjacent to degenerated discs and suggest that damage-associated molecular patterns and marrow fat metabolism are important pathogenetic factors. There is no consensus on the ideal therapy. Non-surgical treatment approaches including intradiscal steroid injections, anti-TNF-α antibody, antibiotics, and bisphosphonates have some demonstrated efficacy in mostly non-replicated clinical studies in reducing Modic changes in the short term, but with unknown long-term benefits. New diagnostic tools and animal models are required to improve painful Modic change identification and classification, and to clarify the pathogenesis.
CONCLUSION
Modic changes are likely to be more than just a coincidental imaging finding in LBP patients and rather represent an underlying pathology that should be a target for therapy.
Topics: Bone Marrow; Humans; Intervertebral Disc; Low Back Pain; Lumbar Vertebrae; Magnetic Resonance Imaging; Models, Biological
PubMed: 26914098
DOI: 10.1007/s00586-016-4459-7 -
European Review For Medical and... Apr 2019This systematic review focuses on 5 key elements that may improve the decision-making process in spondylodiscitis: the infective agent, segmental instability, abscess...
OBJECTIVE
This systematic review focuses on 5 key elements that may improve the decision-making process in spondylodiscitis: the infective agent, segmental instability, abscess development, neurological compromise and focus of infection.
MATERIALS AND METHODS
We included 64 studies published between May 2012 and May 2017, that reported both a description of the discitis and comparative data regarding the disease and its complications.
RESULTS
The majority of cases were caused by Staphylococcus spp (40.3%) and involved the lumbosacral region (52.3%). 27.8% of cases were associated to neurological compromise, 30.4% developed an abscess, 6.6% were associated to instability, and 54.7% underwent surgery. The abscesses mostly involved the lumbosacral region (60.4%) with paravertebral localization; 32.6% of cases involved the thoracic region, showing mostly epidural localization; a small number of cases (7%) involved the cervical region, mostly with epidural localization. 95% of paravertebral abscesses were treated percutaneously, while 85.7% of epidural cases underwent "open" surgery. Spinal cord compression mainly occurred in the cervical region (55.9%), neurological deficit was observed in over half of cases (65%), and surgery was required in most of the cases (83.9%). The majority of cases of instability involved the lumbosacral region (53.3%) and underwent surgery (87%). The focus of infection was mostly lumbosacral (61%) and almost all cases (95%) were treated surgically.
CONCLUSIONS
Spondylodiscitis is a complex and multifactorial disease, whose diagnosis and management are still challenging. Due to its potential morbidity, it is extremely important to investigate the 5 key elements discussed in this paper in order to provide an early diagnosis and initiate the most effective treatment.
Topics: Decision Making; Discitis; Humans
PubMed: 30977878
DOI: 10.26355/eurrev_201904_17481 -
International Orthopaedics Jan 2024Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors.
METHODS
A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed.
RESULTS
In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival.
CONCLUSION
Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.
Topics: Male; Humans; Middle Aged; Female; Candida; Antifungal Agents; Discitis; Candidiasis; Immunocompromised Host
PubMed: 37792014
DOI: 10.1007/s00264-023-05989-2 -
Healthcare (Basel, Switzerland) Sep 2022(), a bacterium that colonizes the gastrointestinal tract, is often isolated from periodontitis and abscesses as part of a complex bacterial infection. However, reports... (Review)
Review
(), a bacterium that colonizes the gastrointestinal tract, is often isolated from periodontitis and abscesses as part of a complex bacterial infection. However, reports of monobacterium infections due to are limited. Here, we report a case of monobacterial bacteremia caused by with the aim of identifying the source of the invasion and clarifying the clinical features. A 54-year-old patient presented with bacteremia due to and with an oral invasion that we suspected resulted from prior dental treatment. Using PubMed and Google Scholar databases, we undertook a systematic review of monobacteremia caused by . We identified 26 patients (mean age, 70.15 years) in our systematic review. bacteremia and its associated phenotypes were most frequently identified in spinal discitis, followed by epidural and lumbar abscesses, and infective endocarditis. The major risk factors were malignancy, diabetes mellitus, and post-arthroplasty. When is detected in blood cultures, evaluation and intervention for oral contamination may be indicated.
PubMed: 36141340
DOI: 10.3390/healthcare10091727 -
Children (Basel, Switzerland) Nov 2022The aim of this systematic review is to distinguish the clinical features of immunocompetent children with non-typhoid spondylodiscitis and summarize the diagnosis,... (Review)
Review
The aim of this systematic review is to distinguish the clinical features of immunocompetent children with non-typhoid spondylodiscitis and summarize the diagnosis, diagnostic tools, and treatment methods to guide clinicians. The review was conducted according to the preferred PRISMA guidelines. We conducted a literature search in the PubMed, Embase, and Cochrane Library databases. Article screening, data extraction, and study evaluation were performed by two independent reviewers. A total of 20 articles, published between 1977 and 2020, were selected, which included 21 patients with average age of 12.76 years (range, 2-18) without comorbidities; in total, 19% of the patients had positive blood cultures for non-typhoid , and 80.9% underwent either CT-guided or open biopsy, which were positive for NTS. All infections were monomicrobial, and 11 different serotypes of non-typhoid were identified. Analyzing the reviewed cases, 52.4% of the patients presented with fever, 90.5% had localized pain, and only 19% had gastroenteritis. The most common level of discitis was the lumbar region, especially the L4/L5 level. Primarily, third-generation cephalosporin was administered, and antibiotic treatment was given for an average of 9.6 weeks. Non-typhoid spondylodiscitis is a rare clinical entity in healthy and immunocompetent children. The identification of the responsible organism is essential to guide antibiotic therapy and define the treatment duration. A significant limiting factor in this systematic review was the lack of published research articles and case series due to the rarity of the disease.
PubMed: 36553297
DOI: 10.3390/children9121852 -
Regional Anesthesia and Pain Medicine Apr 2019Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the... (Review)
Review
Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the traditional landmark-based approach, or with image guidance using either fluoroscopy or ultrasound. In this review, we systematically analyzed reported SGNB-related complications between 1990 and 2018. Seven databases were queried for SGNB between January 1, 1990 and November 27, 2018. Search results of the complications associated with SGNB were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Out of a total of 1909 articles, 67 articles met our inclusion criteria, yielding 260 cases with adverse events. In 134 of the 260 (51.5%) cases, SGNB was performed with image guidance. Sixty-four (24.6%) and 70 (26.9%) of the complication cases reported the use of ultrasound and fluoroscopy guidance, respectively. One hundred and seventy-eight (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB. Complications following SGNB have been reported with both landmark-based techniques and with imaging guidance using fluoroscopy or ultrasound. In our systematic review, most adverse events that were reported occurred during or shortly after SGNB. Vigilance, American Society of Anesthesiologists standard monitors for conscious sedation, and accessibility to resuscitation equipment are vital to the safe performance of SGNB.
PubMed: 30992414
DOI: 10.1136/rapm-2018-100127 -
Journal of Clinical Medicine Research Apr 2023Osteoarticular infections (OAIs) caused by () are a rare clinical entity. This study aimed to review all published cases of OAI due to A systematic review of PubMed,... (Review)
Review
Osteoarticular infections (OAIs) caused by () are a rare clinical entity. This study aimed to review all published cases of OAI due to A systematic review of PubMed, Scopus, and Cochrane Library was conducted to report the demographic and clinical characteristics, microbiological data, management, and outcome of OAIs caused by in the adult population. A total of 16 studies reporting on 16 patients were included in this review. Eight patients had arthritis and eight patients had osteomyelitis/discitis. The most reported risk factors were immunosuppression, poor dental hygiene/dental infections, and recent gastrointestinal (GI) endoscopy. Five cases of arthritis occurred in a native joint while three patients had prostheses. The potential source of infection was documented in more than half of the cases (56%) (most commonly odontogenic and GI sources (25% and 18%, respectively). The knee and hip joints were the most frequently affected joints in patients with arthritis, while the thoracic vertebrae were the most common sites for osteomyelitis/discitis. The blood cultures were positive in three patients with arthritis (37.5%) and five patients with osteomyelitis/discitis (62.5%). Associated endovascular infection was found in five patients with bacteremia. Contiguous spread (adjacent mediastinitis) was documented in two patients with sternal osteomyelitis and thoracic vertebral osteomyelitis. Surgical interventions were performed for 12 patients (75%). Most strains of were susceptible to penicillin and cephalosporins. All patients with reported outcomes had achieved complete recovery. is an emerging pathogen for OAIs in certain susceptible populations with specific risk factors. This review reported the demographic, clinical, and microbiological features of OAIs caused by . A careful evaluation of an underlying infectious focus is warranted to control the source. When bacteremia is present, it is also necessary to have a high index of suspicion to rule out an associated endovascular infection.
PubMed: 37187711
DOI: 10.14740/jocmr4891 -
Scientific Reports Sep 2023Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some... (Meta-Analysis)
Meta-Analysis
Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some advocate that early surgery can improve mortality, relapse rates, and length of stay. Given that the condition carries a high mortality rate of up to 20%, the most effective treatment must be identified. We aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis.
Topics: Humans; Discitis; Spinal Diseases; Conservative Treatment; Databases, Factual; Early Intervention, Educational
PubMed: 37730826
DOI: 10.1038/s41598-023-41381-1 -
AJNR. American Journal of Neuroradiology Oct 2017Image-guided biopsy is routinely conducted in patients with suspected discitis, though the sensitivity reported in the literature ranges widely. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Image-guided biopsy is routinely conducted in patients with suspected discitis, though the sensitivity reported in the literature ranges widely.
PURPOSE
We applied a systematic review and meta-analysis to estimate the yield of image-guided biopsy for infectious discitis.
DATA SOURCES
We performed a literature search of 4 data bases: PubMed, Cochrane CENTRAL Register of Controlled Trials, Embase.com, and Scopus from data base inception to March 2016.
STUDY SELECTION
A screen of 1814 articles identified 88 potentially relevant articles. Data were extracted for 33 articles, which were eligible if they were peer-reviewed publications of patients with clinical suspicion of discitis who underwent image-guided biopsy.
DATA ANALYSIS
Patients with positive cultures out of total image-guided biopsy procedures were pooled to estimate yield with 95% confidence intervals. Hypothesis testing was performed with an inverse variance method after logit transformation.
DATA SYNTHESIS
Image-guided biopsy has a yield of approximately 48% (793/1763), which is significantly lower than the open surgical biopsy yield of 76% (152/201; < .01). Biopsy in patients with prior antibiotic exposure had a yield of 32% (106/346), which was not significantly different from the yield of 43% (336/813; = .08) in patients without prior antibiotic exposure.
LIMITATIONS
The conclusions of this meta-analysis are primarily limited by the heterogeneity of the included studies.
CONCLUSIONS
Image-guided biopsy has a moderate yield for the diagnosis of infectious discitis, which is significantly lower than the yield of open surgical biopsy. This yield is not significantly affected by prior antibiotic use.
Topics: Biopsy, Needle; Discitis; Humans; Image-Guided Biopsy; Infections
PubMed: 28882866
DOI: 10.3174/ajnr.A5337 -
Journal of Clinical Orthopaedics and... Apr 2021Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where... (Review)
Review
Posterior stabilisation without formal debridement for the treatment of non-tuberculous pyogenic spinal infection in frail and debilitated population - A systematic review and meta-analysis.
Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where there is evidence of spinal instability or neurological compromise. The primary surgical procedure, for late-stage PSI, focuses on the anterior approach with aggressive debridement of the infected tissue regions. An alternative treatment method that employs a posterior approach without any formal debridement, is seen as controversial. To the best of our knowledge, few case series and no systematic reviews are assessing the value of this posterior technique. We aim to evaluate the effectiveness of the posterior approach formal debridement and the associated clinical outcomes, for PSI cases requiring surgical intervention. Several databases including MEDLINE, NHS Evidence, and the Cochrane database were searched from the date of creation of each database to December 16, 2019. A selection of the keywords used includes: "posterior approach", "debridement" and "discitis". Studies were excluded if they involved the anterior approach, carried out formal debridement, or were tuberculous spinal infection cases. We accepted any study type which included adult patients, with spinal infection at any level of the vertebral column. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to follow standard systematic review structure. The main clinical outcomes evaluated include pain, neurological recovery (Frankel Grading System, FGS) post-operative complications, and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI). Post-surgical neurological improvement was demonstrated with a mean FGS improvement of 1.12 in 102 patients over the included four articles. Post-operative neurological function was found to be improved at a statistically significant level when a random-effects model was applied, with the effect size found to be at 0.68 (p < 0.001). Pain level was improved significantly postoperatively. There were also enhanced functional outcomes post-intervention when the Kirkaldy-Willis criteria and COMI scores were assessed in certain studies. Within the limit of the available literature, our results showed that the posterior approach with posterior stabilisation without formal debridement can result in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration is strongly recommended.
PubMed: 33717910
DOI: 10.1016/j.jcot.2020.11.009