Abstract Background context The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of ...select patients with SEA. Purpose The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA. Study design/setting This was a retrospective, case-control study. Patient sample Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample. Outcome measures The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits. Methods All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours. Results A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors. Conclusions SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring.
Abstract Background context Traumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability. Purpose To review the most current information ...regarding the pathophysiology, injury pattern, treatment options, and outcomes. Study design Literature review. Methods Relevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed. Results The thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well. Conclusions Thoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together.
Abstract Background context Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after ...administration of allogeneic blood transfusions. Purpose Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused. Study design/Setting This is a retrospective cohort study from a tertiary care spine referral center. Patient Sample A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine. Outcomes measures Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included. Methods Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery. Results The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval CI: 1.7–3.9, p<.001); 2.2 for urinary tract infections (95% CI: 1.3–3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96–5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3–5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis. Conclusions Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.
Abstract Background context Several reports indicate that patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) have increased mortality after cervical spine ...fractures. However, outcomes of the fractured hyperostotic cervical spine are incompletely described, and there are limited data regarding the covariable effects of patient age and medical comorbidities on mortality. Purpose To determine mortality associated with cervical fractures in patients with hyperostotic disease. Study design Retrospective case-control study. Patient sample Forty-three patients identified through a registry as having fractures of the cervical spine in the setting of hyperostotic disease. These patients were matched to 43 controls who did not carry the diagnosis of hyperostotic disease. Outcome measures Mortality at 3 months and 1, 2, and 3 years after fracture. Methods An institutional database was used to identify all cervical fractures sustained by patients aged 65 years and older from 1991 to 2006. Demographic information, date of injury, associated injuries, treatment type, presence of AS or DISH, and comorbidities were abstracted from medical records and radiographs. Mortality was ascertained using the National Death Index. Patients with AS or DISH were matched to controls who did not carry the diagnosis of hyperostotic disease. Risks of mortality were calculated at 3 months, 1 year, 2 years, and 3 years. Kaplan–Meier methods, logistic regression analysis, the two independent sample t test, and the Fisher exact test were used to compare mortalities between the two groups. Statistical significance was determined as p values <.05. Results Forty-three patients were identified as having fractures in the setting of hyperostotic disease of the cervical spine. Twenty-seven individuals had DISH, and 16 had AS. The average age of both the study group and controls was 80 years, with an age range of 68 to 94. There was no significantly increased risk of mortality between the overall study group and control group at 3 months (p=.20), 1 (p=.22), 2 (p=.15), or 3 years (p=.50) after injury. Compared with controls, subgroup analysis of patients with AS showed a statistically increased risk of mortality at 3 months (p<.01) and at 1 and 2 years (p<.01 at both time points). When compared with individuals with DISH, those with AS had an increased risk of mortality at time points up to 2 years after fracture. Patients with DISH did not have an increased mortality risk at any time point when compared with controls. Conclusions The effect of fracture on mortality appears to be greatest in those with AS. Patients with DISH did not demonstrate an increased risk of mortality compared with age- and sex-matched controls. Future studies of patients with hyperostotic disease should analyze patients with DISH and AS separately instead of as a single homogenous group. Level of evidence Level IV.
Abstract Background context Previous studies have reported position-dependent changes of the lumbar intervertebral foramen (LIVF) dimensions at different static flexion-extension postures. However, ...the changes of the LIVF dimensions during dynamic body motion have not been reported. Purpose The objective of this study was to investigate the in vivo dimensions of the LIVF during a dynamic weight-lifting activity. Study design/Setting This was a retrospective study. Methods Ten asymptomatic subjects were recruited for this study. Three-dimensional (3D) vertebral models of the lumbar segments from L2 to S1 were constructed for each subject using magnetic resonance images. The lumbar spine was then imaged using a dual fluoroscopic imaging system as the subject performed a dynamic weight-lifting activity from an upper body position of 45° to a maximal extension position. The in vivo positions of the vertebrae along the motion path were reproduced using the 3D vertebral models and the fluoroscopic images. The minimal area, height, and width of each LIVF during the dynamic body motion were analyzed. Results The LIVF area and width monotonically decreased with lumbar extension at all levels except L5–S1 (p<.05). On average, the LIVF area decreased by 7.4±6.7%, 10.8±7.7%, and 10.0±8.0% at the L2–L3, L3–L4, and L4–L5 levels, respectively, from the flexion to the upright standing position, and by 6.4±5.0%, 7.7±7.4%, and 5.1±5.1%, respectively, from the upright standing to the extension position. The LIVF height remained relatively constant at all segments during the dynamic activity. The foramen area, height, and width of the L5–S1 remained relatively constant throughout the activity. Conclusions Human lumbar foramen dimensions show segment-dependent characteristics during the dynamic weight-lifting activity.
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