Paraspinal Abscess Research Articles

Mediastinal Schwannoma Masquerading as a Cystic Lesion: A Case Report and Review of the Literature

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and minimally invasive diagnostic technique for the analysis of mediastinal lesions. This approach, however, may result in life-threatening mediastinitis. Here we report a rare case of mediastinal schwannoma presenting as a cystic lesion and pose an important question of risk versus benefit of aspiration of cystic lesions. A 39-year-old man developed persistent non-productive cough and dysphasia to solids for several months. A computed tomography (CT) of the chest revealed a large posterior upper mediastinal mass measuring 6.3 x 4.5 x 8.0 cm displacing the esophagus to the right and the trachea anteriorly, with a standardized uptake value (SUV) of 2.8. The patient then had a bronchoscopy, which showed marked extrinsic compression of the mid trachea without endobronchial disease. An esophagoduodenoscopy (EGD) and EUS were performed and were notable for an 8 cm oval, well-demarcated anechoic lesion with both solid and cystic components adjacent to the esophagus. FNA was intentionally not performed due to the risk of mediastinitis. The patient had a subsequent magnetic resonance imaging (MRI) of the chest showing the 9.3 x 4.1 x 6.0 cm midline retrotracheal superior mediastinal mass. He ultimately underwent posterolateral thoracotomy with excision of the lesion. A frozen section was consistent with a neurogenic tumor. Final pathology revealed a schwannoma. Diagnosis of mediastinal masses poses a significant challenge. The differential diagnosis for a posterior mediastinal mass alone includes neurogenic tumor, neuroblastic tumor, non-neurogenic tumor, paraspinal abscess, hernia, lymphadenopathy or lymphoma, foreget duplication cysts, and thoracic meningocele. EUS-FNA is a minimally invasive and a safe procedure with a complication rate (i.e. infection, bleeding, acute pancreatitis) of approximately 1%. This rate, however, increases when the lesion contains a cystic component rather than a purely solid lesion. Several case reports have described cystic infection and mediastinitis despite accepted techniques including prophylactic antibiotics. Schwannomas generally appear as solid lesions when imaged by either CT or MRI. In 23-30% of cases, this subtype of neurofibromas may be cystic and performing a FNA may result in serious consequences. More data are needed to accurately provide the risks and benefits of EUS-FNA of mediastinal cystic lesions and to validate the use of prophylactic antibiotics for aspiration of cystic lesions.

Which tissues are best for microbiological diagnosis in patients with pyogenic vertebral osteomyelitis undergoing needle biopsy?

Identification of the causative microorganism is important in the management of pyogenic vertebral osteomyelitis (PVO). The aim of this study was to investigate whether culture positive rates differ between needle biopsy sites in patients with PVO, and which tissues are best for microbiological diagnosis. Between January 2005 and December 2013, we conducted a retrospective cohort study of PVO patients who had soft-tissue abscesses (paraspinal or psoas abscesses) and who received needle biopsy for microbiological diagnosis. Needle biopsy sites were classified into two anatomical categories: vertebral bodies, or soft tissues (intervertebral discs, paraspinal abscesses, or psoas abscesses). A generalized estimating equation model was developed to identify factors associated with tissue-culture positivity. During the study period a total of 136 tissues were obtained by needle biopsy from 128 PVO patients with soft-tissue abscesses. The culture positive rates of vertebral bodies and soft tissues were 39.7% (29/73), and 63.5% (40/63), respectively (p < 0.05). In a multivariate analysis, male gender (adjusted odds ratio (aOR) 2.24, 95% CI 1.00–5.02), higher C-reactive protein (aOR 1.07, 95% CI 1.01–1.15), positive blood culture (aOR 2.57, 95% CI 1.01–6.59), and soft tissues as biopsy site compared with vertebral bodies (aOR 2.28, 95% CI 1.08–4.78) were independent factors associated with tissue culture positivity. Soft tissues were the best sites for microbiological diagnosis in PVO patients undergoing needle biopsy.

Spinal Tuberculosis Treated Surgically in the Department of Neurosurgery, Almenara Hospital, Lima, Peru

Introduction Peru is the second country in South America with the highest rate of tuberculosis, approximately 0.5% were tuberculosis spondylitis, being a variant of high morbidity because of the bone destruction, deformity, and neurological deficit potential. Tuberculosis is a difficult disease to treat and control because of poor access to health services and the delay in diagnosis. The treatment has undergone changes over time, from purely medical treatment or laminectomy to aggressive surgical treatment combined with specific chemotherapy; this marks a trend that is reflected in the way of acting in our service. Material and Methods We performed a retrospective case series and describe 14 cases collected between 2008 and 2013 hospitalized in the “Neurotrauma and Column,” database of operative reports is reviewed and files medical records. The data obtained are presented in tables and bar frequency and percentage. Results Of the 14 patients, 12 (86%) are women and 2 (14%) were men, the average age was 45 years. Overall, 13 (93%) underwent some form of surgery. The mean disease duration before surgery was 10.3 months the average time motor deficit before surgery was 5.1 months. The region of the spine was most frequently committed to the dorsal region (79%), 93% had vertebral collapse, and all compatible images with paraspinal abscesses and/or intraspinal. Overall, 12 (86%) to motor deficit and 13 (93%) had pain in affected region. With regard to diagnosis, it had microbiological confirmation in five cases (36%), histopathological diagnosis of specific granuloma in seven (50%), and only epidemiological–clinical–radiographical suspicion in two (14%) cases, in response to specific treatment. Using the classification GATA obtain IA (zero), IB (one), II (seven), and III (five). With regard to treatment, only 1 patient received specific chemotherapy (GATA IB), 13 were treated in combination with surgery: 6 (46%) debridement with or without drainage of abscess, interbody graft more transpedicular fixation by posterolateral approach, 4 (31%) laminectomy more biopsy with or without debridement, and 2 (15%) transpedicular fixation more laminectomy 1 (8%) interbody fusion noninstrumented. Of the 13 patients treated surgically, 11 cases showed motor deficit before surgery, 4 (31%) showed no change in the postoperative relative the motor deficit. Overall, nine (69%) improved at follow-up, two of which currently have no motor deficits. Conclusion Spinal tuberculosis is a major cause of disability; the main symptoms are pain and motor engine. Sometimes, confirmatory microbiological diagnosis cannot be established pathologically, but the response to specific treatment directed diagnosis. The surgical approach and technique used must be compatible with the theoretical basis of neurological decompression, fusion and spinal stability, and surgeon experience. In relation to the motor deficit, most improvement and disability significantly reduced, taking into consideration the duration of the motor deficit before surgery.

Infectious spondylitis in the Balearic Islands: An analysis of 51 cases

IntroductionVertebral osteomyelitis (VO) is a rare entity, although its incidence has increased in recent years. The objective is to describe the patients with this infection in our environment and a comparison with other published series. MethodsA retrospective review was conducted of epidemiological, clinical, microbiological, treatment, complications and evolution data of patients with VO during 10 years (2004–2014) in two hospitals of Mallorca. Results51 cases, median age 66 (range 22–85) years, 37 (72.5%) men with a mean onset of symptoms of 80.1±125.1 days. In thirty-six (70.6%) cases the origin of infection was considered hematogenous, although previous bacteremia was documented in 23 (45%) cases, being of urinary in 10 (43.5%) cases. Clinically at the moment of diagnosis 35 (68.8%) had fever, 32 (62.7%) pain, 14 (27.5%) irradiated nerve pain and 10 (19.6%) paralysis/paresia. MRI was the most performed radiological test 46 (90.2%), being pathological in all cases. Staphylococcus aureus 23 (52.3%) was the most common microbiological isolates. At the moment of the diagnosis, blood cultures were positive in 27 (65.8%) of 41 cases and 11 (50%) of 22 percutaneous puncture was positive. Paraspinal, epidural or psoas abscesses were observed in 23 (45.1%), neurological deficit in 7 (13.7%) and chronic pain in 6 (11.8%). One patient (1.9%) died in relation with infection. ConclusionsDiagnosis was delayed in most cases. Previous bacteremia being main predisposing factor and hematogenous origin the main source of infection. S. aureus was the most isolated. Percutaneous puncture together with blood cultures increase etiologic diagnosis. A high percentage of patients had complications or sequelae.

Endocarditis and spondylodiscitis associated with tunneled cuffed hemodialysis catheters: hospitalizations with poor outcomes.

Patients undergoing chronic hemodialysis using tunneled cuffed catheters (TCCs) are at increased risk of metastatic infections, namely endocarditis and spondydodiscitis, and mortality is high in this group. The aim of this study was to determine the clinical features, causative organisms, its susceptibility and outcomes in patients hospitalized with these infections from a single center. All consecutive patients with TCC and endocarditis and/or spondylodiscitis treated at the authors' institution between 2005 and 2011 were selected retrospectively. A total of 7 cases of endocarditis and 7 cases of spondylodiscitis were diagnosed. Concurrent infection was present in 1 patient. The mean age was 63.4 years, 53.8% were male, 23% had diabetes and 31% had previous immunosuppression. The average time on hemodialysis was 24 months. Those patients with endocarditis presented with fever, and 43% had previous valvular disease; mitral valve involvement was the most common. Early surgery was performed in 2 patients.Concerning spondylodiscitis, the median time from first symptom to diagnosis was 48 days. The first manifestation was back pain in 86% percent of patients, and 71% had an epidural or paraspinous abscess demonstrated by neuroimaging. One patient underwent surgical drainage of the abscess. Regarding both infections, staphylococcus aureus was the most common causative agent with a lower rate of negative blood cultures. All patients received intravenous antibiotics for a mean duration of six weeks. The mortality rate was 46%. A high index of suspicion is critical in the early recognition and management of both of these infections.

Espondilitis infecciosa en Baleares: análisis de 51 casos

IntroductionVertebral osteomyelitis (VO) is a rare entity, although its incidence has increased in recent years. The objective is to describe the patients with this infection in our environment and a comparison with other published series. MethodsA retrospective review was conducted of epidemiological, clinical, microbiological, treatment, complications and evolution data of patients with VO during 10 years (2004-2014) in two hospitals of Mallorca. Results51 cases, median age 66 (range 22-85) years, 37 (72.5%) men with a mean onset of symptoms of 80.1 ± 125.1 days. In thirty-six (70.6%) cases the origin of infection was considered hematogenous, although previous bacteremia was documented in 23 (45%) cases, being of urinary in 10 (43.5%) cases. Clinically at the moment of diagnosis 35 (68.8%) had fever, 32 (62.7%) pain, 14 (27.5%) irradiated nerve pain and 10 (19.6%) paralysis/paresia. MRI was the most performed radiological test 46 (90.2%), being pathological in all cases. S. aureus 23 (52.3%) was the most common microbiological isolates. At the moment of the diagnosis, blood cultures were positive in 27 (65.8%) of 41 cases and 11 (50%) of 22 percutaneous puncture was positive. Paraspinal, epidural or psoas abscesses were observed in 23 (45.1%), neurological deficit in 7 (13.7%) and chronic pain in 6 (11.8%). One patient (1.9%) died in relation with infection. ConclusionsDiagnosis was delayed in most cases. Previous bacteremia being main predisposing factor and hematogenous origin the main source of infection. S. aureus was the most isolated. Percutaneous puncture together with blood cultures increase etiologic diagnosis. A high percentage of patients had complications or sequelae.

A new treatment regimen for Potts disease with para-spinal abscesses and sinuses

A new treatment regimen for Potts disease with para-spinal abscesses and sinuses

Vertebral Osteomyelitis and Paraspinal Abscess Among Patients With Brucellosis

Background: Brucellosis is a systemic bacterial disease transmitted from animals to humans and involves many organs and tissues. Symptoms of brucellosis are protean and can be similar to many other infectious diseases. None of the symptoms are specific enough to support the clinical diagnosis. The musculoskeletal system is one of the most commonly affected organs. Disease can be present with bursitis, sacroiliitis, peripheral arthritis, osteomyelitis, spondylitis and paraspinal abscess, which among them vertebral osteomyelitis and paraspinal abscess are rare. Objectives: In this study, we aimed to evaluate the prevalence of vertebral osteomyelitis and paraspinal abscess in patients with brucellosis who were admitted to an infectious hospital in Zahedan, Southeastern Iran. Patients and Methods: During 48 months, from December 2008 to October 2012 we evaluated all patients who were referred to infectious clinics (Zahedan, Southeastern Iran) because of fever, myalgia, arthralgia, chronic low back pain, bone pain and had a wright positive test. Blood samples were tested again for 2ME. A titer of more than 1/80 was positive. All patients with low back pain who had a MRI or spine CT-Scan, which showed a sign of osteomyelitis and/or cold abscess, were included in our study. Results: Among 73 patients with brucellosis (56 males, 17 females; age range 12-69 years), 14 patients (19%; 12 males) had a diagnosis of brucella osteomyelitis. Eleven patients had vertebral osteomyelitis and five showed an abscess next to the involved spine. Patients were treated with a triple regimen including: doxicycline, rifampin and streptomycin, and one patient needed surgery due to pressure effect on the spine. Conclusions: Localized complications of brucellosis such as bone involvement were observed in patients with acute disease or chronic untreated infection. Based on our results, in endemic areas, every patient with low back pain and a positive test for brucella should be evaluated for spinal osteomyelitis.

First Reported Case of Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis with Multiple Spinal and Paraspinal Abscesses Associated with Acupuncture.

Acupuncture is one of the oldest medical procedures in the world and originated in China about 2,000 years ago. Acupuncture is a form of complementary medicine and has gained popularity worldwide in the last few decades. It is mainly used for the treatment of chronic pain. Acupuncture is usually considered a safe procedure but has been reported to cause serious complications including death. It has been associated with transmission of many viruses and bacteria. Two cases of Methicillin-Resistant Staphylococcus aureus have been reported recently following acupuncture therapy. We are reporting a case of a 57-year-old Korean female who developed vertebral osteomyelitis and intraspinal and paraspinal abscesses as a complication of acupuncture. Blood cultures, skin lesion culture, and body fluid culture yielded Methicillin-Resistant Staphylococcus aureus (MRSA). Good anatomical and medical knowledge, good hygiene standards, and proper acupuncture techniques should be followed to prevent the complications. Acupuncturists should consistently review the infection control guidelines to acupuncture. This case should raise awareness of such condition and hazards of presumably benign procedures such as acupuncture.

Paraspinal and Extensive Epidural Abscess: The Great Masqueraders of Abdominal Pain.

Paraspinal and epidural abscesses are rare conditions often diagnosed later in the disease process that can have significant morbidity and mortality. Predisposing risk factors include diabetes, human immunodeficiency virus, intravenous drug abuse, and previous history of spinal surgery or injection. They can threaten the spinal cord by compressive effect, leading to sensory motor deficits and ultimately paralysis and death. Diagnosis may be a challenge due to the delayed presentation of nonspecific back pain or radicular pain such as chest pain or abdominal pain. We present a rare case on a patient with periumbilical pain, constipation, and urinary retention who was ultimately diagnosed with a paraspinal abscess extending into the epidural space from T1 to S2. He underwent decompressive laminectomy with incision and drainage of the abscesses. The patient made an excellent recovery postoperatively, and repeat magnetic resonance imaging at six weeks showed resolution of the abscess.

A Paraspinal Abscess Case Presenting with Transverse Myelitis

44 year old woman was admitted to our clinic with complaints of inability to walk and severe arm and leg pain. Patient’s symptoms began within a week. She has not a systemic disease except diabetes mellitus. Because there was a laryngeal mass which causes difficulty in swallowing, she had recently laryngeal mass operation history. She had tetraparesis and paresthesias in the neurological examination and she had also urinary incontinence. Her deep tendon reflexes were normal. Transverse myelitis were considered at the forefront of these findings. In cervical magnetic resonance imaging, cervical paravertebral abscess and accompanying spinal cord involvement was detected. After appropriate neurosurgical procedure and antibiotic treatment, patient fully recovered.

Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery.

This was a prospective study on the clinical outcomes of single-stage surgery for thoracic and lumbar spine tuberculosis patients with bilateral paraspinal or bilateral psoas abscesses. The aim of this study was to investigate the feasibility of, indications for, and clinical effects of single-stage posterior surgery for the treatment of thoracic and lumbar spinal tuberculosis with bilateral paraspinal or bilateral psoas abscesses. An increasing number of articles have been published on the use of single-stage surgery for spinal tuberculosis; however, none of these articles have discussed the use of such surgery in patients with bilateral abscesses. Between January 2003 and January 2011, 41 patients with thoracic and lumbar spinal tuberculosis and bilateral paraspinal or bilateral psoas abscesses were treated with single-stage posterior surgery. All of the patients were treated preoperatively with 1-2 weeks of antituberculosis drugs. All patients were managed postoperatively with standard courses of chemotherapy with triple or quadruple antituberculosis drugs. The clinical symptoms, complications, and laboratory and image indicators were recorded. There were no local recurrences except in one L3-L4 tuberculosis patient. Two patients presented with extraspinal tuberculosis in the third year. There were no incision complications. Bone fusion was observed 6 months after the operation. The erythrocyte sedimentation rate was normal at 3 weeks-3 months postoperatively. There were no internal fixation failures. The internal fixations in 6 young patients were removed after the spinal tuberculosis was cured. Single-stage posterior surgery with instrumentation results in less operative trauma and can be a suitable alternative for treating thoracic and lumbar tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

Abdominal Hollow Viscus Injuries are Associated with Spine and Neurologic Infections after Penetrating Spinal Cord Injuries

Penetrating spinal cord injuries are rare but potentially devastating injuries that are associated with significant morbidity. The objective of this study was to assess the impact of abdominal hollow viscus injuries (HVIs) on neurologic and spinal infectious complications in patients sustaining penetrating spinal cord injuries. We performed a 13-year retrospective review of a Level I trauma center database. Variables analyzed included demographics, injury patterns and severity, spine operations, and outcomes. Spine and neurologic infections (SNIs) were defined as paraspinal or spinal abscess, osteomyelitis, and meningitis. Multivariate analysis was performed to identify factors associated with SNI. Of 137 patients, there were 126 males (92%) with a mean age of 27 ± 10 years. Eight patients (6%) underwent operative stabilization of their spine. Fifteen patients (11%) developed SNI. There was a higher incidence of SNI among patients with abdominal HVI compared with those without (eight [26%] vs six [6%], P < 0.001). On multivariate analysis, after controlling for injury severity, solid abdominal injury and HVI, vascular injury, and spine operation, abdominal HVIs were independently associated with an increased risk for SNI (odds ratio, 6.88; 95% confidence interval, 2.14 to 22.09; P = 0.001). Further studies are required to determine the optimal management strategy to prevent and successfully treat these infections.

Trachea-Thoracic Vertebral Body Fistula Causing Spinal Cord Injury

A case report and review of the literature. To discuss the significance of identifying trachea-thoracic vertebral body fistula. Several authors have reported the occurrence of communication between the trachea and the spinal canal or paraspinal abscess. However, trachea-thoracic vertebral body fistulas have not been reported. A 77-year-old male experienced gradually worsening lower-extremity palsy. Fifteen years before presentation, he had undergone retrosternal esophageal reconstruction with a gastric tube for esophageal cancer. Computed tomographic scan revealed compression of the Th5 vertebral body; the trachea and the Th5 vertebral body were connected by a fistula, and air seemed to enter Th5 from the trachea. Magnetic resonance image showed severe spinal canal stenosis. Posterior thoracic decompression and fusion was performed. Five months after the procedure, he regained the ability to walk with a cane, and computed tomographic scan revealed closure of the fistula and the bony fusion. To our knowledge, this is the first case report of a trachea-thoracic vertebral body fistula. Because the trachea is adjacent to the anterior aspect of the thoracic vertebrae, in cases of retrosternal esophageal reconstruction, trachea-vertebral body fistula should be a differential diagnosis for destructive changes in thoracic vertebrae without any signs of trauma.

Outcome of culture-negative pyogenic vertebral osteomyelitis: Comparison with microbiologically confirmed pyogenic vertebral osteomyelitis

ObjectivesAlthough pyogenic vertebral osteomyelitis (PVO) with no identified microorganism is treated empirically, the clinical outcome is not well understood. MethodsWe conducted a retrospective review of patients with PVO at a tertiary-care hospital from 2000 through 2012. The study compared clinical features and outcomes of microbiologically confirmed (M-PVO) with clinically diagnosed PVO (C-PVO). ResultsOf 151 patients with PVO, 75 (49.7%) had M-PVO. Compared to patients with M-PVO, patients with C-PVO had fewer underlying medical conditions. In addition, they presented less frequently with fever, high acute-phase reactants levels, and paraspinal abscess. The rate of treatment failure tended to be lower in the C-PVO group [9.2% (7/76) vs. 17.3% (13/75); p = 0.157]. The overall relapse rate was 6.6% and did not differ significantly between groups; notably this rate was higher in patients who received antibiotics for ≤6 weeks [18.8% (3/16)] and ≤8 weeks [12.1% (4/33)]. The independent risk factors for treatment failure were higher CRP levels [odds ratio (OR) = 1.087; 95% confidence interval (CI): 1.025–1.153; p = 0.005] and fever ≥37.8°C (OR = 8.556; 95% CI: 2.273–32.207; p = 0.002). ConclusionsPatients with C-PVO had less systemic inflammatory response and a more favorable outcome compared to M-PVO. Prolonged antibiotic therapy, for at least 8 weeks, might be required for C-PVO, as well as for M-PVO until better outcomes are assured.

Spinal and paraspinal pneumococcal infections—a review

Spinal and paraspinal infections caused by Streptococcus pneumoniae remain a rare event. We present two cases from our institution, discuss the pathophysiology, and present a literature review of an additional 50 cases of spinal pneumococcal infections. Spinal epidural abscess and vertebral osteomyelitis as well as paraspinal abscesses caused by pneumococcus were included in the analysis. As has been reported for spinal infections due to other bacteria, persistent localized back pain with an elevation in inflammatory markers was almost universal. The lumbar spine was the most commonly involved. Pneumococcus was most frequently isolated from material obtained at the site of the infection; blood cultures were a less common source. The majority of patients with neurologic deficits had spinal epidural abscess or phlegmon, and had a higher mortality. Most patients were treated with 6 weeks of parenteral antimicrobials, and surgical intervention was not associated with a mortality benefit.

Extended indications of percutaneous endoscopic lavage and drainage for the treatment of lumbar infectious spondylitis

The treatment of spinal infection remains a challenge for spinal surgeons because of the variable presentations and complicated course. The diagnostic and therapeutic value of percutaneous endoscopic lavage and drainage (PELD) has been proved in some recent studies. The purpose of this study is to evaluate the efficacy of PELD in patients with advanced infectious spondylitis which may traditionally require open surgery. We retrospectively reviewed the medical records of 21 patients who underwent PELD to treat their advanced lumbar infectious spondylitis. Patients with severe infection resulting in significant neurological deficit and mechanical instability were excluded from the PELD procedure, which was only used on selected patients with less severe disease. The 21 patients were categorized into three groups based on their past history, clinical presentation, and imaging studies: those with paraspinal abscesses, postoperative recurrent infection, and multilevel infection. Clinical outcomes were assessed by careful physical examination, Odom's criteria, regular serologic testing, and imaging studies to determine whether continued conservative treatment or surgical intervention was necessary. Causative bacteria were identified in 19 (90.5%) of 21 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from the infected tissue biopsy cultures were prescribed for the patients. All patients reported satisfactory recovery and relief of back pain, except three with multilevel infections who underwent anterior debridement and fusion within 2 weeks after treatment with PELD. The overall infection control rate was 86%. One patient with epidural abscess and spondylolytic spondylolisthesis of the L5-S1 received instrumented fusion surgery due to mechanical instability 5 months later. No surgery-related major complications were found, except 2 patients who had transient paraesthesia in the affected lumbar segment. PELD was successful in obtaining a bacteriologic diagnosis, relieving the patient's symptoms, and assisting in eradication of lumbar infectious spondylitis. The indications of this minimally invasive procedure could be extended to treat patients suffering from spinal infections with paraspinal abscesses and postoperative recurrent infection. Patients with multilevel infection may have trivial benefits from PELD due to poor infection control and mechanical instability of the affected segments.

Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults.

To compare single-stage posterior transforaminal lumbar interbody fusion, debridement, posterior instrumentation, and postural drainage (posterior-only surgery) with a combined posterior-anterior surgical approach for treatment of adults with lumbosacral spinal tuberculosis (STB) with paraspinal abscess and to determine the clinical feasibility and effectiveness of posterior-only surgical treatment. Thirty-nine patients with lumbosacral STB and paraspinal abscess were treated with one of two surgical procedures in our center from September 2003 to December 2012. Nineteen patients were treated with posterior-only surgery (Group A) and 20 were treated with combined posterior-anterior surgery (Group B). Surgery duration, intraoperative blood loss, length of hospitalization, bony fusion rates, complication rates, neurological status, lumbosacral angle correction, and Kirkaldy-Willis functional outcomes of the two groups were compared. The average follow-up period was 39.1±12.0months for Group A and 40.7±12.4months for Group B. Under the Frankel classification, all patients improved with treatment. STB was completely cured and grafted bones were fused within 5-11months in all patients. There were no persistent or recurrent infections or obvious differences in radiological results between the groups. The lumbosacral angle was significantly corrected after surgical management, but loss of correction was seen in both groups. The average operative duration, blood loss, length of hospital stay, and postoperative complication rate of Group A were lower than those of Group B. Posterior-only surgery is feasible and effective, resulting in better clinical outcomes than combined posterior-anterior surgeries, especially in surgical time, blood loss, hospital stay, and complications.

Pott's Disease in a 2-Year-Old Child Treated by Decompression and Anterior-Posterior Instrumented Fusion.

Introduction. Paraplegia and kyphotic deformity are two major disease-related problems of spinal tuberculosis, especially in the early age disease. In this study a 2-year-old boy who underwent surgical decompression, correction, and 360° instrumented fusion via simultaneous anterior-posterior technique for Pott's disease was reported. Case Report. A 2-year-and-9-month-old boy presented with severe back pain and paraparesis of one-month duration. Thoracic magnetic resonance imaging demonstrated destruction with a large paraspinal abscess involving T5-T6-T7 levels, compressing the spinal cord. The paraspinal abscess drained and three-level corpectomy was performed at T5-6-7 with transthoracic approach. Anterior instrumentation and fusion was performed with structural 1 autogenous fibula and rib graft using screw-rod system. In prone position pedicle screws were inserted at T4 and T8 levels and rods were placed. Six months after surgery, there was no weakness or paraparesis and no correction loss at the end of follow-up period. Discussion. In cases of vertebral osteomyelitis with severe anterior column destruction in the very early child ages the use of anterior structural grafts and instrumentation in combination with posterior instrumentation is safe and effective in maintenance of the correction achieved and allows efficient stabilization and early mobilization.

Right upper quadrant pain and raised alkaline phosphatase is not always a hepatobiliary problem

Right upper quadrant pain is a common presenting complaint to the general and hepatobiliary surgical team. Differential diagnoses include gallstones, cholecystitis, liver and pancreatic pathology. A 64-year-old man presented to our general surgical unit with right upper quadrant pain and deranged liver function tests. He underwent ultrasonography several times as well as magnetic resonance cholangiopancreatography (MRCP) in pursuit of hepatobiliary pathology. However, it was the identification of an empyema on MRCP that led to computed tomography of the thorax and the eventual discovery of the cause of the pain: a paraspinal abscess causing T10/T11 discitis. Right upper quadrant pain and deranged liver function tests justify hepatobiliary investigation. Nevertheless, after several negative tests, the differential diagnoses should be broadened and referred pain considered.